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Stress Fracture
Aka: Stress Fracture- Epidemiology: Relative Risks
- Women > Men
- Relative Risk = 3.5
- White males > Black males
- Relative Risk = 4.7
- White females > Black females
- Relative Risk = 8.5
- Women > Men
- Mechanisms of Injury
- Weight bearing
- Muscle forces
- Muscle Strength increases faster than bone strength
- Muscle Fatigue
- Risk factors
- Repetitive activity
- Increases in intensity, frequency, and loading
- Too fast
- Too far
- Too soon
- Biomechanical forces
- Over pronators or Supinators
- Hallux Valgus
- Genu Varum or genu valgus
- Leg Length Discrepancy
- External hip rotation
- Changes in foot gear or training surface
- Muscle Fatigue
- Systemic Diseases that weaken bone
- Rheumatoid Arthritis
- Systemic Lupus Erythematosus
- Osteoarthritis
- Pyrophosphate Arthropathy
- Renal Disease
- Osteoporosis (Female Athlete Triad)
- Joint Replacement
- Nutritional deficiency (e.g. dieting)
- Other Associated risk factors
- Tobacco Abuse
- Alcohol >10 drinks per week
- Female Athlete Triad
- Pathophysiology: Common Stress Fracture Sites
- Tibia Stress Fracture (23% of Stress Fractures)
- Metatarsal Stress Fracture (16% of Stress Fractures)
- Fibula Stress Fracture (15% of Stress Fractures)
- Tarsal Navicular Stress Fracture
- Calcaneal Stress Fracture
- Medial Malleolus Stress Fracture
- Femoral Neck Stress Fracture (6%)
- Femoral Shaft Stress Fracture
- Pubic Ramus Stress Fracture
- Pelvic Stress Fracture (1-2%)
- Seen almost exclusively in women
- Lumbar Stress Fracture
- Coracoid process Stress Fracture
- Humerus Stress Fracture
- Olecranon Stress Fracture
- Symptoms
- Deep ache following rapid training change
- Pain progression
- Start: Pain after activity
- Next: Pain with activity
- Next: Pain with walking (at presentation in 81% of patients)
- Last: Pain at rest
- Night pain rarely occurs
- Consider another diagnosis
- Signs
- Fracture site intense localized pain
- Specific Tests for leg or pelvis Stress Fracture
- Fulcrum Test
- Hop Test
- Poor Specificity (common finding in Shin Splints)
- Batt (1998) Med Sci Sports Exerc 30(11): 1564-71 [PubMed]
- Differential Diagnosis
- Primary benign Bone Neoplasm
- Infections
- Chronic or Subacute Osteomyelitis
- Chronic Musculoskeletal Soft Tissue Injury
- Metastatic Neoplasm to bone
- Primary Malignant Bone Neoplasms
- Nerve Compression Syndromes
- Herniated Intervertebral Disc
- Osteoarthritis
- Hypertrophic Pulmonary Osteoarthropathy
- Imaging
- Overall imaging approach (preferred)
- Step 1: XRay negative and Stress Fracture suspicion persists
- Step 2: Repeat XRay in 2-3 weeks is negative and Stress Fracture suspicion persists
- Step 3: Obtain MRI (preferred) or bone scan
- Imaging modalities
- Stress Fracture XRay
- Stress Fracture Bone Scan
- Stress Fracture CT
- Stress Fracture MRI
- Ultrasound is being investigated for specific Stress Fracture sites (e.g. Metatarsal Stress Fracture)
- Overall imaging approach (preferred)
- Management
- Rest for 4-7 weeks (may require up to 3 months)
- Activity should be pain-free only
- Non-weight bearing until pain free while walking
- Tibia Stress Fracture
- Femoral Stress Fracture
- Analgesia
- Acetaminophen is preferred over NSAIDS
- NSAIDS may delay healing
- Acetaminophen is preferred over NSAIDS
- Immobilization
- Short-leg Casting or CAM-Walker Indications
- Non-compliance
- High-risk for non-union
- Navicular Stress Fracture
- Metatarsal Stress Fracture
- Pneumatic brace (Air cast)
- Support results in quicker recovery and less pain
- Indicated in tibial and fibular Stress Fractures
- Short-leg Casting or CAM-Walker Indications
- Active rest (cross training)
- Consider formal rehabilitation program with physical therapy for strength and Stretching
- Goals
- Cardiovascular conditioning
- Flexibility
- Proprioception
- Strength
- Activities
- Swimming
- Pool Running with float vest
- Biking
- Stair climbing machines (later stages)
- Surgery
- Indications
- High Risk Fractures for non-union
- Non-healing Fractures
- Specific high risk sites
- Tarsal Navicular Stress Fracture
- Proximal anterior Tibia Stress Fracture
- Base of fifth Metatarsal Stress Fracture
- Femoral Neck Stress Fracture
- Indications
- Experimental: Electromagnetic field devices
- Questionable efficacy
- High cost
- Rest for 4-7 weeks (may require up to 3 months)
- Prevention
- Do not increase Exercise intensity >10% per week
- Stretch and warm-up before Exercise
- Choose level Running surfaces
- Shoes should be light weight and in good condition
- Consider Orthotics for biomechanical factor correction
- Shock-absorbing insoles may be beneficial
- Osteoporosis Prevention (unclear efficacy)
- Consider calcium supplement 1000 mg orally daily
- Consider Vitamin D 800 IU orally daily
- Reference