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Stress Fractures Normal Anatomy • Bone remodels under wolff’s law • Remodelling takes place via mechanotransduction • Remodelling is based on the force and load placed through the bone • If loading on a bone increases the bone will remodel itself to become stronger and resist the loading • If loading on a bone decreases the bone will become less dense and weaker due to the lack of stimulus • Remodelling occurs quickly in cancellous bone • Remodelling occurs slowly in cortical bone Pathology • Partial or complete fractures resulting from repetitive and excessive mechanical stress on normal bone Pathology • Normal Stress • Load and stress applied to bone with adequate time to remodel • Bone remodels according to Wolff’s Law • Stress Reaction • Under repetitive loads without sufficient time to remodel bone will fatigue and fail • Osteoclastic activity is greater than osteoblastic activity • Results in microfractures • Stress Fracture • Continued stress results in cortical break Mechanism of Injury • Insidious • Repeated stress or load e.g running Risk Factors • Intrinsic • Female • Low bone mineral density • Nutritional deficiencies • Hormonal irregularities • Leg Length discrepancies • Genu Valgum • Poor lower limb muscle mass • Extrinsic • Running or jumping sports • Rapidly increasing training program • Poor training surface • Running downhill • Poor training footwear • Smoking Classification • Location and type of the fracture predictive of healing • Compression stress fractures more likely to heal with conservative measures • Tension stress fracture usually require surgical intervention • Tension forces can displace fracture site creating instability High Risk Fractures Femoral Neck Stress Fracture • High morbidity in runners • Significant complications if missed • Fracture completion • Avascular necrosis • Arthritis changes • Anterior hip or groin pain worse with activity • Extremes of passive ranges of movement maybe painful • Superior aspect of the femoral neck • Tensile forces • Surgically managed • Inferior aspect of the femoral neck • Compressive forces • Can be managed surgically or conservatively depending on fatigue line Anterior Tibial Shaft Stress Fracture • Tension type stress fracture • Poorly localised anterior leg pain • Risk of non-union • “dreaded black line” anterior tibia radiograph at middle-distal third junction of anterior tibia • Initially conservative but surgical management required 60% of the time Navicular Stress Fracture • Common in athletes requiring a “push off” e.g sprinters, middle distance runners • Navicular avascular • Compression between talus and cuneiform • Vague, poorly localized foot pain of medial dorsum of the foot • Tenderness “N-spot” on the dorsal navicular • Can be managed conservatively if no cortical disruption present, otherwise surgically managed Talar Neck Stress Fracture • Rare • Usually report a trauma th 5 Metatarsal Stress Fracture • Less common metatarsal fracture • Usually in the diaphysis on the lateral side and progresses medially • Tension type • Pain with weight bearing • History of trauma or change in routine/environment/footwear • Tenderness palpation • Surgery considered for • Failed conservative management • Displaced fracture • Elite athlete with need for early return Low Risk Fractures Femoral Shaft Stress Fracture • Usually proximal third • Insidious onset • Non-specific pain localised to the groin, thigh or knee • Conservatively managed Pelvic/ Pubic Ramus Stress Fracture • Groin pain • Pain with single leg stance • Most commonly inferior pubic ramus • Conservatively managed Fibula Stress Fracture • Diffuse lateral leg pain • Usually affect the distal third • Conservatively managed Calcaneus Stress Fracture • Heel pain • Worse on running and jumping • Posterosuperior tenderness on palpation • Conservatively managed nd 2 th -4 Metatarsal Stress Fracture • Most commonly 2nd and 3rd metatarsal • Forefoot pain on activity • Tenderness on palpation Posteromedial Tibial Stress Fracture • Shin pain with weight bearing • Focal tenderness over posteromedial tibia • Occur posteromedial in the proximal or distal parts • Conservatively managed Subjective Examination • Localized area of pain • Insidious onset • Occurs with activity that gradually gets worse • Advanced stages pain could be at rest • History of repeated activity Objective Examination • Focal tenderness • Pain with percussion Further Investigation • MRI • Bone scan • CT Management • Management plan determined by location and risk of fracture • Guided by surgeon Conservative • Activity modification to a pain free threshold • “if it hurts to do it, then don’t do it” • Reduce risk factors • NSAID’s should be avoided • Gradually progress weight bearing activity as pain allows • Maintain general body conditioning, fitness and strength with pain free exercise • Roughly 4 – 8 weeks for adequate healing Plan B • Surgical interventions depend on site References • Aweid, B., O. Aweid, S. Talibi and K. Porter (2013). "Stress fractures." Trauma 15(4): 308-321. • Gallo, R. A., M. Plakke and M. L. Silvis (2012). "Common leg injuries of long-distance runners: anatomical and biomechanical approach." Sports Health 4(6): 485-495. • Kahanov, L., L. E. Eberman, K. E. Games and M. Wasik (2015). "Diagnosis, treatment, and rehabilitation of stress fractures in the lower extremity in runners." Open Access J Sports Med 6: 87-95. • McCormick, F., B. U. Nwachukwu and M. T. Provencher (2012). "Stress fractures in runners." Clin Sports Med 31(2): 291-306.