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Objectives Stress Fractures in Athletes
• Define the history and physical exam findings of stress fractures • Recognize diagnostic parameters and tests for Health Care That Works Conference 2017 stress fractures Dr. Ashley D. Zapf • Describe treatment options for stress fractures in athletes
Disclosures Bone Remodeling
• Dynamic process of resorption and formation of bone None • Normally repetitive loading of a bone causes microdamage that can be repaired • If there is a disruption in the repair process or there is too much repetitive loading, we can develop stress fractures
Risk Factors for Stress Exam Fractures • Bony Tenderness • **History of stress fractures** • Can compare to • Increase in volume or intensity of activity/sport contralateral side • Poor biomechanics • Dorsal and plantar foot • Osteopenia/Osteoporosis • Fulcrum Test Calcium/Vitamin D Deficiency • • Stork Test (one leg hyperextension) • Low BMI • Hop Test Female • Fulcrum Test Stork Test • Menstrual Irregularity
https://musculoskeletalkey.com/wp-content/uploads/2016/11/A320567_1_En_8_Fig9_HTML.jpg
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Imaging Stress Fracture Treatment • Xrays • Stress fractures may not show up on xray • Bone Scan • Sensitive, not specific • If a low risk stress fracture, most will heal with • Can stay positive for a year after healing activity modification and relative rest for 4-8 • *MRI weeks • Sensitive and specific Immobilization and protected weightbearing • CT • • Can help define fracture line/healing • CT SPECT for lumbar stress fracture
High Risk Stress Fractures High Risk Stress Fractures
• Certain fracture locations are considered high • Femoral neck (tension side) risk • Anterior cortex tibia (“dreaded black line”) • Medial malleolus • High risk stress fractures have a tendency to • Talus progress to true fractures, nonunion, require • Navicular th surgery, or recur • Proximal 5 metatarsal • Sesamoids • Pars (spine) • Patella
High Risk Stress Fractures Case 1
• Any suspected high risk stress fracture should be • 14yo cheerleader presents with a 3 week hx of treated with immobilization and non-weightbearing left foot pain. She sustained a hyperflexion injury until ruled out to the left great toe while preforming jumps at • Treatment includes strict non-weightbearing, immobilization. Failure of conservative treatment will practice. Pain has been worsening with time, require surgery. and is now present at rest. • Athlete will need to be healed with a normal exam and • No hx of stress fractures. Regular menstrual painless functional activity prior to return to play. cycle.
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Exam Xrays normal
• No tenderness to palpation of the great toe nor 1st metatarsal shaft. No deficits of great toe. • (+)Tenderness to palpation of the dorsal and plantar aspect of the 2 nd and 3 rd metatarsal shafts • (+)Hop Test
MRI Left Foot MRI Left Foot
2nd metatarsal Medial cuneiform, navicular
3rd metatarsal
MRI Left Foot Treatment
• Diffuse edema throughout 2 nd metatarsal with • Dorsal Navicular Stress Fracture midshaft fracture • Non-weightbearing in cast x6-8 weeks Edema at the base of the 3 rd metatarsal • When non-tender and pain free, will transition to • walking boot and rehab in boot until week 11-12 • Edema dorsal aspect of the navicular as well as • If tenderness or pain persists, refer for surgical eval in the medial, intermediate and lateral cuneiform • Multiple stress fractures • Rule out low Vitamin D and Calcium levels • Rule out Energy Deficiency/Female Athlete Triad
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Female Athlete Triad Female Athlete Triad
• Spectrum of 3 interrelated conditions: • Presentation of multiple stress fractures should • Low Energy Availability (inadvertently or through raise concern for the existence of pathology disordered eating) related to the Female Athlete Triad • Menstrual Dysfunction • Stress fractures are more common in female • Low Bone Mineral Density athletes with low bone mineral density and menstrual dysfunction http://journals.lww.com/cjsportsmed/_layouts/15/oaks.journals/ImageView.aspx?k=cjsportsmed:2014:03000:00 002&i=FF1&year=2014&issue=03000&article=00002&type=Fulltext
Energy Availability Low Energy Availability • Energy Availability (EA) is the amount of energy available for daily physiological functions • Deficit in EA may be unintentional (increasing (growth, thermoregulation, etc) that remains after exercise without increasing kcal) or due to exercise disordered eating (Anorexia, Bulimia, etc)
www.femaleathletetriad.org
Low Energy Availability Low Bone Mineral Density
• Low EA can: • Greater fragility and less repair • Decrease muscle strength • Increased risk of stress fractures, fractures, and • Limit anaerobic activity irreplaceable bone loss both now and throughout • Limit endurance a lifetime • Increase risk for musculoskeletal injury • Cause amenorrhea • Lead to low bone mineral density
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Low Bone Mineral Density Low Bone Mineral Density
• No longer use the terms “osteoporosis” or “osteopenia” in • *Exception is in weight bearing athletes* premenopausal females unless secondary cause present Low BMD is Z-score < -1 (ie malnutrition) • Weight bearing athletes should have a higher BMD than • Z-score < -2 “BMD below expected range for age” • the general population due to repetitive mechanical • Z-score > -2 “BMD within the expected range for loading age” • Z-score < -1 in these athletes may be enough to predispose to fracture
De Souza MJ, Nattiv A, Joy E, Misra M, Williams N, et al. 2014 Female Athlete Triad Coalition Consensus Statement on Treatment and De Souza MJ, Nattiv A, Joy E, Misra M, Williams N, et al. 2014 Female Athlete Triad Coalition Consensus Statement on Treatment and Return to Play of the Female Athlete Triad: 1st International Conference Held in San Francisco, CA, May 2012, and 2nd International Return to Play of the Female Athlete Triad: 1st International Conference Held in San Francisco, CA, May 2012, and 2nd International Conference Held in Indianapolis, IN, May 2013. Clinical Journal of Sport Medicine. 2014 Mar; 24(2): 96-119. Conference Held in Indianapolis, IN, May 2013. Clinical Journal of Sport Medicine. 2014 Mar; 24(2): 96-119.
Case 2 Exam
• 15yo decathlon/track athlete presents with a 4 month history of left low back pain. The pain only occurs with • No tenderness to palpation of the spinous long and triple jump, but persists for 8 hours afterwards. process or paraspinal musculature He has rested from jumping over the past 4 months, • (+)Left sided low back pain with extension and however, pain recurs when attempting to resume triple or facet loading long jump. • Negative Stork Test
Xrays without fracture MRI Lumbar Spine
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MRI Lumbar Spine Spondylolysis Risk for nonunion or progression to spondylolisthesis • Pathologic high signal involving pars interarticularis L5 bilaterally indicating stress injuries bilateral left worse than right
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Treatment Case 3
• Complete rest from athletics until pain free with • 15yo cross country runner presents with a 1 activities of daily living month hx of left tibia pain, mid-shaft. He • Progress to “relative rest” and rehabilitation continued to run until coach noticed his antalgic through physical therapy running form and removed him from participation. • Avoid extension based activities/athletics until • Until recently, he was running 6+ miles daily with clinically healed a 10-12 mile run 1x/week.
Cortical irregularity and periosteal reaction Exam Xrays in midshaft of tibia, posteriorly
• (+)Tenderness to palpation mid-anterior tibia and into medial gastroc • (+)Hop Test
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MRI Left Lower Leg MRI Left Lower Leg
• Focal marrow edema and periosteal edema mid left tibia (posterior cortex) consistent with stress fracture
Treatment Case 4
• Period of protected weightbearing (4-6 weeks) • 53yo runner presents with a 4 month hx of right • Physical therapy prior to return to sport anterior knee pain which started after hill running • Possible surgical intervention if while out of town. She rested x3 weeks then • Failure of symptom improvement with rest increased her mileage by 30% per week. She • Presence of a “dreaded black line” on xray also participated in 8 weeks of physical therapy • Indicative of anterior tibial stress fracture (referred by her PCP). Despite interventions, pain has been worsening.
http://bjsm.bmj.com/content/bjsports/35/1/74.full.pdf
Exam Xrays normal
• (+)Tenderness to palpation along patellar facets. No other tenderness throughout. • (+)Clarke’s Test
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MRI Right Knee MRI Right Knee
• Multifocal areas of bone marrow edema in the patella, femur, and tibia reflecting multiple areas of stress reaction
Treatment Case 5
• 14yo baseball player presents for a pre- • Patellar Stress Reaction participation physical c/o right lateral foot pain. • Non-weightbearing/protected weightbearing x6+ weeks He recalls hitting his foot on a piece of furniture • When non-tender and pain free, transition to physical about 6 weeks prior. Pain has worsened over therapy the past 3 weeks causing him to alter his gait. • Multiple areas of stress reaction • Rule out low Vitamin D and Calcium levels • Rule out osteoporosis with DEXA Scan
Exam Xrays normal
• (+)Tenderness to palpation along the right 5 th metatarsal shaft • No other tenderness to palpation throughout
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Treatment Follow-up
• Diagnosed with right foot contusion • Pt noted overall improvement in his right 5 th • Wear supportive athletic shoes for comfort metatarsal pain, however, he noted continued • Follow-up in 2 weeks for re-evaluation right foot pain with “push-off” and running activities. • He also mentioned that his right heel had been hurting “for awhile,” but did not report this during his initial evaluation.
Exam MRI Right Foot
• (+)Tenderness to palpation of the medial and lateral calcaneus • (+)Squeeze Test • (+)Tenderness to palpation along 5 th metatarsal shaft, dorsal/plantar aspect
• MRI right foot ordered for further evaluation
MRI Right Foot Treatment
• Bone marrow edema within the dorsal aspect of the calcaneus and within the base of the 4 th • Walking boot for 4-6 weeks. He can participate metatarsal consistent with insufficiency type in low impact activity (ie walking, stationary bike) fractures as long as he is pain free. • Multiple stress fractures • Rule out low Vitamin D and Calcium levels
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Take Home Points References
De Souza MJ, Nattiv A, Joy E, Misra M, Williams N, et al. 2014 Female Athlete Triad Coalition Consensus Statement on Treatment and Return to Play of the Female Athlete Triad: 1st International Conference Held in San Francisco, CA, May 2012, and 2nd International Conference Held in Indianapolis, IN, May 2013. Clinical Journal of Sport Medicine. 2014 Mar; 24(2): 96-119.
Eiff MP, Hatch R, Higgins MK. Fracture Management for Primary Care. Philadelphia: Saunders, 2012. • Certain bones are concerning for high risk stress “Female Athlete Triad Coalition: An International Consortium.” n.p., n.d. Web. 27 September 2016. www.femaleathletetriad.org Harrast MA, Finnoff JT. Sports Medicine Study Guide and Review for Boards. New York: Demos Medical, 2012.
fractures Hobart JA, Smucker DR. The Female Athlete Triad. American Family Physician. 2000 Jun; 61(11):3357-3364. • If there is suspicion of a high risk stress fracture, treat Kaeding CC, Yu JR, Wright R, Amendola A, Spindler K. Management and Return to Play of Stress Fractures. Clinical Journal of Sport Medicine . 2005 Nov; 15(6): 442-447. Lebrun CD, Rumball JS. Female Athlete Triad. Sports Medicine and Arthroscopy Review . 2002 Mar; 10(1): 23-32.
accordingly (ie non-weightbearing) until ruled out with Nattiv A, Loucks AB, Manore MM, Sanborn CF, Sundgot-Borgen J, Warren MP. The Female Athlete Triad. Medicine & Science In Sports & Exercise. 2007 Oct; 39(10): 1867-82. MRI • Failure of conservative treatment of a stress fracture may warrant surgical intervention • Multiple stress fractures warrant further work-up
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