Leg and Foot Stress Fractures: Difference between revisions
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From a biomechanical perspective, stress fractures may be a consequence of fatigued muscle which then causes the bone to receive excessive amounts of force.<ref name="Maffulli" /> In addition, the alignment of the lower extremity has been proposed to play a role in the risk of stress fractures, but the evidence is inconclusive.<ref name="Milner" /> Furthermore, earlier studies have shown that narrow tibias, a high degree of hip external rotation, a varus ankle and forefoot, ankle hyperpronation, a foot with a high longitudinal arch, and leg-length discrepancy may increase an athlete’s risk to stress fractures.<ref name="Korpelainen" /> <br><br> | From a biomechanical perspective, stress fractures may be a consequence of fatigued muscle which then causes the bone to receive excessive amounts of force.<ref name="Maffulli" /> In addition, the alignment of the lower extremity has been proposed to play a role in the risk of stress fractures, but the evidence is inconclusive.<ref name="Milner" /> Furthermore, earlier studies have shown that narrow tibias, a high degree of hip external rotation, a varus ankle and forefoot, ankle hyperpronation, a foot with a high longitudinal arch, and leg-length discrepancy may increase an athlete’s risk to stress fractures.<ref name="Korpelainen" /> <br><br> | ||
== | == Clinical Presentation == | ||
Clinical presentations can vary among patients; therefore, obtaining a thorough history is imperative to determine whether a patient may have a possible stress fracture. A patient may describe their symptoms to progressively get worse over time with activity, and no specific mechanism of injury. Initially the pain may only occur during activity but eventually become constant over time. Remember patients may not inform you on their increase in activity or their activity medications they have had to make once their onset of symptoms. 1Patients may present with mild edema and erythema in area of pain, focal/point tenderness (covered by a single finger), leg length discrepancy, and increased pain with weight bearing activities encouraging an antalgic gait. Also, a tuning fork test along the area of pain should exacerbate the patient’s symptoms.3 Research indicates activities with repetitive stress of the foot striking the ground, such as marching will increase the risk for stress fractures. Without sufficient rest between workouts or competitions, patients are also are at increased risk. Other medical studies also claim that women are more susceptible to stress fractures than men. This claim may be attributed to a condition referred to as "the female athlete triad," which includes eating disorders, amenorrhea, and osteoporosis. All of the factors listed above will affect a female’s bone mass, leading to a possible chance of developing a stress fracture. | |||
== Differential Diagnosis == | == Differential Diagnosis == | ||
Revision as of 23:22, 9 July 2011
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Lead Editors - Holly Pulket, Corin Arundale, Brenda Walk, Brittany Buenteo, Melissa Osti
Search Strategy[edit | edit source]
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Keyword Searches: Leg stress fractures, foot stress fractures, military and stress fractures
Search Timeline: June 10, 2011 -
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Definition/Description[edit | edit source]
Stress fractures are partly due to bone that undergoes mechanical fatigue.[1] Stress fractures are a consequence of exceeding amounts of repetitive submaximal loads placed on bones which create an imbalance between bone resorption and bone formation.[2] The fractures usually begin in locations where the bone is experiencing a great deal of stress; this is called “crack initiation”.[2] If this microscopic crack is not able to heal and is subjected to further loading, the microdamage will increase and the crack will enlarge. This increase in damage can cause the bone to break on a macroscopic level.[2]
Epidemiology/Etiology[edit | edit source]
It is estimated that 15-20% of overuse injuries are stress fractures.[1] It is believed that activities of impact with repetitive loading such as marching and running are associated with these types of fractures.[3] About 50% of stress fractures take place in the tibia; however, a stress fracture can occur in any bone. For instance, the foot (especially the second metatarsal) is another common place for stress fractures.[4] Moreover, females are depicted to have a greater percentage of stress fractures; it has been reported that females have a 1.5 to 12 times higher risk of getting a stress fracture as compared to males.[5]
Stress fractures may be due to several factors such as activity level, bone quality, anti-inflammatory drugs, radiation, nutritional status, osteoporosis, imbalanced hormones, sleep deprivation, and collagen anomalies. How often stress fractures occur is dependent upon the composition of bone, adjacent muscle attachments, the vasculature, systemic factors, and the mode of athletic activity.[2] Other possible stress fracture risks include age, sex, footwear, and training regimen.[6] High level female athletes (who are inclined to the athlete triad) and male endurance athletes (who have unusually low levels of sex hormones) are also at risk for stress fractures.[2]
From a biomechanical perspective, stress fractures may be a consequence of fatigued muscle which then causes the bone to receive excessive amounts of force.[2] In addition, the alignment of the lower extremity has been proposed to play a role in the risk of stress fractures, but the evidence is inconclusive.[3] Furthermore, earlier studies have shown that narrow tibias, a high degree of hip external rotation, a varus ankle and forefoot, ankle hyperpronation, a foot with a high longitudinal arch, and leg-length discrepancy may increase an athlete’s risk to stress fractures.[6]
Clinical Presentation[edit | edit source]
Clinical presentations can vary among patients; therefore, obtaining a thorough history is imperative to determine whether a patient may have a possible stress fracture. A patient may describe their symptoms to progressively get worse over time with activity, and no specific mechanism of injury. Initially the pain may only occur during activity but eventually become constant over time. Remember patients may not inform you on their increase in activity or their activity medications they have had to make once their onset of symptoms. 1Patients may present with mild edema and erythema in area of pain, focal/point tenderness (covered by a single finger), leg length discrepancy, and increased pain with weight bearing activities encouraging an antalgic gait. Also, a tuning fork test along the area of pain should exacerbate the patient’s symptoms.3 Research indicates activities with repetitive stress of the foot striking the ground, such as marching will increase the risk for stress fractures. Without sufficient rest between workouts or competitions, patients are also are at increased risk. Other medical studies also claim that women are more susceptible to stress fractures than men. This claim may be attributed to a condition referred to as "the female athlete triad," which includes eating disorders, amenorrhea, and osteoporosis. All of the factors listed above will affect a female’s bone mass, leading to a possible chance of developing a stress fracture.
Differential Diagnosis[edit | edit source]
Depending on the location of the pain, the differential diagnosis may vary. Other diagnoses may include infection, tumor, compartment syndrome, arthritis, nerve entrapment, medial tibial stress syndrome, and other soft tissue injuries.1 Compartment syndrome is developed from pressure within the muscle compartments of the lower leg which are divided up by fascial layers. Pressure within the compartments can result from increased oxygen demand and subsequent blood flow to the exercised muscle.3 Compartment syndrome patients may present with leg cramps, muscle tightness, severe pain, foot drop, and par aesthesia of the foot.3 Compartment syndrome is a red flag condition and surgical fasciotomy is the preferred treatment.3 If there is a suspected stress fracture after the initial evaluation, including a thorough history, the therapist should refer for medical imaging to rule in or out the diagnosis. Standard radiographs are initiated early on despite the poor sensitivity for diagnosis of stress fractures (show up after first 2-3 weeks), followed by the gold standard imaging of a bone scan (show up within 2-3 days of injury).2 Medial tibial stress syndrome (MTSS) comprises periostitis at the junction of the middle and distal thirds of the medial tibial border. This syndrome can result from traction stress of the soleus, flexor digitorum longus, or deep crural fascia.1 Bone scans can also be used to diagnosis MTSS with increased uptake of longer segments of the bone, compared to focal areas with stress fractures.1 When examining those with MTSS, patient may experience diffuse tenderness along the tibial border.
Outcome Measures[edit | edit source]
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Examination[edit | edit source]
When evaluating an adult with a LE stress fracture a thorough history is important.
Key history findings of an individual with a stress fracture (Lassus, Van der Velde):
- Pain with WB
- Recent increase in activity (i.e. high intensity and/or high frequency)
- Gradual onset
- Begins as pain with stress, eventually progressing to pain at rest and during the night
During the physical examination, the clinician will want to take an impairment based approach. Important aspects of the evaluation will include observation, gait analysis, leg length discrepancy, tenderness with palpation, and ROM (Duran-Stanton et al 2011). Patients with stress fractures typically will have tenderness to palpation and edema in surrounding soft tissues (Lassus). According to Hatch et al 2007, during the physical examination it may be important to perform all of the following: a neurologic screen for sensation, a vascular examination (capillary refill and LE pulses), inspect the skin for deformity, edema, or ecchymosis, and ROM to determine if there is a disproportionate amount of pain with movement.
In regards to navicular stress fxs (which is one of the most common types of foot stress fxs), foot shape has been implicated in the past as a risk factor but evidence is inconsisent (Oddy et al 2009, Tuan et al 2004). Injuries appear to occur in patients with pes planus, pes cavus, and normal feet.
Radiographs still are the first tool used for the diagnosis of stress fractures (Lassus). Stress fractures usually don't appear on xrays for two to six weeks (Hatch, Lassus) but when they are visible they will appear as a radiolucent line and may have cortical thickening (Van der Velde, Lassus, Duran-Staton, Baublitz).
Medical Management
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Physical Therapy Management
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Key Research[edit | edit source]
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Resources
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Clinical Bottom Line[edit | edit source]
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Recent Related Research (from Pubmed)[edit | edit source]
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References[edit | edit source]
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- ↑ 1.0 1.1 Edwards WB, Taylor D, Rudolphi TJ, Gillette JC, Derrick TR. Effects of running speed on a probabilistic stress fracture model. Clinical Biomechanics. 2010;25:372-377.
- ↑ 2.0 2.1 2.2 2.3 2.4 2.5 Maffulli N, Longo UG, Denaro V. Femoral Neck Stress Fractures. Operative Techniques in Sports Medicine. 2009;17:90-93.
- ↑ 3.0 3.1 Milner CE, Hamill J, Davis IS. Distinct Hip and Rearfoot Kinematics in Female Runners With a History of Tibial Stress Fracture. Journal of Orthopaedic and Sports Physical Therapy. 2010;40(2):59-66.
- ↑ Bargfeldt C, Krogsgaard M, Rasmussen SW. Stress fracture in combination with avulsion from the tibia in a marathon runner: a case report. Scandinavian Journal of Medicine and Science in Sports. 2011;21:330-332.
- ↑ Queen RM, Abbey AN, Chuckpaiwong B, Nunley JN. Plantar Loading Comparisons Between Women With a History of Second Metatarsal Stress Fractures and Normal Controls. The American Journal of Sports Medicine. 2009;37(2):390-395.
- ↑ 6.0 6.1 Korpelainen R, Orava S, Karpakka J, Siira P, Hulkko A. Risk Factors for Recurrent Stress Fractures in Athletes. American Orthopaedic Society for Sports Medicine. 2001;29(3):304-310.
