Rupture of the bone cortex can be demonstrated through computerized tomography and evidence of periostitis can also be detected in this manner. The sensitivity of computerized tomography is higher than radiography; however, compared with bone scintigraphy and magnetic resonance injury, the sensitivity for revealing stress fractures is low, resulting in a higher rate of false negatives C. Bone scintigraphy has traditionally been the test of choice in this situation, but has been supplanted by magnetic resonance imaging B.
Magnetic resonance imaging has numerous practical advantages over scintigraphy. It provides precise anatomical resolution, can differentiate a stress reaction from a stress fracture, as well as being a noninvasive, multiplanar exam that does not require radiation. It is more sensitive and specific, provides greater information and is capable of detecting pre-radiographic bone changes. The disadvantages include the higher cost, contraindications relating to claustrophobic patients and those with metal implants or surgical materials C.
Ankle Disorders: Causes, Symptoms, and Diagnosis
Follow-up using computerized tomography or magnetic resonance imaging may also be useful to monitor healing of the stress fractures and determining if there is a delay in healing that could require surgical intervention D. In cases of suspected stress fractures, plain radiography of the site of pain should be requested, with diagnosis in the majority of cases via more sensitive and specific imaging exams magnetic resonance imaging.
Various factors contribute to the pathogenesis of the disease, which may be classified into 2 sub-types: intrinsic and extrinsic. In general, extrinsic factors are related to the type and rhythm of training, the use of unsuitable footwear and sports equipment, precarious physical conditioning, the training location, environmental temperature and insufficient recovery time of previous injuries.
Intrinsic factors include age, sex, race, bone density and structure, hormonal, menstrual, metabolic and nutritional balance, sleep pattern and collagen diseases D 4 , 5 , 8 C. Prospective and retrospective studies show a higher incidence among Caucasians. When compared to American black and Hispanic individuals, white individuals are more susceptible to stress fractures D.
With regard to genetic factors, studies on identical twin military recruits submitted to the same treatment in quantity, duration and intensity reveal fatigue fractures in the metatarsal bones in both B. In relation to biomechanical factors, a high longitudinal arch of the foot, difference in the length of the lower limbs and a marked varus foot associated with multiple stress fractures have been observed B 15 , 21 C.
Cavovarus feet have recently been gaining more attention as being a significant risk factor for various conditions of overuse, especially stress fractures. This shape of foot is known for being relatively rigid, with weak capacity for attenuating shock C. In cases of suspected stress fractures, intrinsic and extrinsic factors that favor the occurrence of injury should be investigated. The investigation of these risk factors aids diagnosis and treatment. The main diseases that should be discarded are those resulting from repetitive and excessive effort and that affect the soft tissues that surround the area of bone affected, such as muscle injuries, bursitis, tendinopathy, splints, infections, cancer and compartment syndrome C 28 B.
Dance Injury Treatment
Female athletes are more likely to developing stress fractures C. A general plan can be established divided into two phases: phase I, or modified rest, is characterized by pain control through the use of anti-inflammatory drugs, physiotherapy methods for analgesia and kinesiotherapy, weight-bearing permitted in daily activities and maintenance of aerobic fitness without causing abnormal stress responses in the affected segment.
Phase II begins from the moment in which the athlete no longer presents complaints of pain, which generally occurs within 10 to 14 days from the start of symptoms. A gradual return to the sport is allowed based on the correction of intrinsic and extrinsic factors D. Most stress fractures can be treated conservatively. This implies immobilization in a boot, without sustaining the foot until the symptoms have disappeared, generally around 6 to 8 weeks.
Impact activities are avoided, but low impact workouts such as swimming, cycling, and elliptical machines can be continued to maintain aerobic fitness. Frequent physical exams are useful to identify the resolution of symptoms. Nutritional considerations are important as dietary deficiencies may contribute to the development of stress fractures.
Recent data recommends early surgical treatment of fractures with a high risk of stress to elite athletes owing to the high risk of dislocation and non-consolidation. Early surgical treatment is also associated with a quicker return to the sport B 15 C 49 , 50 D. Electrical stimulation has also been used for the treatment of stress fractures with satisfactory results C.
The treatment of stress fractures in the feet and ankles of athletes is, in most cases, conservative, through the use of analgesic methods, relative rest, not bearing weight, immobilization of the limb, maintaining physical condition with low impact exercise and correcting risk factors. Despite greater awareness about this injury, the treatment of stress fractures in the foot and ankle continue to be a particularly problematic issue, including the navicular bone, fifth metatarsal and medial malleolus. These injuries are often not diagnosed and may occur at a higher frequency than that actually observed.
For example, the navicular bone has a risk of delayed healing because of the poor areas of blood supply, and stress fractures of the medial malleolus have a high rate of dislocation and lack of consolidation. These injuries frequently require surgical stabilization D.
Stress fractures in the navicular bone are often difficult to diagnose. If untreated, they can result in osteoarthritis and delayed consolidation C 34 - 36 B. Given that the published data reveals a high occurrence of delayed consolidation, importance should be given to immediate surgical treatment, especially when the fracture extends to the navicular body or up to the second cortex of the navicular bone B. Generally, bone graphs are reserved for chronic fractures and delayed consolidation and nonunions C. A stress fracture in the fifth metatarsal diaphysis is defined as a stress fracture of the proximal zone of the bone immediately distal to the anatomical area of the Jones fracture C 41 B.
Various surgical treatment methods bone grafts C , 24 , 41 tension bands D 23 and intramedullary screws have been proposed. Fixation with intramedullary screws is the method recommended for the treatment of stress fractures by the majority of authors in the literature C 44 , 47 B. The treatment of stress fractures in the medial malleolus, and the distal end of the fibula depends on several factors. The presence of a fracture line, deviated fracture and athletic participation in the season may influence treatment decisions D. The presence of a fracture line detectable via radiography, especially in high level athletes, or deviation of the fracture is reported as an indication for surgical intervention.
Surgical treatment consists in closed or open reduction and internal fixation with screws B 15 C. Surgical treatment is indicated in cases where the fracture occurs in the shear zone, the location most disposed to delayed consolidation, nonunion or refractures. The best manner of treating stress fractures is prevention. The attending physician is responsible for knowing their athlete well, seeking to detect concurrent intrinsic and extrinsic factors for the injuries caused by microtrauma from repetition, and correcting them D. The prevention of injuries and prognosis are of particular importance to competitive athletes as the objective is not only to start participating again, but to compete at a high level, preventing long term consequences.
Injury prevention strategies and programs are a vital part of the education and training of athletes at all levels C. It is important to educate athletes that continuous pain lasting 3 weeks is a warning sign for the body, and that early diagnosis leads to quicker recovery B. Changes in footwear and the surface for practicing training may help to reduce the number and severity of injuries in relation to the feet and ankles of athletes D. Worn footwear may have a role in increased injury rates.
Stress Fracture of the Foot
Use of light and flexible shoes with less support of the midfoot may places the athlete at risk, as these may offer less protection against potentially harmful forces in the foot A. Running shoes with neutral insoles have recently demonstrated a statistically significant reduction in plantar pressure in athletes with cavus feet A. In relation to refracture, it is well known that returning to sport early is an important risk, therefore athletes should be warned about the complication C.
The decision to return to sport is based on the location of the injury and its corresponding potential for healing and risk of significant complication D. This simplification provides an approximate assessment of the healing time, with high reliability C 35 D. Healing time is defined as the time required to return to full activity without any symptoms. This time was significantly greater in scintigraphy with high grade stress injuries compared with low grade ones. This grading of stress injury provided by scintigraphy was a significant indicator for the time until full recovery B.
Low risk stress fractures generally heal when the athlete is limited to activities without pain, over a period of 4 to 8 weeks. This healing period is an ideal time to assess the modifiable risk factors that could decrease the change of injuries recurring. A gradual increase in activity daily life activities should begin after the athlete is free from pain and the site is not injured D. For stress fractures in the navicular bone, the time for returning to sports activities and condition for returning to competitions is around 4 months B.
B 37 reported on the time to returning to full activity among 55 patients with stress fractures of the navicular bone treated conservatively.
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Considerations related to returning to training for athletes with high risk stress fractures are more difficult than in low risk fractures. In general, returning should only be recommended after suitable treatment and when the injury has completely healed, given that high risk fractures have the most frequent complications, such as delayed consolidation and refracture D.
Returning to practicing sports should be conducted gradually after consolidation of the fracture, which depends on the grade and location of the fracture, with greater rest time required for high risk fractures. Other guidelines at www. Fitch KD.
Stress fractures of the lower limbs in runners. Australian Fam Phys ; Stress fractures. Current concepts os diagnosis and treatment. Sports Med ;22 3 Stress fractures in athletes: a study of cases. Fractures of the Fifth Metatarsal. Our team of specialists and staff believe that informed patients are better equipped to make decisions regarding their health and well being.
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In an avulsion fracture, a small piece of bone is pulled off the main portion of the bone by a tendon or ligament. This type of fracture is the result of an injury in which the ankle rolls. Avulsion fractures are often overlooked when they occur with an ankle sprain. Jones fracture.
Jones fractures occur in a small area of the fifth metatarsal that receives less blood and is therefore more prone to difficulties in healing. A Jones fracture can be either a stress fracture a tiny hairline break that occurs over time or an acute sudden break.
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Jones fractures are caused by overuse, repetitive stress, or trauma. They are less common and more difficult to treat than avulsion fractures. Most stress fractures occur in the bones of the foot and lower leg, which carry the weight of the body. The most common locations of stress fractures are the second and third metatarsals of the foot. Stress fractures are also common in the heel, in the outer bone of the lower leg, and in the navicular a bone in the top of the foot. See illustration.