Stress fractures in athletes

During the 14-year period of 1971-1985, 368 stress fractures in 324 athletes were treated. The series contained 268 fractures in males and 100 fractures in females; 32 fractures occurred in children (less than 16 years), 117 in adolescents (16-19 years), and 219 in adults. Forty-six fractures were incurred by athletes at an international level, 274 by athletes at a national or district level and 48 by recreational athletes. Of the total cases, 72% occurred to runners and a further 12% to athletes in other sports after running exercises. The distribution of the stress fractures by site was: tibia 182, metatarsal bones 73, fibula 44, big toe sesamoid bones 15, femoral shaft 14, femoral neck 9, tarsal navicular 9, pelvis 7, olecranon 5 and other bones 10. Of the total fractures, 342 were treated conservatively and 26 fractures required surgical treatment. The operative indication was dislocation in 5 cases and delayed union/nonunion in 21 cases. The sites most often affected by delayed union were: anterior midtibia, sesamoid bones of the big toe, base of the fifth metatarsal, olecranon, and tarsal navicular. The athletes at an international level experienced the greatest risk of multiple separate fractures, protracted healing, or fractures requiring surgery.     

Stress fractures in figure skaters

In 1987, during two great skating contests--the Universiade in the Tatra Mountains and the Gold Pirouette in Zagreb--a total of 42 world class skaters were asked through a questionnaire if they had ever in their career suffered from a stress fracture. Of the 42 skaters, 9 had stress fractures. Four stress fractures occurred during preseason training (two fibular, one second metatarsal, and two fourth metatarsal stress fractures). Increased mileage was reported by three skaters and the fourth had done too much speed training on hills. Five stress fractures occurred during the season (one tibial and two tarsal navicular stress fractures and two stress fractures of the base of the fifth metatarsal). In all cases, the fracture occurred in the take-off leg. All of the subjects were competitive figure skaters with a daily training period of 3 to 8 hours, six times a week. The time from the onset of symptoms to definite diagnosis ranged from 2 to 10 weeks. Of the nine injured skaters, eight were treated conservatively and one skater with Jones' fracture was treated surgically. All of the skaters were able to resume a preinjury level of activity 3 to 7 months after treatment began. In conclusion, it may be emphasized that stress fractures in figure skaters are not rare and should, therefore, always be considered as a possibility.     

Stress fractures of the navicular bone. Roentgen diagnosis of a rare fracture

Stress fracture of the tarsal navicular are rare and their diagnosis is often delayed. 1982 and 1983 we found stress fractures of the os naviculare pedis in 16 patients, 8 fractures were complete and 10 incomplete. Three types of radiographic findings are sclerosis, radiolucency and radiolucency with sclerotic borders. The fractures were localized in the middle third of the tarsal navicular. Laminography is necessary to evaluate the radiographic changes and their extension.     

Management and return to play of stress fractures.

OBJECTIVE: The purpose of this article is to provide the clinician an evidence/experience-based algorithm for the management of stress fractures. DATA SOURCES: Medline search of peer reviewed publications regarding stress fracture etiology, classification, treatment, and natural history. DATA SYNTHESIS/METHODS: The algorithm was developed from a review of retrospective case series, a few evidence-based papers, and the clinical experience of 4 sports medicine team physicians with a combined experience of over 40 years in the care of athletes at the college and professional level. The literature is almost entirely case series without control groups; therefore, clinical consensus is included as the next best guide to treatment. RESULTS: The emphasis of this article is to provide a clear and simple approach to the management of these fractures by classifying them as either high-risk or low-risk. This separation into 2 groups is based on the biomechanical environment and natural history of the fracture. High-risk stress fractures occur in the superolateral femoral neck, anterior tibial shaft, tarsal navicular, proximal fifth metatarsal, and talar neck. Low-risk stress fractures occur in the lateral malleolus, calcaneus, 2nd through 4th metatarsals, and the femoral shaft. CONCLUSIONS: The undertreatment of high-risk stress fractures can lead to catastrophic bone failure and/or prolonged loss of playing time. Overtreatment of low-risk stress fractures can result in unnecessary deconditioning and unneeded loss of playing time. We propose that the use of the simple and clinically relevant algorithm will help guide appropriate management and return to play decision-making as well as encourage future prospective research.     

Fractures of the base of the fifth metatarsal

In 1902 Sir Robert Jones described a fracture of the fifth metatarsal which he incurred while dancing. Since that time, fractures of the base of the fifth metatarsal have been called "Jones fractures". Fractures of the tuberosity at the base of the fifth metatarsal are common and usually respond readily to conservative treatment. Less frequently the fracture occurs more distally through the proximal metaphysis. Eleven patients with fractures of the proximal metaphysis were reviewed to determine if they represented a clinically distinct subgroup. Seven of the patients were men between 19 and 25 years of age who fractured the fifth metatarsal playing sports. The fractures were slow to heal and one required internal fixation with bone grafting. Fractures of the proximal metaphysis of the fifth metatarsal have a different mechanism of injury and a less favourable prognosis than do tuberosity fractures. When they occur in young athletes, more aggressive treatment is required.     

Metatarsal shaft fractures and fractures of the proximal fifth metatarsal

Metatarsal fractures represent a relatively common injury, especially in athletes. The pertinent anatomy, evaluation, diagnosis, classification, and treatment of acute and chronic (stress) metatarsal shaft fractures are discussed. Fractures of the proximal fifth metatarsal, which are unique and important injuries, are also discussed. Treatment remains relatively straightforward for the traumatic metatarsal injury, whereas traditional stress fractures typically heal with decreased activity. The problematic proximal fifth metatarsal fracture (Jones fracture) frequently requires surgical intervention in patients who want to avoid non-weight-bearing cast immobilization. The authors' current treatment for this fracture includes the option of intramedullary fixation versus cast immobilization.     

Detecting and Treating Common Foot and Ankle

Midfoot and forefoot fractures commonly seen in a primary care practice include navicular and metatarsal stress fracture, tarsometatarsal fracture-dislocation, and acute fracture of the metatarsals, sesamoid, great toe, or lesser toes. A careful history to determine the mechanism of injury and a methodical physical exam to detect sites of tenderness are essential. X-rays are usually required, but stress fractures may warrant bone scans. Compared with ankle and hindfoot fractures, sports-related midfoot and forefoot fractures are more often treated conservatively with casting or wooden shoes. Tarsometatarsal disruption and Jones fractures are more likely to require surgery.     

The non-surgical and surgical treatment of tarsal navicular stress fractures

Stress fractures of the tarsal navicular, first described in 1970, were initially thought to be rare injuries. Heightened awareness and increased participation in athletics has resulted in more frequent diagnosis and more aggressive treatment. The vascular supply of the tarsal navicular results in a relatively avascular zone in the central one-third, which experiences severe compressive forces during explosive manoeuvers such as jumping and sprinting. Repetitive activities can result in stress reactions or even fracture. Patients often initially complain of vague midfoot pain localized to the medial border of the foot. The pain is usually exacerbated by activity and relieved with rest. The diagnosis of tarsal navicular stress fracture is challenging because of the high false negative rate of plain radiographs. Additional diagnostic testing with bone scan, CT and MRI are often required for diagnosis. The proper treatment of tarsal navicular stress fractures has become a topic of debate as surgical intervention for these injuries has increased. In a recent meta-analysis, Torg et al. found that 96% of tarsal navicular stress fractures treated with non-weight-bearing (NWB) conservative treatment for 5 weeks went on to successful outcomes. However, only 44% of patients treated with weight-bearing (WB) conservative treatment had successful outcomes. Surgical treatment resulted in successful outcome in 82% of patients. Interestingly, the meta-analysis also found that fracture type did not correlate with outcomes, regardless of treatment. The meta-analysis also found no difference in time to return to activity between patients treated surgically and those who underwent NWB conservative treatment. The recent literature indicates that patients are undergoing surgery or are receiving WB conservative management as a first-line treatment option with the expectation that they will return to their activity more quickly. Although surgical treatment seems increasingly common, the results statistically demonstrate an inferior trend to conservative NWB management. Conservative NWB management is the standard of care for initial treatment of both partial and complete stress fractures of the tarsal navicular. WB conservative treatment and surgical intervention are not recommended.     

Second metatarsal stress fracture in sport: comparative risk factors between proximal and non-proximal locations

Background

Stress fractures of the second metatarsal are common injuries in athletes and military recruits. There are two distinct areas in the second metatarsal where stress fractures develop: one proximal (at the base) and the other non‐proximal (distal). Diagnosis can be difficult, and there is a difference in prognosis and treatment of the two types of stress fracture. Therefore differentiation of fracture location is warranted. Differences in risk factors and clinical outcomes between proximal and non‐proximal stress fractures have not been studied.

Objective

To determine whether different risk factors and/or clinical outcomes associated with proximal and non‐proximal stress fractures of the second metatarsal exist.

Methods

Patients diagnosed with proximal stress fractures of the second metatarsal were included in the study. Retrospectively, an age‐matched control group with a non‐proximal stress fracture was selected for comparison. Statistical analysis involved bivariate comparisons of demographic variables and clinical measurement between the two groups.

Results

Patients with proximal stress fractures were more likely to be chronically affected, usually exhibited an Achilles contracture, showed differences in length of first compared with second metatarsal, were more likely to experience multiple stress fractures, and exhibited low bone mass. In addition, a high degree of training slightly increased the risk of a non‐proximal fracture, whereas low training volume was associated with a proximal stress fracture.

Conclusion

The signs, symptoms and clinical findings associated with proximal metatarsal stress fractures are different from those of non‐proximal stress fractures.     

Stress avulsion fracture of the tarsal navicular. An uncommon sports-related overuse injury

We report nine cases of stress-related avulsion fracture of the tarsal navicular in athletes. This uncommon over-use injury is thought to occur following repetitive cyclic compressive loading secondary to an impingement of the tarsal navicular. The small dorsal triangular fragment is best seen in weightbearing lateral view radiographs and isotope scan and/or tomography help confirm the diagnosis. We feel that operative treatment is the method of choice in highly symptomatic cases and among top athletes because of the shorter recovery time.     

The os supranaviculare and navicular stress fractures

Tarsal navicular stress fractures are injuries more commonly observed in athletes involved in sprinting and jumping sports. Known risk factors for the development of navicular stress fractures include pes cavus, metatarsus adductus, limited subtalar or ankle motion, medial narrowing of the talonavicular joint, as well as a short first metatarsal. The presence of an os supranaviculare has yet to be described as a predisposing factor in the occurrence of navicular stress fractures. We present two cases of navicular stress fractures in patients with an os supranaviculare and discuss possible reasons for such an association.     

Less common stress fractures in the foot

In a series of 827 stress fractures in soldiers, 15 were found in the first metatarsal, representing 11% of all stress fractures in the metatarsals. All were in the proximal end of the bone. Eight fractures were found in the fourth and four in the fifth metatarsal. In the cuneiform bones three fractures were found, and one in the talus. One fracture was revealed in the lateral sesamoid of the hallux and one in the peroneal bone. Ten patients had stress fractures in other bones too. The radiological appearance and the corresponding stress mechanisms are discussed.     

Tension-band wiring for fractures of the fifth metatarsal located in the junction of the proximal metaphysis and diaphysis

BACKGROUND: Fractures of the proximal fifth metatarsal, other than those involving the tuberosity, have a tendency to delayed union or even nonunion. HYPOTHESIS: Tension-band wire technique is a good alternative in treating fractures of the fifth metatarsal located in the proximal junction of the metaphysis and the diaphysis. STUDY DESIGN: Case series; level of evidence, 4. METHODS: Between 1996 and 2001, a total of 27 cases of proximal metaphysial/diaphysial fractures of the fifth metatarsal were treated with tension-band wiring. All of the patients had undergone prior unsuccessful nonoperative or operative treatment. The mean delay from the diagnosis of the fracture to the final operative procedure was 19.5 weeks (range, 6-48 weeks). RESULTS: The mean length of follow-up was 35 months (range, 12-70 months). All patients were able to return to their prior levels of activity. The mean time for union as shown on radiographs was 12.8 weeks, and the return to full activity took 8 to 20 weeks (mean, 14.7 weeks). There were no delayed unions, nonunions, or refractures during the follow-up. CONCLUSION: The tension-band wire technique seems to give good results in the treatment of proximal metaphysial/diaphysial fractures of the fifth metatarsal in cases of primary unsuccessful nonoperative treatment or primary unsuccessful intramedullary screw fixation.     

Transverse tibial stress fractures. A special problem

Five transverse tibial stress fractures have been reviewed. Two of three cases in the anterior midtibia and one in the proximal posteromedial tibia had radionuclide scans. These cases demonstrated minimal scan activity at the stress fracture site. This minimal scan activity in patients with a clinical history of pain and a tender mass suggests poor bone reparation and nonunion. One anterior midtibial stress fracture developed a complete fracture. A proximal anterior tibial ridge stress fracture revealed radiological and clinical evidence of healing.     

Stress fracture of the tarsal navicular

Stress fractures of the lower extremity are common among military members and athletes at all levels of participation. They typically occur when an individual begins a new or different type of physical training or during periods of abrupt increase in the level of training. Stress fractures represent an incomplete remodeling of bone that occurs secondary to repetitive mechanical loading. In response to this increased loading, the osteoclastic resorption of lamellar bone outpaces the ability of the osteoblasts to create new lamellar bone, eventually leading to structural failure. The following case report reviews the typical clinical presentation, imaging findings, and treatment of the tarsal navicular stress fracture.     

A review of nonoperative treatment of Jones' fracture

Sir Robert Jones, in 1902, described a transverse fracture of the proximal diaphysis of the fifth metatarsal, which he treated conservatively with good results. Since that time, classification into acute and chronic categories by several authors has been proposed and most agree with the relatively high incidence of non-union. Controversy exists concerning operative versus nonoperative primary treatment especially in athletes. The purpose of this study was to determine if nonoperative treatment could be used effectively in treating these fractures. A retrospective study of nine patients with 10 Jones' fractures was completed. The cases were categorized as acute or chronic by clinical history and radiographic appearance. The average age was 23.6 years. There were eight males and one female. In this group, competitive athletes sustained chronic fractures, while acute fractures occurred in nonathletes. Treatment consisted of a short leg nonweightbearing cast until radiographic and clinical healing occurred, followed by 6 weeks of limited activity. Mean clinical and radiographic union of chronic fractures was 9.4 weeks; acute fractures, 22 weeks. All competitive athletes returned to their preinjury level of competition at an average of 12 weeks following initiation of treatment. There was one refracture. Our data indicate that nonoperative treatment of early chronic or subacute fractures without intramedullary sclerosis can compare favorably with surgical treatment procedures reported in other studies in returning athletes to play postinjury. We suggest serious consideration be given to the method herein as a form of primary treatment of the early chronic Jones' fracture without intramedullary sclerosis.     

Non-union of the clavicle and delayed union of the proximal fifth metatarsal treated with low-intensity pulsed ultrasound in two soccer players

Operative treatment has become the treatment of choice in athletes and active patients in non-union of the clavicle and delayed union of the proximal fifth metatarsal. The purpose of this study was to review the short- and long-term clinical results of low-intensity pulsed ultrasound treatment in a non-union of the clavicle and in a delayed union of the proximal fifth metatarsal in 2 elite soccer players. In both patients, the treatment sessions were performed with an ultrasound signal that was composed of a burst width of 200+/-10% mus containing 1.5+/-5% MHz sine waves, with a repeating rate of 1+/-10% kHz and a spatial average temporal intensity of 30+/-30% mW/cm2. The application of the ultrasound was performed by the patients at home for 20 min/day for 3 months. The healing of the non-union of the clavicle was followed by MR imaging and of the delayed union of the proximal fifth metatarsal by radiographs. In both of the cases the end-results were excellent and the players could continue playing at the highest level. The ultrasound method was successful and afforded players a quick return to sport activity.     

Navicular stress fractures

Since the stress fracture of the tarsal navicular was first described in 1970, awareness of the injury has increased, and navicular stress fractures have represented up to 35% of stress fractures in recent series. However, these injuries remain difficult to diagnose and treat because of their often vague clinical presentation and the poor correlation between radiographic and clinical findings.