Managing Stress Fractures In Athletes

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Brian W. Fullem, DPM, FACFAS, FAAPSM

   Uchiyama and colleagues presented an excellent paper on the use of low intensity pulsed ultrasound in the treatment of anterior tibial stress fractures.13 These fractures are notoriously slow to heal. One aspect of this paper that differentiates it from other papers is the evaluation of the return to full activity for athletes, making it more applicable for sports medicine. Athletes returned to full activity two to three times faster with the use of bone stimulation in comparison to other modalities for the same injury.

   Further scientific studies are warranted but even a few weeks of added training can mean a great difference to a professional runner or a college or high school runner with a limited amount of eligibility to compete. The use of bone stimulation has almost no downside other than cost.

   Extracorporeal shockwave therapy (ESWT) is another modality that shows promise to help improve healing times for stress fractures. Taki and colleagues examined five athletes who had delayed or nonunions of stress fractures, and each injury showed significant improvements.14 The authors opined that ESWT promotes osteogenesis and helped these athletes heal faster.

   Moretti and co-workers also found that ESWT can speed the healing process.15 They conducted a retrospective study of 10 athletes affected by chronic stress fractures of the fifth metatarsal and tibia who received three to four sessions of low-middle energy ESWT. The authors concluded that at the follow-up (eight weeks on average), the clinical and radiography results were excellent, and enabled all players to gradually return to sports activities.

   These reports show that ESWT is a noninvasive and effective treatment for resistant stress fractures. Similar to the use of bone stimulation, there are no known negative effects for the use of shockwave therapy for stress fractures.

When To Attempt Surgery

When conservative treatment fails to heal a navicular stress fracture, one should proceed to open reduction internal fixation. Two articles show a faster return to activity following surgical management of navicular fractures than conservative treatment.18,19 Saxena and colleagues proposed an excellent classification system for the treatment of these injuries based on CT findings. This classification system is both prognostic and diagnostic.18

   Surgery is often a last resort but it is a viable alternative and the athlete should be assured that full return to activity should be attainable. Navicular type II and III injuries that do not heal within the six to eight weeks of conservative treatment will respond well to surgery. After conservative options fail, one should also consider excision of sesamoids that do not heal.

In Conclusion

The most important aspects of treating stress fractures in athletes involve making a timely diagnosis, the prevention of causative factors in the future and giving consideration to reducing the return to activity to the shortest possible time that is safe for the athlete.

   Dr. Fullem is a Fellow of the American College of Foot and Ankle Surgeons, and the American Academy of Podiatric Sports Medicine. He is board-certified in foot and ankle surgery by the American Board of Podiatric Surgery. Dr. Fullem practices in Tampa, Fla.


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