Bone Stress Injuries Flashcards
Bone stress injury
Gradual injury to the bone
Stress fracture is the end of the spectrum
One of main overuse injuries
Bone stress injury- is … to diagnose
Difficult
Mimic other overuse injuries
Injuries in track and field athletes
Overuse injuries are majority
From those, 15% are bone stress injuries
Lower limb bone stress injuries location
51% tibia > metatarsal > navicular
Location can contribute to
Risk of healing
Complications
Surgery
Risk of non-union
High risk BSI lead to delayed diagnosis + treatment, which leads to increase in the above
Low risk areas BSI
Posteromedial border of tibia Femur 1-4th metatarsals Ribs Ulna
High risk areas BSI
Anterior tibia
Navicular
Femoral neck
5th metatarsal
BSI more common on which side for track and field runners
Left Hand Side
BSI Grade 1
Symptoms occur end of training
TUSA (+-)
Endosteal marrow oedema
Return to Play 3-4 weeks
BSI Grade 2
Symptoms occur mid of training
TUSA (+-)
Periosteal + endosteal marrow oedema
RTP 5-8 weeks
BSI Grade 3
Symptoms occur whole training
TUSA (+)
Periosteal + endosteal marrow oedema + soft tissues oedema
RTP 9-16 weeks
BSI Grade 4
Symptoms occur during daily activities
TUSA (+)
Fracture line
RTP 16+ weeks
BSI History
Sport
Event
Training intensity
Previous BSI
BSI Symptoms
Gradual exercise related leg pain
Progressively worse
No night pain
Intermediate pain
BSI clinical evaluation
Localised pain Lumbar spine Hip One leg hop One leg extension
BSI Diagnostic test
Therapeutic USS- to assess BSI, compare to the other side
Positive is the feeling of pain during TUS assessment
TUSS
Therapeutic USS
+ve if feeling of pain during TUS assessment
Gold standard for BSI
MRI
BSI MRI- Grade 1
Endosteal marrow oedema
TUS +/-
BSI MRI- Grade 2
Periosteal and Endosteal marrow oedema
TUS +/-
BSI MRI- Grade 3
Grade 2 + soft tissue oedema
TUS +
BSI MRI- Grade 4
Fracture line
TUS +
BSI MRI- If nefative
Plain XR
No findings in early stages, usually from 4-6 weeks
BSI differential diagnosis
MTSS CSS Radiculopathy Popliteal artery entrapment Bone contusion Osteomyelitis Neoplasm Lymphoma Leukemia
MTSS
Traction on tibia from tibialis posterior
PAE
Pain in uphill training
Differential diagnoses diagnosis
Based on clinical symptoms
TUSA (gives early assessment)
MRI
BSI treatment- if MRI +
Blood test (calcium VitD) CT (to ensure bone oedema isn't masking a fracture line)
BSI treatment- if MRI -
BSI grade 1
BSI treatment if TUSA - and XR -
DD or treat as BSI grade 1
BSI if high risk of non-union
Referral and operative fixation may be considered
BSI Management
Control pain After at least 1 week pain free: Modify training Functional RTP RTP
BSI management- Control pain
NWB (5+ days)
Swimming, core, stability
Local treatment- low intensity pulsed TUS, ESWT?
BSI management- modify training
Low intensity TUS, ?ESWT
Deal with modifiable RFs
BSI management- Functional RTP
Sport specific
10% increase every 10 days (intensity, duration)
BSI management- RTP
Symptom free TUS or threshold markedly increased Grade 1- 4 weeks Grade 2- 8 weeks Grade 3- 10-16 weeks Grade 4- 16+ weeks
BSI management- modifying training load
Alter G treadmill
Underwater running
Swimming
Core
BSI management- medications
Calcium D3
Vit D
NEVER NSAIDs as mask symptoms
BSI management- physio modalities
Can benefit from local treatment
TUSA, pulsed USS, ESWT, exogen is a portable TUSA
BSI management- predisposing factors
Biomechanics Running style Footwear Orthoses Nutrition
RFs for Stress Fractures
Intrinsic
Extrensic
RFs for Stress Fractures- intrinsic
Leg length discrepancy Female sex Poor nutrition Older age (20+) Smoking FHx
RFs for Stress Fractures- extrinsic
Milage Inadequate rest Running pace Downhill running Surface Footwear
Stress fractures with low risk of non-union
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
Low risk stress fractures management
Can be managed conservatively
Slowly increase impact loading once ambulation and day to day activity are pain free
Stress fractures with high risk of non-union
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
Fractures in areas of tension
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
Prevention of BSI
Periodisation
Deal with modifiable RFs
Optimum nutrition
Periodisation
3 week and then 1 de-load
Allows subsequent metabolic adaptation to occur
Optimal nutrition
Especially for female athletes
Minimum of 1500mg of calcium needed/day
Femoral stress fractures
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
2nd-4th Metatarsal
20% of all stress fractures of lower extremity
4-6 weeks limited activities or casting for 4-6 weeks
5th metatarsal
6-8 weeks NWB cast
70% healing (1 in 3 athletes might not respond to treatment)
Navicular
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
Tibial stress fractures
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
