Managing Stress Fractures In Athletes

Brian W. Fullem, DPM, FACFAS, FAAPSM

When getting athletes back on their feet following a stress fracture, one must balance the need to return to sport with the need for safe healing. Combining a thorough review of the literature with practical pearls from his clinical experience, this author offers salient diagnostic insights and perspectives on non-weightbearing, bone stimulation and other treatment measures.

The treatment of stress fractures in athletes can be a challenging task. Athletes who are competing in school, professionally or at the highest recreational levels often have a narrow timeframe to train and compete in their desired sporting activities. Reducing healing time by every means possible is crucial to the success of these athletes and, in turn, achieving success as a sports medicine physician.

   The goal of any sports medicine professional should always be to return the athlete back to activity as soon as is safely possible for the athlete. Most competitive athletes will straddle the fine line between optimal fitness and injury in order to achieve the best performance possible.

   In 1855, Breithaupt first described stress fractures as “march fractures” and made the clinical description of swelling and pain in the foot of a metatarsal stress fracture.1 The fractures were closely associated with the marching of soldiers. In 1897, Stechow described the radiographic appearance in military recruits forced to go on long marches, establishing the association between stress fractures and overuse.2

   Matheson and colleagues analyzed cases of 320 athletes with bone scan positive stress fractures treated over 3.5 years and assessed the results of conservative management.3 The most common bone injured was the tibia (49.1 percent). This was followed by the tarsals (2.3 percent), metatarsals (8.8 percent), femur (7.2 percent), fibula (6.6 percent), pelvis (1.6 percent), sesamoids (0.9 percent) and spine (0.6 percent). Stress fractures were bilateral in 16.6 percent of cases.

What Are The Most Frequent Causes Of Stress Fractures?

Much of the literature points to overuse as one of the main causes of a stress fracture. Overuse or training errors can account for the extrinsic factors in an injury. However, there are typically other more intrinsic factors such as poor bone density, low body weight, weakness of the core muscles and biomechanical abnormalities including limb length differences, all of which can lead to a stress fracture. It is the duty of the physician to make the proper diagnosis and ascertain the possible cause to attempt to prevent future injuries.

   Fredericson and colleagues found that athletes who played ball sports such as basketball or soccer during childhood had a decreased incidence of stress fractures as adults.4 One can make a correlation that these athletes have developed better core musculature such as their hip abductors, which leads to fewer injuries.

   Fredericson, Akuthota and respective colleagues have further proven that improving hip abductor strength is the key component for treatment of iliotibial band syndrome.5,6 They note that improving hip abductor strength is also useful in the prevention and treatment of other lower extremity injuries such as Achilles tendonitis and medial tibial stress syndrome.5,6 Athletes are often searching for ways to improve performance and adding a core strengthening program is arguably the best way to help prevent injury leading to improved performance.

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