Return to sports after stress fractures of the tibial diaphysis: a systematic review

Osseous Stress Injuries: Treatment Algorithms and Return to Play

Osseous stress injuries are common in athletes. Specifically, lower extremity injuries are prevalent in running athletes and upper extremity injuries are prevalent in throwing athletes. Such injuries are suspected when there is focal bone tenderness and increased pain with the inciting activity. In elite athletes, osseous stress injuries are a relatively common culprit in lost play time. Thus rapid diagnosis and treatment is imperative to expedite return to play (RTP). The radiologist's role in these cases is not only for diagnosis, but also to grade the injury, which has implications in determining a treatment regimen. The high sensitivity and specificity of magnetic resonance imaging is thus the preferred imaging modality. This article discusses common osseous stress injuries, the imaging findings, and how different treatment regimens affect RTP.

Quantifying the Performance of Professional Athletes Following Traumatic Tibial Fractures

INTRODUCTION

A tibial fracture is an uncommon, yet severe injury that occurs in professional athletes within all major sports leagues. These injuries are often debilitating for professional athletes and can require extensive rehabilitation prior to returning to play. The purpose of this study is to investigate the impact of a tibial fracture on athletic performance in all four major United States sports leagues.

METHODS

A publicly available professional sports database, Pro Sports Transactions, was queried for tibial injuries from January 01, 2015, to May 31, 2023. The search included all four major U.S. sports leagues. To quantify and compare athletic ability before and after injury, performance-based statistics were collected from standardized player ratings in periods surrounding the date of injury. The percent change in player performance was measured and stratified. The Pearson correlation test was used to analyze player demographics.

RESULTS

There were a total of 24 professional athletes who suffered 28 confirmed tibial fractures across all leagues. Upon return, there was a 14.7% decrease in overall player performance across all leagues. National Basketball Association, National Football League, and National Hockey League athletes had a decrease of 34.5%, 29.1%, and 14.2%, respectively, following their return to play. Major League Baseball players demonstrated an 8.1% increase in player performance following their recovery from tibial fracture.

CONCLUSION

Players who suffer tibial fractures often undergo immediate surgery and, in unfortunate cases, may require multiple subsequent procedures. Additionally, athletes spend several months recovering prior to their return. Upon return, athletes' performance may be decreased; however, further study is required to strengthen the association between player performance and tibial fracture recovery.

Effect of increased running speed and weight carriage on peak and cumulative tibial loading

INTRODUCTION

Tibial stress injuries are a burdensome injury among military recruits. Military activities include running and the carriage of additional weight, and this may be related to the high risk of bone stress injuries. The aim of this study was to quantify tibial loading when running at two different speeds, with and without additional weight, and to quantify their combined influence.

METHODS

Fourteen male distance runners who ran at least 40 km per week ran barefoot on a force-instrumented treadmill in four conditions representing preferred running speed (mean (SD) 3.1 (0.3) m/s) and 20% increased running speed (3.8 (0.4) m/s), with and without 20% of body weight carried in a weight vest. Kinematics and kinetics were synchronously collected. Bending moments were estimated about the medial-lateral axis of the tibial centroid located 1/3rd of the length from distal to proximal. Static equilibrium was ensured at each 1% of stance. Peak bending moments were obtained in addition to cumulative-weighted loading, where weighted loading accounted for the relative importance of the magnitude of the bending moment and the quantity of loading using a bone-dependent weighting factor.

RESULTS

There were no interaction effects for running speed and weight carriage on peak or cumulative tibial loading. Running at a 20% faster speed increased peak and cumulative loading per kilometer by 8.0% (p < 0.001) and 4.8% (p < 0.001), respectively. Carriage of an additional 20% of body weight increased peak and cumulative loading per kilometer by 6.6% (p < 0.001) and 8.5% (p < 0.001), respectively.

INTERPRETATION

Increasing the physical demand of running by increasing speed or weight carriage increased peak tibial loading and cumulative tibial loading per kilometer, and this may increase the risk of tibial stress injury. Running speed and weight carriage independently influenced tibial loading.

[High-risk stress fractures in competitive athletes]

Bone stress injuries are chronic overload reactions of the bone, which are characterized by the load-dependent occurrence of locally perceived pain and tenderness on palpation at the site of the injury. Structurally normal bone becomes fatigued as a result of repetitive submaximal loading and/or inadequate regeneration. Certain stress fractures of the femoral neck (tension side), patella, anterior tibial cortex, medial malleolus, talus, tarsal navicular bone, proximal fifth metatarsal, and sesamoid bones of the great toe tend to develop complications (complete fractures, delayed union, pseudarthrosis, dislocation, arthrosis). These injuries are classified as high-risk stress fractures. Aggressive diagnostics and treatment are recommended when a high-risk stress fracture is suspected. Treatment is frequently different from low-risk stress fractures, including prolonged non-weight-bearing immobilization. In rare cases, surgery is indicated when conservative treatment fails, when a complete or non-healing fracture develops, or in cases of dislocation. The outcomes of both conservative and operative treatment are described as less successful compared with low-risk stress injuries.

Return to sport following toe phalanx fractures: A systematic review

BACKGROUND

Evidence-based guidance on return to sport following toe phalanx fractures is limited.

AIM

To systemically review all studies recording return to sport following toe phalanx fractures (both acute fractures and stress fractures), and to collate information on return rates to sport (RRS) and mean return times (RTS) to the sport.

METHODS

A systematic search of PubMed, MEDLINE, EMBASE, CINAHL, Cochrane Library, Physiotherapy Evidence Database, and Google Scholar was performed in December 2022 using the keywords ‘Toe’, ‘Phalanx’, ‘Fracture’, ‘injury’, ‘athletes’, ‘sports’, ‘non-operative’, ‘conservative’, ‘operative’, ‘return to sport’. All studies which recorded RRS and RTS following toe phalanx fractures were included.

RESULTS

Thirteen studies were included: one retrospective cohort study and twelve case series. Seven studies reported on acute fractures. Six studies reported on stress fractures. For the acute fractures (n = 156), 63 were treated with primary conservative management (PCM), 6 with primary surgical management (PSM) (all displaced intra-articular (physeal) fractures of the great toe base of the proximal phalanx), 1 with secondary surgical management (SSM) and 87 did not specify treatment modality. For the stress fractures (n = 26), 23 were treated with PCM, 3 with PSM, and 6 with SSM. For acute fractures, RRS with PCM ranged from 0 to 100%, and RTS with PCM ranged from 1.2 to 24 wk. For acute fractures, RRS with PSM were all 100%, and RTS with PSM ranged from 12 to 24 wk. One case of an undisplaced intra-articular (physeal) fracture treated conservatively required conversion to SSM on refracture with a return to sport. For stress fractures, RRS with PCM ranged from 0% to 100%, and RTS with PCM ranged from 5 to 10 wk. For stress fractures, RRS with PSM were all 100%, and RTS with surgical management ranged from 10 to 16 wk. Six cases of conservatively-managed stress fractures required conversion to SSM. Two of these cases were associated with a prolonged delay to diagnosis (1 year, 2 years) and four cases with an underlying deformity [hallux valgus (n = 3), claw toe (n = 1)]. All six cases returned to the sport after SSM.

CONCLUSION

The majority of sport-related toe phalanx fractures (acute and stress) are managed conservatively with overall satisfactory RRS and RTS. For acute fractures, surgical management is indicated for displaced, intra-articular (physeal) fractures, which offers satisfactory RRS and RTS. For stress fractures, surgical management is indicated for cases with delayed diagnosis and established non-union at presentation, or with significant underlying deformity: both can expect satisfactory RRS and RTS.

Nonoperative Management of Tibial Stress Fractures Result in Higher Return to Sport Rates Despite Increased Failure Versus Operative Management: A Systematic Review

Purpose

To compare return to sport (RTS) rates and complications after nonoperative versus operative management of tibial stress fractures.

Methods

A literature search was conducted per the 2020 Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines using EMBASE, PubMed, and Scopus computerized data from database inception to February 2023. Studies evaluating RTS sport rates and complications after nonoperative or operative management of tibial stress fractures were included. Failure was defined as defined by persistent stress fracture line seen on radiographic imaging. Study quality was assessed using the Modified Coleman Methodology Score.

Results

Twenty-two studies consisting of 341 patients were identified. The overall RTS rate ranged from 91.2% to 100% in the nonoperative group and 75.5% to 100% in the operative group. Failures rates ranged from 0% to 25% in the nonoperative groups and 0% to 6% in the operative group. Reoperations were reported in 0% to 6.1% of patients in the operative group, whereas 0% to 12.5% of patients initially managed nonoperatively eventually required operative treatment.

Conclusions

Patients can expect high RTS rates after appropriate nonoperative and operative management of tibial stress fractures. Treatment failure rates were greater in patients undergoing nonoperative management, with up to 12.5% initially treated nonoperatively later undergoing operative treatment.

Level of Evidence

Level IV; Systematic Review of level I-IV studies.

Impact loading in female runners with single and multiple bone stress injuries during fresh and exerted conditions

BACKGROUND

Bone stress injuries (BSIs) are common in female runners, and recurrent BSI rates are high. Previous work suggests an association between higher impact loading during running and tibial BSI. However, it is unknown whether impact loading and fatigue-related loading changes discriminate women with a history of multiple BSIs. This study compared impact variables at the beginning of a treadmill run to exertion and the changes in those variables with exertion among female runners with no history of BSI as well as among those with a history of single or multiple BSIs.

METHODS

We enrolled 45 female runners (aged 18-40 years) for this cross-sectional study: having no history of diagnosed lower extremity BSI (N-BSI, n = 14); a history of 1 lower extremity BSI (1-BSI, n = 16); and diagnosed by imaging, or a history of multiple (≥3) lower extremity BSIs (M-BSI, n = 15). Participants completed a 5-km race speed run on an instrumented treadmill while wearing an Inertial Measurement Unit. The vertical average loading rate (VALR), vertical instantaneous loading rate (VILR), vertical stiffness during impact via instrumented treadmill, and tibial shock determined as the peak positive tibial acceleration via Inertial Measurement Unit were measured at the beginning and the end of the run.

RESULTS

There were no differences between groups in VALR, VILR, vertical stiffness, or tibial shock in a fresh or exerted condition. However, compared to N-BSI, women with M-BSI had greater increase with exertion in VALR (-1.8% vs. 6.1%, p = 0.01) and VILR (1.5% vs. 4.8%, p = 0.03). Similarly, compared to N-BSI, vertical stiffness increased more with exertion among women with M-BSI (-0.9% vs. 7.3%, p = 0.006) and 1-BSI (-0.9% vs. 1.8%, p = 0.05). Finally, compared to N-BSI, the increase in tibial shock from fresh to exerted condition was greater among women with M-BSI (0.9% vs. 5.5%, p = 0.03) and 1-BSI (0.9% vs. 11.2%, p = 0.02).

CONCLUSION

Women with 1-BSI or M-BSIs experience greater exertion-related increases in impact loading than women with N-BSI. These observations imply that exertion-related changes in gait biomechanics may contribute to risk of BSI.

Intramedullary Nailing of Concurrent Bilateral Tibial Stress Fractures Followed by Unilateral Tension Plating for a Nonunion in a Vitamin D-Deficient Elite Football Player

Stress fractures consist of a type of bone fracture that occurs due to repetitive mechanical stress instead of acute forceful injuries that cause common fractures. They are quite common among athletes at all competition levels and in army recruits who are expected to undergo extremely demanding exercises. While stress fractures can occur in any long bone, they are usually associated with the most common weight-bearing sites of lower extremities such as phalanges, metatarsals, tarsal bones, the tibia, and fibula. In this study, we report the surgical management of a 23-year-old African football player who sustained concurrent bilateral anterior cortex tibial midshaft fractures. His initial symptom was persistent subacute pain in both tibias. The initial conservative treatment was not successful and the patient was surgically treated with bilateral tibial intramedullary nails. However, the right tibia subsequently developed nonunion. Both intramedullary nails were removed and a tension plate was applied with an autologous iliac crest graft on the right tibia. Further blood test analysis revealed a significant vitamin D deficiency. The purpose of this article is to report different outcomes of the same primary surgical treatment for concurrent bilateral tibia stress fracture syndrome in an elite athlete due to vitamin D deficiency. To our knowledge, this is the first study that highlights the necessity of revising one of the intramedullary nailed concurrent tibia stress fractures with a tension plate and autologous graft to treat the established nonunion in an elite football player.

Impact of Low Energy Availability on Skeletal Health in Physically Active Adults

For decades researchers reported that pre-menopausal women who engage in extensive endurance exercise and have menstrual dysfunction can develop low bone mineral density (BMD) or osteoporosis. More recently, low energy availability has been recognized as the initiating factor for low BMD in these women. Furthermore, the relationship between low energy availability and poor skeletal health is not exclusive to women engaging in endurance exercise. Rather, both males and females commonly experience endocrine dysfunction resulting from low energy availability and high exercise levels that degrades skeletal health. Consequences to skeletal health can range from short-term changes in bone metabolism and increased risk of bone stress injuries to long-term consequences of low BMD, such as osteoporosis and related fragility fractures. The degree to which low energy availability degrades skeletal health may be dependent on the length and extent of the energy deficit. However, the complex relationships between under-fueling, short- and long-term skeletal consequences and the factors that mediate these relationships are not well described. In this review, we discuss the consequences of low energy availability on sex hormones and skeletal health in two highly-active populations-athletes and military trainees-and provide a summary of existing knowledge gaps for future study.

Uncommon Bone Injuries in Soccer Players

Soccer is the most common team sport in the world. A significant number of players are associated with a large number of injuries. Injuries occur in a variety of contexts regardless of the age or performance level of players. The vast majority of injuries involve soft tissues. Bone injuries are less common, but usually result in long-term exclusion from the game. Three different types of fractures related to soccer are classified as acute types, stress fractures and avulsion. This manuscript outlines the diagnostic procedures and treatments for stress fractures, avulsion fractures and bone cyst. The common feature of the described injuries includes frequent difficulties associated with the correct diagnosis and treatment direction. In therapeutic treatment, the doctor and the patient often have to choose between conservative treatment and surgical treatment, which in many cases is not simple. We suggest that in the event of injuries to soccer players, surgical treatment should be used, shortening the time to return to full sports activity. A very important element of the therapeutic process is proper rehabilitation, which should be individually tailored to the patient in order to optimize the treatment process. Some of the rehabilitation protocols should be permanently incorporated into the warm-up protocols for training. Such a procedure has a preventive effect.

Case Report: Stress Fracture in an International Triple Jumper: Importance of an Integrated Care Approach Which Also Incorporates Biomechanics

Athletes fear stress fracture (SF) injuries as they can put a premature end to their athletic careers. Understanding any mechanical constraints can suggest preventive management approach. Specifically, for the triple jump, the mechanical stresses that occur during the event appear to be the main factors for risk of injury. This clinical case describes three successive episodes of anterior tibial fracture in an international triple jumper between 2011 and 2013. The first fracture received surgical treatment involving intramedullary nailing. The second fracture occurred in the same location and was considered a recurrence requiring medical treatment, whilst the third was a complete fracture of the surgical material and required surgical revision. These recurrent fractures can be explained by the fatigue of materials (bone and nail) induced by triple jump practice and emphasize the importance of integrating biomechanics into an assessment of the case. The use of biomechanical modelization to identify these weaknesses could be an approach for clinical management of such patients. Observation of the intrinsic mechanical stresses during high-level triple jump may lead to identification of modifiable risk factors for bone fragility.

A Novel Stress Fracture Rehabilitation Program: A Pilot Study

INTRODUCTION

Stress fractures (SFx) of the tibia are common and limit military readiness, but there is presently no scientifically validated program that objectively fosters tibia SFx rehabilitation. Therefore, this pilot study evaluated the feasibility of a Graduated Exercise Program (GEP) based on the theory that programmed rest between exercise bouts improves the osteogenic response, which may enhance rehabilitation and military readiness.

METHODS

Participants were randomly assigned to the GEP or standard-of-care exercise program. Both programs use a walk-jog-run progression, but the GEP splits daily exercise into morning and evening episodes and provides 5 days of programmed rest after each stage is completed. The GEP included autonomy support to foster program adherence. Outcome measures included adherence, subjective and ActiGraph-validated objective assessments of exercise duration and intensity, pain assessments, and autonomy support assessments. Participants offered suggestions for program improvement.

RESULTS

Quantitative findings were mixed, but more importantly, this pilot study showed that the measurement, support, and self-reporting parameters were feasible, with high compliance by participants. Barriers to recruitment and retention were identified, along with solutions to overcome these barriers, starting with obtaining unit support for GEP participation.

CONCLUSION

This pilot study demonstrated the feasibility of a GEP with autonomy support, along with challenges and their solutions, providing the foundation for a formal large-sample study.

Changes in Volumetric Bone Mineral Density Over 12 Months After a Tibial Bone Stress Injury Diagnosis: Implications for Return to Sports and Military Duty

BACKGROUND

Bone stress injuries (BSIs) occur in up to 20% of runners and military personnel. Typically, after a period of unloading and gradual return to weightbearing activities, athletes return to unrestricted sports participation or military duty approximately 4 to 14 weeks after a BSI diagnosis, depending on the injury location and severity. However, the time course of the recovery of the bone's mechanical competence is not well-characterized, and reinjury rates are high.

PURPOSE

To assess the bone microarchitecture and volumetric bone mineral density (vBMD) over 12 months after a tibial BSI diagnosis.

STUDY DESIGN

Case-control study; Level of evidence, 3.

METHODS

We enrolled 30 female athletes from the local community (aged 18-35 years) with a tibial BSI (grade ≥2 of 4 on magnetic resonance imaging) for this prospective observational study. Participants completed a baseline visit within 3 weeks of the diagnosis. At baseline and 6, 12, 24, and 52 weeks after the BSI diagnosis, we collected high-resolution peripheral quantitative computed tomography scans of the ultradistal tibia (4% of tibial length) of the injured and uninjured legs as well as pain and physical activity assessment findings.

RESULTS

From baseline to 12 weeks after the diagnosis, total, trabecular, and cortical vBMD declined by 0.58% to 0.94% (P < .05 for all) in the injured leg. Total and trabecular vBMD also declined by 0.61% and 0.67%, respectively, in the uninjured leg (P < .05 for both). At 24 weeks, mean values for all bone parameters were nearly equivalent to baseline values, and by 52 weeks, several mean values had surpassed baseline values. Of the 30 participants, 10 incurred a subsequent BSI during the course of the study, and 1 of these 10 incurred 2 subsequent BSIs. Participants who suffered an additional BSI were younger and had a later age of menarche, a greater incidence of previous fractures, and lower serum parathyroid hormone levels (P < .05 for all).

CONCLUSION

Bone density declined in both the injured and the uninjured legs and, on average, did not return to baseline for 3 to 6 months after a tibial BSI diagnosis. The observed time to the recovery of baseline vBMD, coupled with the high rate of recurrent BSIs, suggests that improved return-to-sports and military duty guidelines may be in order.

Part II: presentation, diagnosis, classification, treatment, and prevention of stress fractures in female athletes

Objectives: Stress fractures (SFx) occur as the result of repetitive loads over short periods of time, which leads to micro-damage of the bone through cortical resorption, ultimately leading to fracture. They are a common injury in female athletes and often cause significant morbidity. The goal of this study is to review the presentation, diagnosis, classification, treatment, and prevention of SFx in female athletes.Results: A thorough history, physical exam, and appropriate imaging can facilitate early diagnosis of stress fracture (SFx) and faster resolution of symptoms with more conservative management. The female athlete triad is an especially important factor that contributes to the increased risk of SFx in females. The continuum of stress injuries ranges from mild microfailure to complete fracture, which has resulted in the development of newer grading schemas through MRI and radiographic findings. Stress fractures are also classified as low- or high-risk according to anatomic location, as blood supply and applied forces at different locations affect the likelihood of fracture propagation, displacement, delayed union, or non-union.Conclusions: The ability to screen for at-risk athletes is paramount in preventing SFx. Recognition and prompt treatment of the female athlete triad requires a multidisciplinary approach in order to restore energy balance, correct menstrual irregularities, and improve bone health. This review provides a basis for understanding how to identify and treat stress fractures, which may allow treating physicians to diagnose this condition earlier and minimize any associated morbidity.

Return to sport following Lisfranc injuries: A systematic review and meta-analysis

BACKGROUND

Information regarding return rates (RR) and mean return times (RT) to sport following Lisfranc injuries remains limited.

METHODS

A systematic search of nine major databases was performed to identify all studies which recorded RR or RT to sport following lisfranc injuries.

RESULTS

Seventeen studies were included (n=366). For undisplaced (Stage 1) injuries managed nonoperatively (n=35), RR was 100% and RT was 4.0 (0-15) wks. For stable minimally-displaced (Stage 2) injuries managed nonoperatively (n=16), RR was 100% and RT was 9.1 (4-14) wks. For the operatively-managed injuries, Percutaneous Reduction Internal Fixation (PRIF) (n=42), showed significantly better RR and RT compared to both: Open Reduction Internal Fixation (ORIF) (n=139) (RR - 98% vs 78%, p<0.019; RT - 11.6 wks vs 19.6 wks, p<0.001); and Primary Partial Arthrodesis (PPA) (n=85) (RR - 98% vs 85%, p<0.047; RT - 11.6 wks vs 22.0 wks, p<0.002).

CONCLUSIONS

Stage 1 and stable Stage 2 Lisfranc injuries show good results with nonoperative management. PRIF offers the best RR and RT from the operative methods, though this may not be possible with high-energy injuries.

LEVEL OF EVIDENCE

IV. Systematic Review of Level I to Level IV Studies.

Return to sport following surgical management of triangular fibrocartilage tears: a systematic review

INTRODUCTION

This review aims to provide information on return rates and times to return to sport following surgical management of triangular fibrocartilage (TFC) tears.

SOURCES OF DATA

A systematic search of CINAHAL, Cochrane, EMBASE, Google Scholar, Medline, PEDro, Scopus, SPORTDiscus and Web of Science was performed using the keywords 'triangular', 'fibro-cartilage', 'complex', 'tear', 'distal radio-ulnar joint', 'athletes', 'sports', 'non-operative', 'conservative', 'operative' and 'return to sport'.

AREAS OF AGREEMENT

In all of the 10 studies included, conservative management for 6 weeks to 6 months was the first-line treatment. If symptoms persisted following this period, surgical management was advised. Arthroscopic debridement was recommended for central tears, and arthroscopic repair was recommended for peripheral tears.

AREAS OF CONTROVERSY

The optimal treatment modalities for TFC tears remain to be defined.

GROWING POINTS

Traumatic central tears can be treated with arthroscopic debridement alone. Arthroscopic repair with an all-inside repair can improve return rates to sport over an outside-in technique for ulna-sided tears.

AREAS TIMELY FOR DEVELOPING RESEARCH

Future prospective studies should aim to establish the optimal treatment modalities for TFC tears.

Return to sport following scaphoid fractures: A systematic review and meta-analysis

BACKGROUND

Scaphoid fracture is the most commonly fractured carpal bone in the athletic patient, accounting for over 85% of all sport-related carpal bone fractures, and is particularly common in sports involving high impact injuries to the wrist. The management of such injuries comprises both conservative and surgical techniques, as guided by fracture location and type. Athletes demonstrate a unique challenge with regards to the management of scaphoid fractures due to their requirement to return to sport, as soon as able.

AIM

To review systemically all studies recording return to sport following scaphoid fractures, to collate information on return rates to sport (RRS) and mean return times (RTS) to sport and to determine differences in sporting outcome for the various treatment methods.

METHODS

A systematic search of MEDLINE, EMBASE, CINAHAL, Cochrane, Google Scholar, Physiotherapy Evidence Database, SPORTDiscus, Web of Science and Scopus was performed in August 2018 using the keywords “scaphoid”, “fracture”, “acute”, “carpal”, “athletes”, “sports”, “non-operative”, “conservative”, “operative” and “return to sport”. All studies that recorded RRS and RTS following scaphoid fractures were included. RTS was recorded as the length of time from commencement of either primary conservative management or primary surgical procedure to return to sport.

RESULTS

Eleven studies were included: Two randomised controlled trials, six retrospective cohort studies and three case series. Seven studies reported on conservative management (n = 77), and eight studies reported on surgical management (n = 83). For conservative management, RRS was 90% (69/77), and the mean RTS was 9.6 wk. Three studies allowed to return to sport in cast [RRS 89% (25/28); RTS 1.9 wk], and four studies required completion of cast treatment prior to returning to sport [RRS 90% (44/49); RTS 13.9 wk]. Four studies recorded fracture union data: Union rate 85% (47/55); mean time to union 14.0 wk. For surgical management, RRS was 98% (81/83), and RTS was 7.3 wk. Three studies reported on Percutaneous Screw Fixation [RRS 97% (32/33); RTS 6.5 wk], and five studies reported on Open Reduction Internal Fixation [RRS 98% (49/50); RTS 7.9 wk]. Six studies recorded fracture union data: Union rate 97% (69/71); mean time to union 9.8 wk. On meta-analysis, RRS (RR = 1.09; 95% confidence interval (CI): 1.00-1.18; P < 0.045), RTS (MD 2.3 wk; 95%CI: 0.79-3.87; P < 0.002), union rates (RR = 1.14; 95%CI: 1.01-1.28; P < 0.030) and mean times to union (MD 4.2 wk; 95%CI: 3.94-4.36; P < 0.001) were all significantly better for the surgical cohort compared to the conservative cohort.

CONCLUSION

Surgical management of scaphoid fractures can provide significantly improved RRS and RTS to sport compared to conservative management. Both treatments, however, remain acceptable options, and athletes should be fully informed of the benefits and risks of both prior to deciding treatment plans. Immediate return to sport in a cast should be avoided due to the significant risk of non-union.

The Effects of Endurance Sports on Children and Youth

In the United States, youth participation in sports continues to increase yearly. This increase in participation, in conjunction with the trend toward early sports specialization and year round training, has led to a similar increase in athletically developed injuries. These injuries vary in nature and acuity, with the type of injury often related to the athlete's age, sport, and level of training. Endurance athletes are at an elevated risk of injury as they frequently push their body to the limit during their arduous training. Pediatric endurance athletes can be particularly vulnerable, especially to overuse injuries, given their unique and ever-changing physiological state. It is important to understand the specific challenges facing not only the physical, but also the emotional well-being of these pediatric endurance athletes to maximize performance while minimizing injury and potential long-term sequelae.

Negative magnetic resonance imaging in three cases of anterior tibial cortex stress fractures

Anterior mid-tibial cortex stress fractures (ATCSF) are uncommon and notoriously challenging to treat. They are termed high risk due to their predilection to prolonged recovery, nonunion and complete fracture. Early diagnosis is essential to avoid progression and reduce fracture complications. Imaging plays a key role in confirming the diagnosis. Magnetic resonance imaging (MRI) is accepted as the gold standard modality due to its high accuracy and nonionizing properties. This report describes three cases of ATCSFs in recreational athletes who had positive radiographic findings with no significant MRI changes. Two athletes had multiple striations within their tibias. Despite the radiographic findings, their severity of symptoms were low with mild or no tenderness on examination. Clinicians should be mindful that the ATCSFs may not present with typical acute stress fracture symptoms. We recommend that plain radiographs should be used as the first line investigation when suspecting ATCSFs. Clinicians should be aware that despite MRI being considered the gold standard imaging modality, we report three cases where the MRI was unremarkable, whilst radiographs and computed tomography confirmed the diagnosis. We urge clinicians to continue to use radiographs as the first line imaging modality for ATCSFs and not to directly rely on MRI. Those who opt directly for MRI may be falsely reassured causing a delay in diagnosis.

Return to sport following tibial plateau fractures: A systematic review

AIM

To systemically review all studies reporting return to sport following tibial plateau fracture, in order to provide information on return rates and times to sport, and to assess variations in sporting outcome for different treatment methods.

METHODS

A systematic search of CINAHAL, Cochrane, EMBASE, Google Scholar, MEDLINE, PEDro, Scopus, SPORTDiscus and Web of Science was performed in January 2017 using the keywords “tibial”, “plateau”, “fractures”, “knee”, “athletes”, “sports”, “non-operative”, “conservative”, “operative”, “return to sport”. All studies which recorded return rates and times to sport following tibial plateau fractures were included.

RESULTS

Twenty-seven studies were included: 1 was a randomised controlled trial, 7 were prospective cohort studies, 16 were retrospective cohort studies, 3 were case series. One study reported on the outcome of conservative management (n = 3); 27 reported on the outcome of surgical management (n = 917). Nine studies reported on Open Reduction Internal Fixation (ORIF) (n = 193), 11 on Arthroscopic-Assisted Reduction Internal Fixation (ARIF) (n = 253) and 7 on Frame-Assisted Fixation (FRAME) (n = 262). All studies recorded “return to sport” rates. Only one study recorded a “return to sport” time. The return rate to sport for the total cohort was 70%. For the conservatively-managed fractures, the return rate was 100%. For the surgically-managed fractures, the return rate was 70%. For fractures managed with ORIF, the return rate was 60%. For fractures managed with ARIF, the return rate was 83%. For fractures managed with FRAME was 52%. The return rate for ARIF was found to be significantly greater than that for ORIF (OR 3.22, 95%CI: 2.09-4.97, P < 0.001) and for FRAME (OR 4.33, 95%CI: 2.89-6.50, P < 0.001). No difference was found between the return rates for ORIF and FRAME (OR 1.35, 95%CI: 0.92-1.96, P = 0.122). The recorded return time was 6.9 mo (median), from a study reporting on ORIF.

CONCLUSION

Return rates to sport for tibial plateau fractures remain limited compared to other fractures. ARIF provides the best return rates. There is limited data regarding return times to sport. Further research is required to determine return times to sport, and to improve return rates to sport, through treatment and rehabilitation optimisation.

Return to sport following stress fractures of the great toe sesamoids: a systematic review

INTRODUCTION

This review aims to provide information on return rates and times to sport following stress fractures of the great toe sesamoids (SFGTSs).

SOURCES OF DATA

A systematic search of CINAHAL, Cochrane, EMBASE, Google Scholar, Medline, PEDro, Scopus, SPORTDiscus and Web of Science was performed using the keywords 'stress', 'fractures', 'great', 'toe', 'sesamoid', 'athletes', 'sports', 'non-operative', 'conservative', 'operative' and 'return to sport'.

AREAS OF AGREEMENT

Fourteen studies were included: three studies reported on the outcome of conservatively-managed SFGTSs; thirteen studies reported on the outcome of surgically-managed SFGTSs. The management principles were to attempt conservative management for 2-6 months using activity modification, analgesia, orthotics and physiotherapy; if symptoms persisted following this, surgical management was to be recommended, either with internal fixation or sesamoidectomy.

AREAS OF CONTROVERSY

The optimal treatment modalities for SFGTSs remain to be defined.

GROWING POINTS

Internal fixation shows the best return to full-level sport rates with low rates of complications.

AREAS TIMELY FOR DEVELOPING RESEARCH

Future prospective studies should aim to establish the optimal treatment modalities for SFGTSs.

Lower limb stress fractures in sport: Optimising their management and outcome

Stress fractures in sport are becoming increasing more common, comprising up to 10% of all of sporting injuries. Around 90% of such injuries are located in the lower limb. This articles aims to define the optimal management of lower limb stress fractures in the athlete, with a view to maximise return rates and minimise return times to sport. Treatment planning of this condition is specific to the location of the injury. However, there remains a clear division of stress fractures by “high” and “low” risk. “Low risk” stress fractures are those with a low probability of fracture propagation, delayed union, or non-union, and so can be managed reliably with rest and exercise limitation. These include stress fractures of the Postero-Medial Tibial Diaphysis, Metatarsal Shafts, Distal Fibula, Medial Femoral Neck, Femoral Shaft and Calcaneus. “High risk” stress fractures, in contrast, have increased rates of fracture propagation, displacement, delayed and non-union, and so require immediate cessation of activity, with orthopaedic referral, to assess the need for surgical intervention. These include stress fractures of the Anterior Tibial Diaphysis, Fifth Metatarsal Base, Medial Malleolus, Lateral Femoral Neck, Tarsal Navicular and Great Toe Sesamoids. In order to establish the optimal methods for managing these injuries, we present and review the current evidence which guides the treatment of stress fractures in athletes. From this, we note an increased role for surgical management of certain high risk stress fractures to improve return times and rates to sport. Following this, key recommendations are provided for the management of the common stress fracture types seen in the athlete. Five case reports are also presented to illustrate the application of sport-focussed lower limb stress fracture treatment in the clinical setting.

Exertional Leg Pain

Exertional leg pain is a common condition seen in runners and the general population. Given the broad differential diagnosis of this complaint, this article focuses on the incidence, anatomy, pathophysiology, clinical presentation, diagnostic evaluation, and management of common causes that include medial tibial stress syndrome, tibial bone stress injury, chronic exertional compartment syndrome, arterial endofibrosis, popliteal artery entrapment syndrome, and entrapment of the common peroneal, superficial peroneal, and saphenous nerves. Successful diagnosis of these conditions hinges on performing a thorough history and physical examination followed by proper diagnostic testing and appropriate management.

Return to sport following clavicle fractures: a systematic review

INTRODUCTION

This review aims to provide information on the return rates and return times to sport following clavicle fractures.

SOURCES OF DATA

A systematic search of Medline, EMBASE, CINAHAL, Cochrane, Web of Science, PEDro, SPORTDiscus, Scopus and Google Scholar was performed using the keywords 'clavicle', 'clavicular', 'fractures', 'athletes', 'sports', 'non-operative', 'conservative', 'operative', 'return to sport'.

AREAS OF AGREEMENT

Twenty-three studies were included: 10 reported on mid-shaft fractures, 14 on lateral fractures. The management principles for athletic patients were to attempt non-operative management for undisplaced fractures to undertake operative intervention for displaced lateral fractures and to recommend operative intervention for displaced mid-shaft fractures.

AREAS OF CONTROVERSY

The optimal surgical modality for mid-shaft and lateral clavicle fractures.

GROWING POINTS

Operative management of displaced mid-shaft fractures offers improved return rates and times to sport compared to non-operative management. Suture fixation and non-acromio-clavicular joint (ACJ)-spanning plate fixation of displaced lateral fractures show promising results.

AREAS TIMELY FOR DEVELOPING RESEARCH

Future prospective studies should aim to establish the optimal treatment modalities for clavicle fractures.

Return to Sport After Tibial Shaft Fractures: A Systematic Review

CONTEXT

Acute tibial shaft fractures represent one of the most severe injuries in sports. Return rates and return-to-sport times after these injuries are limited, particularly with regard to the outcomes of different treatment methods.

OBJECTIVE

To determine the current evidence for the treatment of and return to sport after tibial shaft fractures.

DATA SOURCES

OVID/MEDLINE (PubMed), EMBASE, CINAHL, Cochrane Collaboration Database, Web of Science, PEDro, SPORTDiscus, Scopus, and Google Scholar were all searched for articles published from 1988 to 2014.

STUDY SELECTION

Inclusion criteria comprised studies of level 1 to 4 evidence, written in the English language, that reported on the management and outcome of tibial shaft fractures and included data on either return-to-sport rate or time. Studies that failed to report on sporting outcomes, those of level 5 evidence, and those in non-English language were excluded.

STUDY DESIGN

Systematic review.

LEVEL OF EVIDENCE

Level 4.

DATA EXTRACTION

The search used combinations of the terms tibial, tibia, acute, fracture, athletes, sports, nonoperative, conservative, operative, and return to sport. Two authors independently reviewed the selected articles and created separate data sets, which were subsequently combined for final analysis.

RESULTS

A total of 16 studies (10 retrospective, 3 prospective, 3 randomized controlled trials) were included (n = 889 patients). Seventy-six percent (672/889) of the patients were men, with a mean age of 27.7 years. Surgical management was assessed in 14 studies, and nonsurgical management was assessed in 8 studies. Return to sport ranged from 12 to 54 weeks after surgical intervention and from 28 to 182 weeks after nonsurgical management (mean difference, 69.5 weeks; 95% CI, -83.36 to -55.64; P < 0.01). Fractures treated surgically had a return-to-sport rate of 92%, whereas those treated nonsurgically had a return rate of 67% (risk ratio, 1.37; 95% CI, 1.20 to 1.57; P < 0.01).

CONCLUSION

The general principles are to undertake surgical management for displaced fractures and to attempt nonsurgical management for undisplaced fractures. Primary surgical intervention of undisplaced fractures, however, may result in higher return rates and shorter return times, though this exposes the patient to the risk of surgical complications, which include surgical site infection and compartment syndrome.