Nagging Injuries in the Athlete: Tibial, 5th Metatarsal and Navicular Stress Fractures Kenneth J. Hunt, M.D. 2014 COA Annual Meeting Monterey, CA Disclosures

I have no potential conflicts of interest with regard to this presentation Nagging Injuries in the Athlete

Stress Fractures in the foot, ankle and lower extremity are very common in elite athletes Nagging Injuries in the Athlete

Stress fracture: A partial or complete bone fracture that results from repeated application of stress of a lower magnitude than the stress required for bone to fail in a single loading

Many occur as an acute injury after build-up of stress Nagging Injuries in the Athlete Who gets them? • Annual incidence of stress fractures in athletes estimated 2% to 21%. • Track and field – Distance runners – Sprinters • Basketball • Tennis • Volleyball • Soccer Stress Fractures in the Athlete The Burden • Up to 20% of Sports Medicine Visits • 80% are in Foot/Legs • “High Risk” stress fx: – Tibia – Navicular – Proximal 5th Metatarsal (Jones)

High risk of displacement, non-union or refracture, requires surgical decision-making

Fredericson et al. 2006. Top Magn Reson Imaging Risk Factors Stress Fractures

• Intrinsic risk factors: – Muscle fatigue/poor conditioning – Weakness/strength imbalance – Menstrual/hormonal irregularities – Lower limb malalignment – Foot structure (cavovarus) Unmodifiable – Height - Tall stature – Genetic predisposition Risk Factors Stress Fractures

Pes cavus = High arch foot Pes planus = Flatfoot

Varus Valgus Risk Factors Stress Fractures • Extrinsic risk factors – Excessive volume or intensity of training – Change in training regimen – Change in training surface – Worn-out training shoes – Cigarette smoking – Inadequate nutrition – • calories, calcium, vitamin D – Medications- • chronic steroid use Risk Factors Stress Fractures • Female Athlete Triad: – Disordered eating – Amenorrhoea/oligomenorrhoea – Osteopenia

• 50% increase in stress fracture risk

Barrack et al., 2014 AJSM High Risk Stress Fractures

• Tibia

– Posterior cortex Low risk – Anterior tibial cortex – Medial malleolus • Navicular High Risk • 5th Metatarsal (Jones fracture) High Risk Stress Fractures

• Tibia

– Posterior cortex Low risk – Anterior tibial cortex – Medial malleolus • Navicular High Risk • 5th Metatarsal (Jones fracture) Tibia Stress Fractures • Most common stress fx in active population – Military recruits – Running and jumping athletes (very little data) • Up to 75% of chronic leg pain in athletes • Posteromedial cortex is most common location Pathophysiology

• Disrupted bone homoeostasis and inadequate repair in the face of repetitive overload Pathophysiology

• Disrupted bone homoeostasis and inadequate repair in the face of repetitive overload • Wolff’s law – Remodeling of microdamage Julius Wolff Pathophysiology

• Disrupted bone homoeostasis and inadequate repair in the face of repetitive overload • Wolff’s law Tibia – Remodeling of microdamage • Repeated pull of the gastrocnemius/soleus complex Soleus Post contributes to failure the bone Tib. – Proximal third in young patients – Mid/distal 1/3 junction in runners Clinical Features • Pain with activity – Especially longer periods • Mild discomfort persistent pain • Eventually unable to participate/train • Pain persists after cessation of activity – Night pain • Exam: – Tenderness at midshaft tibia (medial border) – Swelling, erythema, warmth Radiographs • Normal in early stages • Lucency followed by Cortical thickening at 2-3 weeks 99Tc Bone Scan versus MRI • Bone scan pos at 2-8 days • MRI more sensitive and specific

MRI CT Bone Scan Sensitivity 88% 42% 74-90%

Specificity 95-100% 89-100% 33-47% Treatment Low Risk • Phase 1 – Rest from aggravating activities – Ice, NSAIDs, Diet – Usually No immobilization – Pool, elliptical, weights • Phase 2 – Graduated return when pain-free – Shoe wear and running surface – Functional orthotics, bracing • Shock absorption • Correct mechanical imbalance Treatment Low Risk • Other modalities – Bisphosphonates • Stewart et al., 2005, CJSM – Bone stimulators • Effective in delayed unions • Theoretical in stress fx • No evidence in stress fractures High Risk Stress Fractures

• Tibia

– Posterior cortex Low risk – Anterior tibial cortex – Medial malleolus • Navicular High Risk • 5th Metatarsal (Jones fracture) Tibial Stress Fractures Anterior Cortex • More common in jumpers – Rare in distance runners • Poor vascularity and repetitive loads • Dreaded black line on radiograph – Non-union – Bone scan may be normal Tibial Stress Fractures Anterior Cortex • More common in jumpers – Rare in distance runners • Poor vascularity and repetitive loads • Dreaded black line on XR – Non-union – Bone scan may be normal • MRI Scan – Confirm location/extent – Acuity Tibial Stress Fractures Anterior Cortex • Treatment – Immobilize NWB 6-8 weeks – Pneumatic leg brace – Electric stim up to 10 hrs per day • Return to sport – Radiographic healing – Resolution of symptoms • Surgery if no healing at 4-6 months – Sooner in elite athletes? Treatment • Surgical treatments – Excision and bone grafting (Green 1985 AJSM) – Drilling of defect (Rettig AJSM 1988) – Reamed IM Nailing (Varner et al., 2005 AJSM) • 11 tibia stress fractures (failed non-op) • All fractures healed (mean 3 months) • Return to sport by 4 months High Risk Stress Fractures

• Tibia

– Posterior cortex Low risk – Anterior tibial cortex – Medial malleolus • Navicular High Risk • 5th Metatarsal (Jones fracture) Medial Malleolar Stress Fractures

• Running/jumping athletes – Repeated dorsiflexion, pronation and rotation – Insidious onset of medial ankle pain Medial Malleolar Stress Fractures Clinical Features • History – Pain over medial malleolus – Swelling, no loss of ROM • Radiographs – May be negative up to 2 months – Bone scan or MRI – CT scan to confirm fracture Medial Malleolar Stress Fractures Treatment

• Modified rest 3-8 weeks – Transition to boot when pain-free – Gradual return to activity • Complete healing averages 6 months • Surgery – Any displacement – Fracture line on x-ray in high level athlete Medial Malleolar Stress Fractures Treatment

• Plate and screws Fracture • Graft for non-union • 4-6 weeks NWB • Return to sport - 4.2 months • No level 1 or 2 studies Medial Malleolar Stress Fractures Treatment

• Associated impingement lesion common – Jowett et al (2008, FAI) • Advanced imaging can usually detect • Consider arthroscopy to remove High Risk Stress Fractures

• Tibia

– Posterior cortex Low risk – Anterior tibial cortex – Medial malleolus • Navicular High Risk • 5th Metatarsal (Jones fracture) Navicular Stress Fracture Evaluation

• Diagnosis – Running athletes – “Ankle pain” – Navicular Tenderness • The “N” spot Navicular Stress Fracture Radiographs

• X-rays often normal Navicular Stress Fracture Radiographic Imaging

• Imaging – Bone scan/MRI – Positive before fracture appears Navicular Stress Fracture Radiographic Imaging

• Imaging – Early CT scan if stress fracture is suspected Navicular Stress Fracture Radiographic Imaging

• CT scan – Determines whether complete or incomplete – Surgery planning Navicular Stress Fracture Blood Supply

• Central hypovascular region – Only in 20% of patients – 60% with normal vascularity

McKeon et al. 2012 FAI Navicular Stress Fracture Treatment

“Incomplete” “Complete” I: Dorsal cortex III: Extends to plantar cortex

II: Extends to N-C joint Navicular Stress Fracture Treatment

“Incomplete” Stress Fx • In the athlete these tend to progress  screw fixation – 1-2 screws Navicular Stress Fracture Treatment

“Incomplete” Stress Fx • 20 yo basketball player • Negative x-rays Navicular Stress Fracture Treatment

“Incomplete” Stress Fx • 20 yo basketball player Navicular Stress Fracture Treatment

“Incomplete” Stress Fx • 20 yo basketball player Navicular Stress Fracture Treatment

“Incomplete” Stress Fx • 20 yo basketball player • Post-op – 6 weeks NWB – Early ROM – Return to play 4-6 months Navicular Stress Fracture Treatment

“Incomplete” Stress Fx • 20 yo basketball player • Post-op CT Navicular Stress Fracture Treatment “Complete” Stress Fx • In Athletes – without delay • Open bone grafting and screw fixation • Often need to debride joints Navicular Stress Fracture Results “Complete” Stress Fx • In non-athletes • Fixation is preferred by most • Role for conservative management? • Torg et al., 2010 AJSM – Non-op best for both complete and incomplete Non-op: 96% success Surgery: 82% success Nagging Injuries in the Athlete

• Posteromedial diaphysis Low risk • Anterior tibial cortex • Medial malleolus High Risk • Navicular • 5th Metatarsal (Jones fracture) What is a Jones Fracture? Definition= • A fracture of the 5th metatarsal at the metaphyseal-diaphyseal junction in the region the 4/5 intermetatarsal articulation Vascular water-shed region Jones Fracture The Problem

Non-operative Treatment – 72-76% heal by 5 months – Many fail to heal or refracture

Quill et al. 1995. Orthop Clin North Am Jones Fracture Treatment Surgical Treatment • Indications – Athlete • Acute/stress fx – Nonunion – Refracture

In Sports Medicine- Our Threshold to operate is decreasing! Jones Fracture Treatment

Operative goals • Expedite healing • More rapid recovery • Accelerated rehab • Decrease refracture risk Jones Fracture Treatment

Operative technique • Screw fixation – Percutaneous (no big incision) Jones Fracture Treatment

Operative technique • Percutaneus approach • (+/-) Bone graft or substitute Insert Screw “High and Inside”

HIGH & INSIDE Jones Fracture

Surgical treatment • Option to inject bone graft or BMA + DBM Jones Fracture Treatment

Aggressive postoperative management – Weight bearing at 2 weeks – Begin running in modified shoewear at 6 weeks (if clinically nontender) – Avg. return to play 8 weeks Post-Operative Bracing Clamshell Orthosis Post-Operative Bracing Clamshell Orthosis Post-Operative Bracing Custom Orthoses Gait Analysis Gait Analysis No Orthotic W/ Orthotic Jones Fractures Pitfalls

• Beware of Cavus Foot Jones Fractures Pitfalls

• Beware of Cavus Foot • Beware of Medial Cortex Penetration – Use multiple fluoro views Jones Fractures Pitfalls

• Beware of Cavus Foot • Beware of Medial Cortex Penetration • Beware of poor start point Jones Fracture Treatment

• Treatment of Refractures and non-unions • Revision Fixation • Larger diameter screw • ICBG, or BMA + DBM Jones Fracture Treatment

• 21 Elite Athletes • Mean Age: 27 yrs • Union: 100% • Ave Return 12 weeks – (8 weeks for primary)

Hunt et al. 2010 (Am J Sports Med) Jones Fracture Treatment Meta analysis - mostly Level 4 data • Return to sport ranged from 4 to 18 weeks • Non-operative treatment: union rate 76 % • Surgical treatment: union rate 96 % • Non-unions: – Treated non-operatively had a union rate of 44% – Treated surgically had union rate of 97 %

Roche and Calder, KSSTA (2013) 21:1307–1315 Summary Nagging injuries in the Athlete

• Stress Fractures are very common • Be aware of risk factors – good history • Pay attention to alignment – correct as needed • Get the imaging you need • Remember that sometimes surgery is the more conservative treatment Thank You 1. Pfeffer G, Bacchetti P, Deland J, et al: Comparison of custom and prefabricated orthoses in the initial treatment of proximal plantar fasciitis. Foot Ankle Int 20(4):214-221, 1999. 2. Crawford F, Thomson C: Interventions for treating plantar heel pain. Cochrane Database Syst Rev 3:CD000416, 2003. 3. Buchbinder R: Clinical practice: Plantar fasciitis. N Engl J Med 350:2159-2166, 2004. 4. Tisdel CL: Heel pain, in Orthopaedic Knowledge Update: Foot and Ankle 3. Rosemont, IL: American Academy of Orthopaedic Surgeons, 2003. pp 113-119. 5. Shmokler RL, Bravo AA, Lynch FR, et al: A new use of instrumentation in fluoroscopy controlled heel spur surgery. J Am Podiatr Med Assoc 78:194-197, 1988. 6. Snook GA, Chrisman OD: The management of subcalcaneal pain. Clin Orthop 82:163-168, 1972. 7. Davis PF, Severud E, Baxter DE: Painful heel syndrome: Results of nonoperative treatment. Foot Ankle Int 15(10):531-535, 1995. 8. American Orthopaedic Foot and Ankle Society: AOFAS Position Statement: Endoscopic and open heel surgery. Available at http://www.aofas.org/displaycommon.cfm?an=1subarticleenbr=31. 9. DiGiovanni BF, Nawocznski DA, Lintal ME, et al: Tissue-specific plantar fascia-stretching exercises enhances outcomes in patients with chronic heel pain. A prospective, randomized study. J Bone Joint Surg Am 85:1270-1277, 2003. 10. Rompe JD, Hopf C, Nafe B, Burger R: Low-energy extracorporeal shock wave therapy for painful heel: A prospective controlled single-blind study. Arch Orthop Traum Surg 115:75-79, 1996. 11. Hammer DS, Rupp S, Ensslin S, et al: Extracorporeal shock wave therapy in patients with tennis elbow and painful heel. Arch Orthop Traum Surg 120:304-307, 2000. 12. Ogden JA, Alvarez RG, Marlow M: Shockwave therapy for chronic proximal plantar fasciitis: A meta- analyis. Foot Ankle Int 23(4):301-308, 2002. 13. Chen H, Chen L, Huang T: Treatment of painful heel syndrome with shock waves. Clin Orthop Relat Res 387:41-46, 2001. 14. Sellman JR. Plantar fascia rupture associated with corticosteroid injection. Foot Ankle Int 15(7):376- 81, 1994. 15. Acevedo JI, Beskin JL: Complications of plantar fascia rupture associated with corticosteroid injection. Foot Ankle Int 19(2):91-97, 1998.