Managing Stress Fractures In Athletes

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Author(s): 
Brian W. Fullem, DPM, FACFAS, FAAPSM

   Research has shown MRI to have a higher specificity for detecting the exact location for the injury. However, one must use caution in interpreting MRI results as bone marrow edema, which is commonly associated with a stress reaction or stress fracture, can also be seen in asymptomatic individuals. Amol Saxena, DPM, observes that further testing and correlation with clinical symptoms is extremely important.9 Dr. Saxena had a patient who was being evaluated for a sesamoid injury via MRI of the feet and legs as a screening prior to signing a professional soccer contract. The athlete had spent the morning practicing with a lot of ball strikes and the physician read the MRI as multiple stress fractures of the metatarsals despite the fact that the patient did not have any symptoms in that area.

   A CT scan is a much better option for some bones such as the navicular or cuboid, and when an MRI is inconclusive, and shows an increase of bone marrow edema. Computed tomography shows the cortex of bone much better than MRI.

Is Complete Non-Weightbearing Required To Facilitate Stress Fracture Healing?

A stress fracture is one of the few injuries in an athlete that requires almost complete cessation of weightbearing exercise. One exception to this rule is use of the Alter G treadmill (Alter G), which creates a vacuum around the runner and allows running at a reduced body weight of down to 20 percent.

   Takacs recently presented a case study of a patient with multiple stress fractures, who used the Alter G treadmill while rehabilitating from these fractures.10 The patient experienced a significant reduction in pain and an improvement in ankle range of motion, walking speed and physical function, which the researchers assessed via the Foot and Ankle Module of the American Academy of Orthopaedic Surgeons Lower Limb Outcomes Assessment Instrument. Training did not appear to have any adverse effect on fracture healing as was evident on the radiograph.

   A good general rule of thumb to guide treatment is that patients should avoid anything that causes pain. Use of a surgical shoe to offload the painful area will often suffice for metatarsal stress fractures. If the patient has pain when walking in a surgical shoe, then it may be necessary to move to a controlled ankle motion (CAM) walker. If pain is still present, then non-weightbearing may be warranted. The addition of a high ankle brace can be helpful with tibial and fibular stress fractures.

   Navicular stress fractures in particular occur in runners at a surprisingly high rate and require more aggressive conservative treatment. The Matheson study found that 25 percent of the fractures were of tarsal bones.3 The diagnosis and treatment of navicular stress fractures require a high index of suspicion and eight to 10 weeks of immobilization including non-weightbearing.

What You Should Know About Bone Stimulation

Bone stimulation may also help an injured athlete recover faster from a stress fracture. A study by Saxena showed that using a pulsed electromagnetic field allowed athletes to return much quicker from their stress fractures.11 Saxena presented a small, prospective, unblinded analysis of 73 stress fractures that were confirmed via bone scan, MRI or CT scan. The electromagnetic group returned to activity in 8.8 weeks versus the non-electromagnetic group, which returned to activity in 17.6 weeks.

   Beck and co-workers evaluated femoral stress fractures, and their whole group analysis did not detect an effect of capacitively coupled electric field stimulation on tibial stress fracture healing.12 However, greater device use and less weightbearing loading enhanced the effectiveness of the active device. More severe stress fractures healed more quickly with capacitively coupled electric field stimulation.

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