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Sports and Exercise Medicine iBSc > Bone Stress Injuries > Flashcards

Bone Stress Injuries Flashcards

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1
Q

Bone stress injury

A

Gradual injury to the bone
Stress fracture is the end of the spectrum
One of main overuse injuries

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2
Q

Bone stress injury- is … to diagnose

A

Difficult

Mimic other overuse injuries

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3
Q

Injuries in track and field athletes

A

Overuse injuries are majority

From those, 15% are bone stress injuries

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4
Q

Lower limb bone stress injuries location

A

51% tibia > metatarsal > navicular

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5
Q

Location can contribute to

A

Risk of healing
Complications
Surgery
Risk of non-union

High risk BSI lead to delayed diagnosis + treatment, which leads to increase in the above

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6
Q

Low risk areas BSI

A 
Posteromedial border of tibia
Femur
1-4th metatarsals
Ribs
Ulna
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7
Q

High risk areas BSI

A

Anterior tibia
Navicular
Femoral neck
5th metatarsal

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8
Q

BSI more common on which side for track and field runners

A

Left Hand Side

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9
Q

BSI Grade 1

A

Symptoms occur end of training
TUSA (+-)
Endosteal marrow oedema
Return to Play 3-4 weeks

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10
Q

BSI Grade 2

A

Symptoms occur mid of training
TUSA (+-)
Periosteal + endosteal marrow oedema
RTP 5-8 weeks

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11
Q

BSI Grade 3

A

Symptoms occur whole training
TUSA (+)
Periosteal + endosteal marrow oedema + soft tissues oedema
RTP 9-16 weeks

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12
Q

BSI Grade 4

A

Symptoms occur during daily activities
TUSA (+)
Fracture line
RTP 16+ weeks

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13
Q

BSI History

A

Sport
Event
Training intensity
Previous BSI

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14
Q

BSI Symptoms

A

Gradual exercise related leg pain
Progressively worse
No night pain
Intermediate pain

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15
Q

BSI clinical evaluation

A 
Localised pain
Lumbar spine
Hip
One leg hop
One leg extension
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16
Q

BSI Diagnostic test

A

Therapeutic USS- to assess BSI, compare to the other side

Positive is the feeling of pain during TUS assessment

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17
Q

TUSS

A

Therapeutic USS

+ve if feeling of pain during TUS assessment

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18
Q

Gold standard for BSI

A

MRI

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19
Q

BSI MRI- Grade 1

A

Endosteal marrow oedema

TUS +/-

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20
Q

BSI MRI- Grade 2

A

Periosteal and Endosteal marrow oedema

TUS +/-

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21
Q

BSI MRI- Grade 3

A

Grade 2 + soft tissue oedema

TUS +

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22
Q

BSI MRI- Grade 4

A

Fracture line

TUS +

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23
Q

BSI MRI- If nefative

A

Plain XR

No findings in early stages, usually from 4-6 weeks

24
Q

BSI differential diagnosis

A 
MTSS 
CSS
Radiculopathy
Popliteal artery entrapment
Bone contusion
Osteomyelitis
Neoplasm
Lymphoma
Leukemia
25
Q

MTSS

A

Traction on tibia from tibialis posterior

26
Q

PAE

A

Pain in uphill training

27
Q

Differential diagnoses diagnosis

A

Based on clinical symptoms
TUSA (gives early assessment)
MRI

28
Q

BSI treatment- if MRI +

A 
Blood test (calcium VitD)
CT (to ensure bone oedema isn't masking a fracture line)
29
Q

BSI treatment- if MRI -

A

BSI grade 1

30
Q

BSI treatment if TUSA - and XR -

A

DD or treat as BSI grade 1

31
Q

BSI if high risk of non-union

A

Referral and operative fixation may be considered

32
Q

BSI Management

A 
Control pain
After at least 1 week pain free:
Modify training
Functional RTP
RTP
33
Q

BSI management- Control pain

A

NWB (5+ days)
Swimming, core, stability
Local treatment- low intensity pulsed TUS, ESWT?

34
Q

BSI management- modify training

A

Low intensity TUS, ?ESWT

Deal with modifiable RFs

35
Q

BSI management- Functional RTP

A

Sport specific

10% increase every 10 days (intensity, duration)

36
Q

BSI management- RTP

A 
Symptom free TUS or threshold markedly increased
Grade 1- 4 weeks
Grade 2- 8 weeks
Grade 3- 10-16 weeks
Grade 4- 16+ weeks
37
Q

BSI management- modifying training load

A

Alter G treadmill
Underwater running
Swimming
Core

38
Q

BSI management- medications

A

Calcium D3
Vit D
NEVER NSAIDs as mask symptoms

39
Q

BSI management- physio modalities

A

Can benefit from local treatment

TUSA, pulsed USS, ESWT, exogen is a portable TUSA

40
Q

BSI management- predisposing factors

A 
Biomechanics
Running style
Footwear
Orthoses
Nutrition
41
Q

RFs for Stress Fractures

A

Intrinsic

Extrensic

42
Q

RFs for Stress Fractures- intrinsic

A 
Leg length discrepancy
Female sex
Poor nutrition
Older age (20+)
Smoking
FHx
43
Q

RFs for Stress Fractures- extrinsic

A 
Milage
Inadequate rest
Running pace
Downhill running
Surface
Footwear
44
Q

Stress fractures with low risk of non-union

A 
Femoral neck fractures of medial cortex
Tibial shaft fractures of the posteromedial cortex
Fractures of the distal 2nd to 4th metatarsals
Calcaneal fractures
Fractures of the fibula
Fractures of the pubic ramus
Cuboid fractures
Cuneiform fractures
45
Q

Low risk stress fractures management

A

Can be managed conservatively

Slowly increase impact loading once ambulation and day to day activity are pain free

46
Q

Stress fractures with high risk of non-union

A

Femoral neck fractures of superior cortex
Tibial shaft fractures of anterior cortex
5th metatarsal, at diaphyseal-metaphyseal junction
Navicular fractures
Proximal fractures of the 2nd metatarsal
Fractures of the talus
Fractures of the medial malleolus
Sesamoids

47
Q

Fractures in areas of tension

A

Along the anterior portion of tibia + lateral femoral neck
Or in bones with retrograde blood supply such as talus + navicular
At risk of delayed union or non-union and often require operative management

48
Q

Prevention of BSI

A

Periodisation
Deal with modifiable RFs
Optimum nutrition

49
Q

Periodisation

A

3 week and then 1 de-load

Allows subsequent metabolic adaptation to occur

50
Q

Optimal nutrition

A

Especially for female athletes

Minimum of 1500mg of calcium needed/day

51
Q

Femoral stress fractures

A

Pain in anterior inguinal area
Hop test (70%) diagnostic
Conservative therapy for compression fractures (TRP 8-16 weeks)
Internal fixation for tension type fractures or displaces

52
Q

2nd-4th Metatarsal

A

20% of all stress fractures of lower extremity

4-6 weeks limited activities or casting for 4-6 weeks

53
Q

5th metatarsal

A

6-8 weeks NWB cast

70% healing (1 in 3 athletes might not respond to treatment)

54
Q

Navicular

A

Up to 16 weeks RTP
6-8 weeks in boot NWB- if no pain, 86% rate of healing
If still pain- then 6-8 weeks booted WB (if still symptomatic)
Operate if failed conservative- return to sport 16-20 weeks

55
Q

Tibial stress fractures

A

40-50% of athletes
RFs- ER-hip, width of tibia bone
Location- posteromedial-anterior
Aircast splinting if more severe symptoms or if not resolved with conservative treatment
Casting for mid-shaft fracture until pain-free and radiographic evidence of healing
Surgery (intramedullary nailing and/or grafting) if no improvement after 6 months of treatment

Sports and Exercise Medicine iBSc (13 decks)

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