Nagging Injuries in the Athlete:Tibial, 5th Metatarsal and Navicular
Stress Fractures
Kenneth J. Hunt, M.D.
2014 COA Annual Meeting
Monterey, CA
Disclosures
I have no potential conflicts of interest with regard to this presentation
Stress Fractures in the foot, ankle and lower
extremity are very common in elite athletes
Nagging Injuries in the Athlete
Stress fracture:
A partial or complete bone fracture that
results from repeated application of stress of
a lower magnitude than the stress required
for bone to fail in a single loading
Nagging Injuries in the Athlete
Many occur as an acute injury after
build-up of stress
Nagging Injuries in the Athlete
• Annual incidence of stress fractures in
athletes estimated 2% to 21%.
• Track and field
– Distance runners
– Sprinters
• Basketball
• Tennis
• Volleyball
• Soccer
Who gets them?
Stress Fractures in the Athlete
• Up to 20% of Sports Medicine Visits
• 80% are in Foot/Legs
• “High Risk” stress fx:
– Tibia
– Navicular
– Proximal 5th Metatarsal (Jones)
Fredericson et al. 2006. Top Magn Reson Imaging
High risk of displacement, non-union or
refracture, requires surgical decision-making
The Burden
Risk Factors
• Intrinsic risk factors:
– Muscle fatigue/poor conditioning
– Weakness/strength imbalance
– Menstrual/hormonal irregularities
– Lower limb malalignment
– Foot structure (cavovarus)
– Height - Tall stature
– Genetic predisposition
Unmodifiable
Stress Fractures
Pes planus = FlatfootPes cavus = High arch foot
Risk FactorsStress Fractures
Varus Valgus
• Extrinsic risk factors
– Excessive volume or intensity of training
– Change in training regimen
– Change in training surface
– Worn-out training shoes
– Cigarette smoking
– Inadequate nutrition –
• calories, calcium, vitamin D
– Medications-
• chronic steroid use
Risk FactorsStress Fractures
• Female Athlete Triad:
– Disordered eating
– Amenorrhoea/oligomenorrhoea
– Osteopenia
• 50% increase in stress
fracture risk
Risk FactorsStress Fractures
Barrack et al., 2014 AJSM
High Risk Stress Fractures
• Tibia
– Posterior cortex
– Anterior tibial cortex
– Medial malleolus
• Navicular
• 5th Metatarsal (Jones fracture)
High Risk
Low risk
High Risk Stress Fractures
• Tibia
– Posterior cortex
– Anterior tibial cortex
– Medial malleolus
• Navicular
• 5th Metatarsal (Jones fracture)
High Risk
Low risk
Tibia Stress Fractures
• Most common stress fx in active population
– Military recruits
– Running and jumping athletes (very little data)
• Up to 75% of chronic leg pain in athletes
• Posteromedial cortex is most common location
Pathophysiology
• Disrupted bone homoeostasis and inadequate repair in the face of repetitive overload
Pathophysiology
• Disrupted bone homoeostasis and inadequate repair in the face of repetitive overload
• Wolff’s law
– Remodeling of microdamageJulius Wolff
Pathophysiology
• Disrupted bone homoeostasis and inadequate repair in the face of repetitive overload
• Wolff’s law
– Remodeling of microdamage
• Repeated pull of the gastrocnemius/soleus complex contributes to failure the bone
– Proximal third in young patients
– Mid/distal 1/3 junction in runners
Tibia
Soleus
Post
Tib.
Clinical Features
• Pain with activity
– Especially longer periods
• Mild discomfort persistent pain
• Eventually unable to participate/train
• Pain persists after cessation of activity
– Night pain
• Exam:
– Tenderness at midshaft tibia (medial border)
– Swelling, erythema, warmth
Radiographs
• Normal in early stages
• Lucency followed by Cortical thickening at
2-3 weeks
99Tc Bone Scan versus MRI
• Bone scan pos at 2-8 days
• MRI more sensitive and specific
MRI CT Bone Scan
Sensitivity 88% 42% 74-90%
Specificity 95-100% 89-100% 33-47%
Treatment
• Phase 1
– Rest from aggravating activities
– Ice, NSAIDs, Diet
– Usually No immobilization
– Pool, elliptical, weights
• Phase 2
– Graduated return when pain-free
– Shoe wear and running surface
– Functional orthotics, bracing • Shock absorption
• Correct mechanical imbalance
Low Risk
Treatment
• Other modalities
– Bisphosphonates • Stewart et al., 2005, CJSM
– Bone stimulators
• Effective in delayed unions
• Theoretical in stress fx
• No evidence in stress fractures
Low Risk
High Risk Stress Fractures
• Tibia
– Posterior cortex
– Anterior tibial cortex
– Medial malleolus
• Navicular
• 5th Metatarsal (Jones fracture)
High Risk
Low risk
• More common in jumpers
– Rare in distance runners
• Poor vascularity and repetitive loads
• Dreaded black line on radiograph
– Non-union
– Bone scan may be normal
Tibial Stress FracturesAnterior Cortex
• More common in jumpers
– Rare in distance runners
• Poor vascularity and repetitive loads
• Dreaded black line on XR
– Non-union
– Bone scan may be normal
• MRI Scan
– Confirm location/extent
– Acuity
Tibial Stress FracturesAnterior Cortex
• Treatment– Immobilize NWB 6-8 weeks
– Pneumatic leg brace
– Electric stim up to 10 hrs per day
• Return to sport
– Radiographic healing
– Resolution of symptoms
• Surgery if no healing at 4-6 months
– Sooner in elite athletes?
Tibial Stress FracturesAnterior Cortex
Treatment
• Surgical treatments
– Excision and bone grafting (Green 1985 AJSM)
– Drilling of defect (Rettig AJSM 1988)
– Reamed IM Nailing (Varner et al., 2005 AJSM)
• 11 tibia stress fractures (failed non-op)
• All fractures healed (mean 3 months)
• Return to sport by 4 months
High Risk Stress Fractures
• Tibia
– Posterior cortex
– Anterior tibial cortex
– Medial malleolus
• Navicular
• 5th Metatarsal (Jones fracture)
High Risk
Low risk
Medial Malleolar Stress Fractures
• Running/jumping athletes
– Repeated dorsiflexion, pronation and rotation
– Insidious onset of medial ankle pain
Medial Malleolar Stress Fractures
• History
– Pain over medial malleolus
– Swelling, no loss of ROM
• Radiographs
– May be negative up to 2 months
– Bone scan or MRI
– CT scan to confirm fracture
Clinical Features
Medial Malleolar Stress Fractures
• Modified rest 3-8 weeks
– Transition to boot when pain-free
– Gradual return to activity
• Complete healing averages 6 months
• Surgery
– Any displacement
– Fracture line on x-ray in high level athlete
Treatment
• Plate and screws
• Graft for non-union
• 4-6 weeks NWB
• Return to sport - 4.2 months
• No level 1 or 2 studies
Fracture
Medial Malleolar Stress FracturesTreatment
• Associated impingement lesion common
– Jowett et al (2008, FAI)
• Advanced imaging can usually detect
• Consider arthroscopy to remove
Medial Malleolar Stress FracturesTreatment
High Risk Stress Fractures
• Tibia
– Posterior cortex
– Anterior tibial cortex
– Medial malleolus
• Navicular
• 5th Metatarsal (Jones fracture)
High Risk
Low risk
• Diagnosis
– Running athletes
– “Ankle pain”
– Navicular Tenderness• The “N” spot
Navicular Stress FractureEvaluation
• X-rays often normal
Navicular Stress FractureRadiographs
• Imaging
– Bone scan/MRI
– Positive before fracture appears
Navicular Stress FractureRadiographic Imaging
• Imaging
– Early CT scan if
stress fracture is
suspected
Navicular Stress FractureRadiographic Imaging
• CT scan
– Determines whether complete or incomplete
– Surgery planning
Navicular Stress FractureRadiographic Imaging
• Central hypovascular region– Only in 20% of patients
– 60% with normal vascularity
Navicular Stress FractureBlood Supply
McKeon et al. 2012 FAI
“Incomplete”
Navicular Stress FractureTreatment
“Complete”I: Dorsal cortex
II: Extends to N-C joint
III: Extends to plantar cortex
“Incomplete” Stress Fx
• In the athlete these
tend to progress
screw fixation
– 1-2 screws
Navicular Stress FractureTreatment
“Incomplete” Stress Fx
• 20 yo basketball
player
• Negative x-rays
Navicular Stress FractureTreatment
“Incomplete” Stress Fx
• 20 yo basketball
player
Navicular Stress FractureTreatment
“Incomplete” Stress Fx
• 20 yo basketball
player
Navicular Stress FractureTreatment
“Incomplete” Stress Fx
• 20 yo basketball
player
• Post-op
– 6 weeks NWB
– Early ROM
– Return to play 4-6
months
Navicular Stress FractureTreatment
“Incomplete” Stress Fx
• 20 yo basketball
player
• Post-op CT
Navicular Stress FractureTreatment
“Complete” Stress Fx
• In Athletes – without delay
• Open bone grafting and screw
fixation
• Often need to debride joints
Navicular Stress FractureTreatment
“Complete” Stress Fx
• In non-athletes
• Fixation is preferred by most
• Role for conservative management?
• Torg et al., 2010 AJSM
– Non-op best for both
complete and incomplete
Non-op: 96% success
Surgery: 82% success
Navicular Stress FractureResults
Nagging Injuries in the Athlete
• Posteromedial diaphysis
• Anterior tibial cortex
• Medial malleolus
• Navicular
• 5th Metatarsal (Jones fracture)
High Risk
Low risk
What is a Jones Fracture?
Definition=
• A fracture of the 5th
metatarsal at the
metaphyseal-diaphyseal
junction in the region the
4/5 intermetatarsal
articulation
Vascular water-shed region
Non-operative
Treatment
– 72-76% heal by 5
months
– Many fail to heal or
refracture
Jones FractureThe Problem
Quill et al. 1995. Orthop Clin North Am
Surgical Treatment
• Indications
– Athlete
• Acute/stress fx
– Nonunion
– Refracture
In Sports Medicine- Our Threshold to
operate is decreasing!
Jones FractureTreatment
Operative goals
• Expedite healing
• More rapid recovery
• Accelerated rehab
• Decrease refracture risk
Jones FractureTreatment
Operative technique
• Screw fixation
– Percutaneous (no big
incision)
Jones FractureTreatment
Operative technique
• Percutaneus approach
• (+/-) Bone graft or
substitute
Jones FractureTreatment
Insert Screw “High and Inside”
HIGH & INSIDE
Jones Fracture
Surgical treatment
• Option to inject
bone graft or
BMA + DBM
Aggressive postoperative management– Weight bearing at 2 weeks
– Begin running in modified shoewear at 6 weeks (if clinically nontender)
– Avg. return to play 8 weeks
Jones FractureTreatment
Post-Operative BracingClamshell Orthosis
Post-Operative BracingClamshell Orthosis
Post-Operative BracingCustom Orthoses
Gait Analysis
Gait Analysis
No Orthotic W/ Orthotic
Jones Fractures
• Beware of Cavus Foot
Pitfalls
Jones Fractures
• Beware of Cavus Foot
• Beware of Medial Cortex Penetration
– Use multiple fluoro views
Pitfalls
Jones Fractures
• Beware of Cavus Foot
• Beware of Medial Cortex Penetration
• Beware of poor start point
Pitfalls
• Treatment of Refractures and non-unions
• Revision Fixation
• Larger diameter screw
• ICBG, or BMA + DBM
Jones FractureTreatment
• 21 Elite Athletes
• Mean Age: 27 yrs
• Union: 100%
• Ave Return 12 weeks
– (8 weeks for primary)
Hunt et al. 2010 (Am J Sports Med)
Jones FractureTreatment
Meta analysis - mostly Level 4 data
• Return to sport ranged from 4 to 18 weeks
• Non-operative treatment: union rate 76 %
• Surgical treatment: union rate 96 %
• Non-unions:
– Treated non-operatively had a union rate of 44%
– Treated surgically had union rate of 97 %
Roche and Calder, KSSTA (2013) 21:1307–1315
Jones FractureTreatment
• Stress Fractures are very common
• Be aware of risk factors – good history
• Pay attention to alignment – correct as needed
• Get the imaging you need
• Remember that sometimes surgery is the more
conservative treatment
SummaryNagging injuries in the Athlete
Thank You
1. Pfeffer G, Bacchetti P, Deland J, et al: Comparison of custom and prefabricated orthoses in the initial treatment of proximal plantar fasciitis. Foot Ankle Int 20(4):214-221, 1999.
2. Crawford F, Thomson C: Interventions for treating plantar heel pain. Cochrane Database Syst Rev 3:CD000416, 2003.
3. Buchbinder R: Clinical practice: Plantar fasciitis. N Engl J Med 350:2159-2166, 2004.
4. Tisdel CL: Heel pain, in Orthopaedic Knowledge Update: Foot and Ankle 3. Rosemont, IL: American Academy of Orthopaedic Surgeons, 2003. pp 113-119.
5. Shmokler RL, Bravo AA, Lynch FR, et al: A new use of instrumentation in fluoroscopy controlled heel spur surgery. J Am Podiatr Med Assoc 78:194-197, 1988.
6. Snook GA, Chrisman OD: The management of subcalcaneal pain. Clin Orthop 82:163-168, 1972.
7. Davis PF, Severud E, Baxter DE: Painful heel syndrome: Results of nonoperative treatment. Foot Ankle Int 15(10):531-535, 1995.
8. American Orthopaedic Foot and Ankle Society: AOFAS Position Statement: Endoscopic and open heel surgery. Available at http://www.aofas.org/displaycommon.cfm?an=1subarticleenbr=31.
9. DiGiovanni BF, Nawocznski DA, Lintal ME, et al: Tissue-specific plantar fascia-stretching exercises enhances outcomes in patients with chronic heel pain. A prospective, randomized study. J Bone Joint Surg Am 85:1270-1277, 2003.
10. Rompe JD, Hopf C, Nafe B, Burger R: Low-energy extracorporeal shock wave therapy for painful heel: A prospective controlled single-blind study. Arch Orthop Traum Surg 115:75-79, 1996.
11. Hammer DS, Rupp S, Ensslin S, et al: Extracorporeal shock wave therapy in patients with tennis elbow and painful heel. Arch Orthop Traum Surg 120:304-307, 2000.
12. Ogden JA, Alvarez RG, Marlow M: Shockwave therapy for chronic proximal plantar fasciitis: A meta-analyis. Foot Ankle Int 23(4):301-308, 2002.
13. Chen H, Chen L, Huang T: Treatment of painful heel syndrome with shock waves. Clin Orthop Relat Res 387:41-46, 2001.
14. Sellman JR. Plantar fascia rupture associated with corticosteroid injection. Foot Ankle Int 15(7):376-81, 1994.
15. Acevedo JI, Beskin JL: Complications of plantar fascia rupture associated with corticosteroid injection. Foot Ankle Int 19(2):91-97, 1998.