stress fractures dave haight, md sports medicine fellow april 2009
TRANSCRIPT
![Page 1: STRESS FRACTURES DAVE HAIGHT, MD Sports Medicine Fellow April 2009](https://reader035.vdocuments.us/reader035/viewer/2022062219/551804cb550346c6568b5325/html5/thumbnails/1.jpg)
STRESS FRACTURESSTRESS FRACTURES
DAVE HAIGHT, MD
Sports Medicine Fellow
April 2009
![Page 2: STRESS FRACTURES DAVE HAIGHT, MD Sports Medicine Fellow April 2009](https://reader035.vdocuments.us/reader035/viewer/2022062219/551804cb550346c6568b5325/html5/thumbnails/2.jpg)
OutlineOutline
• Pathophysiology• Risk Factors• Associations• Diagnosis• General Treatment• Specific Cases
![Page 3: STRESS FRACTURES DAVE HAIGHT, MD Sports Medicine Fellow April 2009](https://reader035.vdocuments.us/reader035/viewer/2022062219/551804cb550346c6568b5325/html5/thumbnails/3.jpg)
CAUSECAUSE
• Change in load
• Small number of repetitions with large load
• Large number of reps, usual load
• Intermediate combination of increased load and repetition
![Page 4: STRESS FRACTURES DAVE HAIGHT, MD Sports Medicine Fellow April 2009](https://reader035.vdocuments.us/reader035/viewer/2022062219/551804cb550346c6568b5325/html5/thumbnails/4.jpg)
PATHOPHYSIOLOGYPATHOPHYSIOLOGY
• Wolff’s Law: change in external stress leads to change in shape and strength of bone• bone re-models in response to stress
• ABRUPT Increase in duration, intensity, frequency without adequate rest (re-modeling)
• Stress fracture: imbalance between bone resorption and formation
• Microfracture -> continued load -> stress fracture
![Page 5: STRESS FRACTURES DAVE HAIGHT, MD Sports Medicine Fellow April 2009](https://reader035.vdocuments.us/reader035/viewer/2022062219/551804cb550346c6568b5325/html5/thumbnails/5.jpg)
EPIDEMIOLOGYEPIDEMIOLOGY
• 1% of general population
• 1-8% of collegiate team sports
• Up to 31% of military recruits
• 13-52% of runners
![Page 6: STRESS FRACTURES DAVE HAIGHT, MD Sports Medicine Fellow April 2009](https://reader035.vdocuments.us/reader035/viewer/2022062219/551804cb550346c6568b5325/html5/thumbnails/6.jpg)
RISK FACTORSRISK FACTORS
• History of prior stress fracture• Low level of physical fitness, non-athlete• Increasing volume and intensity• Female Gender• Menstrual irregularity• Diet poor in calcium• Poor bone health• Poor biomechanics
![Page 7: STRESS FRACTURES DAVE HAIGHT, MD Sports Medicine Fellow April 2009](https://reader035.vdocuments.us/reader035/viewer/2022062219/551804cb550346c6568b5325/html5/thumbnails/7.jpg)
RISK FACTORS contRISK FACTORS cont
• Prior stress fracture: • 6 x risk in distance runner and military recruits• 60% of track athletes have hx of prior stress
fracture• One year recurrence: 13%
• Poor Physical Fitness - muscles absorb impact• >1cm decrease in calf girth• Less lean mass in LE• Less than 7 months prior strength training
![Page 8: STRESS FRACTURES DAVE HAIGHT, MD Sports Medicine Fellow April 2009](https://reader035.vdocuments.us/reader035/viewer/2022062219/551804cb550346c6568b5325/html5/thumbnails/8.jpg)
INTRINSIC FACTORSINTRINSIC FACTORS
• Extreme arch morphologies:• Pes cavus• Pes planus
• Biomechanical factors:• Shorter duration of foot pronation• Sub-talar joint control• Tibial striking torque• Early hindfoot eversion
![Page 9: STRESS FRACTURES DAVE HAIGHT, MD Sports Medicine Fellow April 2009](https://reader035.vdocuments.us/reader035/viewer/2022062219/551804cb550346c6568b5325/html5/thumbnails/9.jpg)
EXTRINSIC FACTORSEXTRINSIC FACTORS
• Activity type and intensity
• Footwear• Older shoes
• Shock absorbing cushioned inserts
• Running Surface• Treadmill
• Track
![Page 10: STRESS FRACTURES DAVE HAIGHT, MD Sports Medicine Fellow April 2009](https://reader035.vdocuments.us/reader035/viewer/2022062219/551804cb550346c6568b5325/html5/thumbnails/10.jpg)
ASSOCIATIONSASSOCIATIONS
• Ballet:• Runners:• Sprinters: • Long dist runner:• Baseball, tennis: • Gymnasts: • Rowers, golfers:• Hurdlers:• Rowers, Aerobics:• Bowling, running:
Lumbar, femur, metatarsalTibia, metatarsalNavicular Femoral neck, pelvisHumerusSpine, foot, pelvisRibsPatellaSacrumPelvis
![Page 11: STRESS FRACTURES DAVE HAIGHT, MD Sports Medicine Fellow April 2009](https://reader035.vdocuments.us/reader035/viewer/2022062219/551804cb550346c6568b5325/html5/thumbnails/11.jpg)
Classic Clinical HistoryClassic Clinical History
• Change in training or equipment
• Gradual onset over 2 to 4 weeks
• Initially pain only with activity
• Progresses to pain after activity
• Eventually constant pain with ADLs
![Page 12: STRESS FRACTURES DAVE HAIGHT, MD Sports Medicine Fellow April 2009](https://reader035.vdocuments.us/reader035/viewer/2022062219/551804cb550346c6568b5325/html5/thumbnails/12.jpg)
DIAGNOSISHistory
DIAGNOSISHistory
• Sports participation • Significant change in training
• Hills, surface, intensity
• Dietary History: adequacy, Vit D, Calcium• Menstrual History• General Health• Occupation• Past medical history• Medications• Family history (osteoporosis)
![Page 13: STRESS FRACTURES DAVE HAIGHT, MD Sports Medicine Fellow April 2009](https://reader035.vdocuments.us/reader035/viewer/2022062219/551804cb550346c6568b5325/html5/thumbnails/13.jpg)
IMAGINGX-ray
IMAGINGX-ray
• Only ~ 30% positive on initial examination
• 10 - 20% never show up on plain films
• If a positive x-ray
• Localized periosteal reaction
• Radiolucent line
• Cancellous bone - band-like focal sclerosis
![Page 14: STRESS FRACTURES DAVE HAIGHT, MD Sports Medicine Fellow April 2009](https://reader035.vdocuments.us/reader035/viewer/2022062219/551804cb550346c6568b5325/html5/thumbnails/14.jpg)
Early Metatarsal Stress Fracture
Early Metatarsal Stress Fracture
![Page 15: STRESS FRACTURES DAVE HAIGHT, MD Sports Medicine Fellow April 2009](https://reader035.vdocuments.us/reader035/viewer/2022062219/551804cb550346c6568b5325/html5/thumbnails/15.jpg)
One Week Later…..One Week Later…..
![Page 16: STRESS FRACTURES DAVE HAIGHT, MD Sports Medicine Fellow April 2009](https://reader035.vdocuments.us/reader035/viewer/2022062219/551804cb550346c6568b5325/html5/thumbnails/16.jpg)
Bone ScanBone Scan
• 95% show up after 1 day
• Extremely sensitive but not as specific with up to 24% false-positive results (stress reaction)
• Differentiate between acute and old lesions
• Acute stress fracture: three phase positive
• Shin splint: delayed phase only
![Page 17: STRESS FRACTURES DAVE HAIGHT, MD Sports Medicine Fellow April 2009](https://reader035.vdocuments.us/reader035/viewer/2022062219/551804cb550346c6568b5325/html5/thumbnails/17.jpg)
MRI vs. bone scan, CJSM 2002
MRI vs. bone scan, CJSM 2002
• MRI less invasive, provided more information than bone scan and recommended for initial diagnosis and staging of stress injuries
• “Limited” MRI may be cheaper than bone scan at some institutions
![Page 18: STRESS FRACTURES DAVE HAIGHT, MD Sports Medicine Fellow April 2009](https://reader035.vdocuments.us/reader035/viewer/2022062219/551804cb550346c6568b5325/html5/thumbnails/18.jpg)
How I Decide Between an MRI and Bone Scan
How I Decide Between an MRI and Bone Scan
• MRI• Usually can be done more quickly (1 vs. 4
hours) and scheduled for a sooner date• No radiation• Better soft tissue detail
• Bone Scan• Covers a wider area of the body (if bilateral or
diffuse symptoms)• Sometimes easier to interpret• Cheaper
![Page 19: STRESS FRACTURES DAVE HAIGHT, MD Sports Medicine Fellow April 2009](https://reader035.vdocuments.us/reader035/viewer/2022062219/551804cb550346c6568b5325/html5/thumbnails/19.jpg)
RADIATION COMPARISONRADIATION COMPARISON
Study mSv relative radiation
Plain film foot <0.01 < 1.5 daysPlain film CXR 0.02 2.4 days
Plain film pelvis 0.7 3.2 mo
Tech-99 bone scan 3 (150 CXR) 1.2 yrs
CT L-spine 6 (300 CXR) 2.3 yrsCT abd / pelvis 10 (500 CXR) 4.5 yrs
![Page 20: STRESS FRACTURES DAVE HAIGHT, MD Sports Medicine Fellow April 2009](https://reader035.vdocuments.us/reader035/viewer/2022062219/551804cb550346c6568b5325/html5/thumbnails/20.jpg)
GENERAL TREATMENTGENERAL TREATMENT
• PROTECTION• Reduce pain• Promote healing• Prevent further bone damage• ADLs are permitted
• Stretching and flexibility exercises
• Cross-training (non-weight-bearing exercise)
• Modified rest for six to eight weeks (or until pain-free for two to three weeks)
![Page 21: STRESS FRACTURES DAVE HAIGHT, MD Sports Medicine Fellow April 2009](https://reader035.vdocuments.us/reader035/viewer/2022062219/551804cb550346c6568b5325/html5/thumbnails/21.jpg)
ACTIVITY MODIFICATIONACTIVITY MODIFICATION
• Activity should be pain free• Approximate desired activity
• Cycle• Swim• Walk• Elliptical• Deep water running• MUST BE PAIN FREE
![Page 22: STRESS FRACTURES DAVE HAIGHT, MD Sports Medicine Fellow April 2009](https://reader035.vdocuments.us/reader035/viewer/2022062219/551804cb550346c6568b5325/html5/thumbnails/22.jpg)
REHAB EXERCISEREHAB EXERCISE
• Address biomechanical issues: • Muscle inflexibility• Limb Length Discrepancy • Excessive pronation, pes cavus, pes
planus• Replace running shoes• Strength training
![Page 23: STRESS FRACTURES DAVE HAIGHT, MD Sports Medicine Fellow April 2009](https://reader035.vdocuments.us/reader035/viewer/2022062219/551804cb550346c6568b5325/html5/thumbnails/23.jpg)
Site of Stress FracturesSite of Stress Fractures
• Tibia - 39.5%• Metatarsals - 21.6%• Fibula - 12.2%• Navicular - 8.0%• Femur - 6.4%• Pelvis - 1.9%
![Page 24: STRESS FRACTURES DAVE HAIGHT, MD Sports Medicine Fellow April 2009](https://reader035.vdocuments.us/reader035/viewer/2022062219/551804cb550346c6568b5325/html5/thumbnails/24.jpg)
HIGH RISKHIGH RISK
• High Risk• Talus• Tarsal navicular• Proximal fifth
metatarsal
• Great toe sesamoid
• Base of second metatarsal
• Medial malleolus
• High Risk• Pars interarticularis• Femoral head• Femoral neck
(tension side)• Patella• Anterior cortex of tibia
(tension side)
![Page 25: STRESS FRACTURES DAVE HAIGHT, MD Sports Medicine Fellow April 2009](https://reader035.vdocuments.us/reader035/viewer/2022062219/551804cb550346c6568b5325/html5/thumbnails/25.jpg)
High-Risk Tibial Stress FxHigh-Risk Tibial Stress Fx
• Anterior, middle-third stress fractures are very concerning
• Tension side of bone
• May present like shin splints
• Seen more commonly in jumpers and leapers
• See “dreaded black line” on x-ray
• Heal very poorly
![Page 26: STRESS FRACTURES DAVE HAIGHT, MD Sports Medicine Fellow April 2009](https://reader035.vdocuments.us/reader035/viewer/2022062219/551804cb550346c6568b5325/html5/thumbnails/26.jpg)
Dreaded Black Line
![Page 27: STRESS FRACTURES DAVE HAIGHT, MD Sports Medicine Fellow April 2009](https://reader035.vdocuments.us/reader035/viewer/2022062219/551804cb550346c6568b5325/html5/thumbnails/27.jpg)
Management of High-Risk Tibial Stress Fx
Management of High-Risk Tibial Stress Fx
• Immobilization
• 4-6 months of rest
• Pulsed low-intensity U/S or electrical stimulation may decrease symptoms and speed return to activity, 30 minutes/day x 3-9 mos.
• IM rod for failed conservative or patient preference
![Page 28: STRESS FRACTURES DAVE HAIGHT, MD Sports Medicine Fellow April 2009](https://reader035.vdocuments.us/reader035/viewer/2022062219/551804cb550346c6568b5325/html5/thumbnails/28.jpg)
5th metatarsal stress fracture
![Page 29: STRESS FRACTURES DAVE HAIGHT, MD Sports Medicine Fellow April 2009](https://reader035.vdocuments.us/reader035/viewer/2022062219/551804cb550346c6568b5325/html5/thumbnails/29.jpg)
Types of Proximal 5th MT Fractures
Types of Proximal 5th MT Fractures
![Page 30: STRESS FRACTURES DAVE HAIGHT, MD Sports Medicine Fellow April 2009](https://reader035.vdocuments.us/reader035/viewer/2022062219/551804cb550346c6568b5325/html5/thumbnails/30.jpg)
Mgmt. of 5th Metatarsal Stress Fx
Mgmt. of 5th Metatarsal Stress Fx
• High risk for delayed union or nonunion
• Non-weight-bearing cast for 6 weeks versus IM screw fixation
![Page 31: STRESS FRACTURES DAVE HAIGHT, MD Sports Medicine Fellow April 2009](https://reader035.vdocuments.us/reader035/viewer/2022062219/551804cb550346c6568b5325/html5/thumbnails/31.jpg)
IM Screw FixationIM Screw Fixation
![Page 32: STRESS FRACTURES DAVE HAIGHT, MD Sports Medicine Fellow April 2009](https://reader035.vdocuments.us/reader035/viewer/2022062219/551804cb550346c6568b5325/html5/thumbnails/32.jpg)
Femoral Stress FxFemoral Stress Fx
• Primary presenting symptom is groin pain; possibly thigh or knee pain
• Hip motion may be painful
• Hop test
• Fulcrum test for shaft fx
![Page 33: STRESS FRACTURES DAVE HAIGHT, MD Sports Medicine Fellow April 2009](https://reader035.vdocuments.us/reader035/viewer/2022062219/551804cb550346c6568b5325/html5/thumbnails/33.jpg)
Femoral Neck Stress FxFemoral Neck Stress Fx
• Early diagnosis critical
• If x-rays negative, bone scan/MRI
• MRI diagnostic imaging of choice for femoral neck stress fractures
![Page 34: STRESS FRACTURES DAVE HAIGHT, MD Sports Medicine Fellow April 2009](https://reader035.vdocuments.us/reader035/viewer/2022062219/551804cb550346c6568b5325/html5/thumbnails/34.jpg)
Femoral Neck Stress FxFemoral Neck Stress Fx
• Compression side.• Inferior part of femoral neck
• Younger patients
• Less likely to become displaced
• Complications possible
• Treatment-non-weight bearing, followed by touch-down WB, then partial WB over a total of 8-12 weeks
![Page 35: STRESS FRACTURES DAVE HAIGHT, MD Sports Medicine Fellow April 2009](https://reader035.vdocuments.us/reader035/viewer/2022062219/551804cb550346c6568b5325/html5/thumbnails/35.jpg)
Femoral Neck Stress FxFemoral Neck Stress Fx
• Distraction side
• Superior cortex or tension side of neck
• High propensity to become displaced
• Frequent complications
• Treated acutely with internal fixation
![Page 36: STRESS FRACTURES DAVE HAIGHT, MD Sports Medicine Fellow April 2009](https://reader035.vdocuments.us/reader035/viewer/2022062219/551804cb550346c6568b5325/html5/thumbnails/36.jpg)
Tarsal Navicular Stress FxTarsal Navicular Stress Fx
• Consider in: Sprinters, Jumpers, Hurdlers, Basketball, Football
• Mean interval of 7 -12 months before diagnosis
• Vague mid-foot pain• Pain on dorsum of foot• Foot cramping
![Page 37: STRESS FRACTURES DAVE HAIGHT, MD Sports Medicine Fellow April 2009](https://reader035.vdocuments.us/reader035/viewer/2022062219/551804cb550346c6568b5325/html5/thumbnails/37.jpg)
![Page 38: STRESS FRACTURES DAVE HAIGHT, MD Sports Medicine Fellow April 2009](https://reader035.vdocuments.us/reader035/viewer/2022062219/551804cb550346c6568b5325/html5/thumbnails/38.jpg)
![Page 39: STRESS FRACTURES DAVE HAIGHT, MD Sports Medicine Fellow April 2009](https://reader035.vdocuments.us/reader035/viewer/2022062219/551804cb550346c6568b5325/html5/thumbnails/39.jpg)
Tarsal Navicular Stress FxTarsal Navicular Stress Fx
• X-rays usually negative• Bone scan vs. MRI vs. thin cut CT
![Page 40: STRESS FRACTURES DAVE HAIGHT, MD Sports Medicine Fellow April 2009](https://reader035.vdocuments.us/reader035/viewer/2022062219/551804cb550346c6568b5325/html5/thumbnails/40.jpg)
Mgmt. of Navicular Stress Fx
Mgmt. of Navicular Stress Fx
• Most studies suggest that allowance of weight-bearing immediately after diagnosis increases the non-union rate
• General/simple rules:• (+) bone scan/MRI/CT and/or incomplete fx-
NWB cast x 6-8 weeks, and then gradual rehab
• Complete fx and/or bony sclerosis- ORIF with compression screw +/- bone graft
![Page 41: STRESS FRACTURES DAVE HAIGHT, MD Sports Medicine Fellow April 2009](https://reader035.vdocuments.us/reader035/viewer/2022062219/551804cb550346c6568b5325/html5/thumbnails/41.jpg)
Orthopedic ConsultationOrthopedic Consultation
• High Risk Fracture sites• Femoral Neck - tension side• Navicular • 5th Metatarsal• Anterior tibial shaft
• High Level Athlete/Laborer
• Failed conservative therapy
![Page 42: STRESS FRACTURES DAVE HAIGHT, MD Sports Medicine Fellow April 2009](https://reader035.vdocuments.us/reader035/viewer/2022062219/551804cb550346c6568b5325/html5/thumbnails/42.jpg)
PREVENTIONPREVENTION
• Small incremental increases in training FITT• Shock absorbing shoe/boot inserts• Calcium 200mg, Vit D 800IU (27% decr.)• OCPs: sig increase in bone mineral density,
no impact on stress fracture rate• Modification of female recruit training:
• Lower march speed• Softer surface• Individual step length/speed• Interval training instead of longer runs
![Page 43: STRESS FRACTURES DAVE HAIGHT, MD Sports Medicine Fellow April 2009](https://reader035.vdocuments.us/reader035/viewer/2022062219/551804cb550346c6568b5325/html5/thumbnails/43.jpg)
Take Home PointsTake Home Points
• Avoid a delay in diagnosis, image early
• REST is a 4-letter word to athletes; thus advise relative rest, allowing for cross-training or unaffected body-training during the healing period
![Page 44: STRESS FRACTURES DAVE HAIGHT, MD Sports Medicine Fellow April 2009](https://reader035.vdocuments.us/reader035/viewer/2022062219/551804cb550346c6568b5325/html5/thumbnails/44.jpg)
Take Home PointsTake Home Points
• Correct underlying nutritional, hormonal or biomechanical abnormalities to promote healing and prevent recurrence
• Despite our best efforts, some athletes will never return to their pre-injury level of competition due to some specific stress fractures (navicular, femoral neck, anterior tibia)
![Page 45: STRESS FRACTURES DAVE HAIGHT, MD Sports Medicine Fellow April 2009](https://reader035.vdocuments.us/reader035/viewer/2022062219/551804cb550346c6568b5325/html5/thumbnails/45.jpg)
QUESTIONS?QUESTIONS?