Lower limb stress fractures in runners
Stress reactions/fractures account for up to 20% of athletic injuries and are common in high load bearing and endurance activities, particularly distance running. Early detection is the most critical part of management and MRI is the most sensitive study to request in most lower limb stress fractures. Most stress fractures heal within 8 weeks with conservative management which includes a period of either non-weight-bearing or weight-bearing as tolerated depending on location and severity. Recovery timeframes are improved by recognising and modifying both intrinsic (e.g poor foot mechanics, strength deficits, diet) and extrinsic risk factors (e.g old/inappropriate footwear, high load, non-periodised training regimes).
Tibial, navicular and 2nd/3rd metatarsal stress fractures are the most common. Once the diagnosis of a stress reaction/fracture has been confirmed by MRI, a 2 phase rehabilitation protocol should begin. Phase 1 includes non-weight bearing or weight-bearing as tolerated with boot or cructches to enable pain free ambulation. Maintenance of aerobic fitness via swimming or cycling is important and NSAIDS should be avoided as they may slow bone healing. Phase 2 can begin 2 weeks after the athlete is walking pain free as long as there is no focal point tenderness. Phase 2 includes progressive loading and addressing intrinsic risk factors such as calf girth/weakness, excessive hip adduction, rearfoot eversion and the female athlete triad.
A return to sport after 4-6weeks of progressive loading should be monitored closely. The athelete should receive advice regarding diet, footwear, training surfaces, training loads and periodisation to reduce the risk of re-occurence.
Do we address ALL the risk factors in clinical practice or do we just try to focus on what we feel are the most critical?
> From: Kahanov et al., Open Access J Sports Med 6 (2015) 87-95(Epub ahead of print). All rights reserved to Elsevier. Click here for the Pubmed summary.