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Kelly S, Waring A, Stone B, Pollock N. Epidemiology of bone injuries in elite athletics: A prospective 9-year cohort study. Phys Ther Sport 2024; 66:67-75. [PMID: 38340615 DOI: 10.1016/j.ptsp.2024.01.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Revised: 01/15/2024] [Accepted: 01/17/2024] [Indexed: 02/12/2024]
Abstract
OBJECTIVES To describe bone injury patterns in elite track and field athletes. To investigate relationships between bone injury and athlete characteristics to inform future injury prevention strategies. DESIGN Descriptive epidemiology study. SETTING Elite athletics training centres across the United Kingdom and internationally, observed between 2012 and 2020. PARTICIPANTS 207 Olympic programme senior track and field athletes. MAIN OUTCOME MEASURES Injury number, Incidence, Severity, Burden, Time Loss. RESULTS There were 78 fractures during the study period. Gradual repetitive bone injuries were the most common type of injury mode. The foot, pelvis and the lumbar spine were the regions with the highest number of bone stress injuries. Stress fractures had a higher burden overall compared to stress reactions. Average return to full training was 67.4 days (±73.1) for stress reactions and 199 (±205.2) days for stress fractures. There was no relationship between bone injury type and age, sex, ethnicity, side dominance or event group. CONCLUSION Bone stress injuries in athletics have a high severity and burden warranting continued efforts to prevent their occurrence and optimize management. Age, sex, ethnicity, side dominance and event region do not have any relationship with bone injury occurrence and are therefore unlikely to increase risk in this cohort.
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Affiliation(s)
- Shane Kelly
- Ballet Healthcare, The Royal Opera House, London, WC2E9DD, United Kingdom.
| | - Anthony Waring
- Fortius Clinic, 17 Fitzhardinge Street, London, W1H 6EQ, United Kingdom. https://twitter.com/Sport_Ex_Dr
| | - Ben Stone
- British Athletics, National Performance Institute (NPI), Loughborough, LE11 3TU, United Kingdom. https://twitter.com/B_W_Stone
| | - Noel Pollock
- Institute of Sport, Exercise and Health (ISEH), University College of London, London, W1T 7HA, United Kingdom. https://twitter.com/DrNoelPollock
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2
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Paavana T, Rammohan R, Hariharan K. Stress fractures of the foot - current evidence on management. J Clin Orthop Trauma 2024; 50:102381. [PMID: 38435398 PMCID: PMC10904895 DOI: 10.1016/j.jcot.2024.102381] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Revised: 02/06/2024] [Accepted: 02/21/2024] [Indexed: 03/05/2024] Open
Abstract
Stress fractures are a consequence of repeated submaximal loads with inadequate time for recovery and biologic repair or remodelling. The foot and ankle complex (FAC) represents a common site for development of stress fractures. Whilst the overall incidence of stress fractures is low, they are prevalent in athletes and military personnel causing significant time away from sports or work. Within these populations, certain stress fractures directly correlate to specific activities. Factors that commonly influence these fractures include an acute increase in new repetitive physical activity combined with muscle fatigue, training errors or improper athletic techniques, which challenge the regenerative and remodelling capacity of bone. Depending on the site that is subject to repetitive loading, various biomechanical factors can result in abnormal concentration of forces to specific areas of the FAC resulting in stress fracture. Decreased bone marrow density (BMD) is a major biologic cause for developing stress fractures. The female athlete triad comprising eating disorder, amenorrhea and osteoporosis in competitive athletes also predisposes to stress fractures. Vitamin D deficiency is also postulated to be the cause of these fractures and may contribute to poor healing. Clinical presentation is usually with vague pain of insidious onset which worsens with activity and improves with rest. Diffuse tenderness over the affected bone is common with only a minority having any visible swelling. Plain radiographs are the first line of investigation but rarely reveal an obvious fracture. MRI scans aid in diagnosis and CT scans help in treatment and characterisation of the fracture and monitor healing. Management relates to the site of injury, which stratifies them into high or low-risk. Stress fractures of the calcaneus, cuboid and cuneiforms are classed as low-risk fractures as they usually heal with simple activity modification or short duration of non-weight bearing. Stress fractures of the navicular, talus and hallucal sesamoids are classed as high-risk fractures due to higher rates of non-union and prolonged recovery time. Metatarsal fractures can be considered high or low-risk depending on location. These warrant aggressive management, often requiring surgical intervention. Adjuncts such as vitamin D supplements, external shockwave therapy, low-intensity pulsed ultrasound therapy have been used with varying success but there remains little supportive evidence of superiority in the available literature.
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Affiliation(s)
- Thumri Paavana
- The Robert Jones and Agnes Hunt Orthopaedic Hospital, Oswestry, United Kingdom
| | - R. Rammohan
- The Grange University Hospital, Cwmbran, United Kingdom
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3
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Lohrer H. [High-risk stress fractures in competitive athletes]. UNFALLCHIRURGIE (HEIDELBERG, GERMANY) 2023; 126:848-855. [PMID: 37341736 DOI: 10.1007/s00113-023-01339-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 05/08/2023] [Indexed: 06/22/2023]
Abstract
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.
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Affiliation(s)
- Heinz Lohrer
- ESN - European SportsCare Network, Zentrum für Sportorthopädie, Borsigstr. 2, 65205, Wiesbaden-Nordenstadt, Deutschland.
- Institut für Sport und Sportwissenschaft, Albert-Ludwigs-Universität, Freiburg, Deutschland.
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Drexelius K, Bartolomei J, Shu A, Hunt KJ. Os supranaviculare and navicular osteochondral lesion contributing to the development of a navicular stress fracture in an adolescent male athlete: Case report. J ISAKOS 2022; 8:128-134. [PMID: 36370967 DOI: 10.1016/j.jisako.2022.10.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Revised: 08/30/2022] [Accepted: 10/23/2022] [Indexed: 11/11/2022]
Abstract
Stress fractures of the tarsal navicular bone can be problematic in the athlete. This case details the injury and outcome of an adolescent male athlete who experienced one year of intermittent foot pain without acute trauma. Radiographs and computed tomography demonstrated a triad of a navicular stress fracture, an os supranaviculare, and an osteochondral defect of the navicular bone. The patient underwent successful operative fixation and returned to painless full function with imaging demonstrating healing at six months. Diagnosis of a navicular stress fracture in the setting of both an os supranaviculare and osteochondral lesion of the navicular bone have not been reported elsewhere in the literature. While repetitive loading on the navicular bone can independently produce a stress fracture, the patient had an increased risk for this injury; the presumably pre-existing navicular osteochondral lesion and os supranaviculare may have resulted in decreased effective articular surface area, thereby increasing force on the navicular bone and producing a stress fracture. Understanding navicular stress fractures and concomitant bony pathology contributing to injury is crucial to successful diagnosis, management, and prevention of recurrence.
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Affiliation(s)
- Katherine Drexelius
- University of Colorado School of Medicine, 13001 E. 17th Pl, Box C290, Aurora, CO 80045, USA
| | - Jonathan Bartolomei
- Department of Orthopedic Surgery, University of Colorado, 12631 E. 17th Ave, Room 4508, Aurora, CO 80045, USA
| | - Alexander Shu
- University of Colorado School of Medicine, 13001 E. 17th Pl, Box C290, Aurora, CO 80045, USA
| | - Kenneth J Hunt
- Department of Orthopedic Surgery, University of Colorado, 12631 E. 17th Ave, Room 4508, Aurora, CO 80045, USA.
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5
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Tzagiollari A, McCarthy HO, Levingstone TJ, Dunne NJ. Biodegradable and Biocompatible Adhesives for the Effective Stabilisation, Repair and Regeneration of Bone. BIOENGINEERING (BASEL, SWITZERLAND) 2022; 9:bioengineering9060250. [PMID: 35735493 PMCID: PMC9219717 DOI: 10.3390/bioengineering9060250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Revised: 05/11/2022] [Accepted: 06/06/2022] [Indexed: 11/19/2022]
Abstract
Bone defects and complex fractures present significant challenges for orthopaedic surgeons. Current surgical procedures involve the reconstruction and mechanical stabilisation of complex fractures using metal hardware (i.e., wires, plates and screws). However, these procedures often result in poor healing. An injectable, biocompatible, biodegradable bone adhesive that could glue bone fragments back together would present a highly attractive solution. A bone adhesive that meets the many clinical requirements for such an application has yet to be developed. While synthetic and biological polymer-based adhesives (e.g., cyanoacrylates, PMMA, fibrin, etc.) have been used effectively as bone void fillers, these materials lack biomechanical integrity and demonstrate poor injectability, which limits the clinical effectiveness and potential for minimally invasive delivery. This systematic review summarises conventional approaches and recent developments in the area of bone adhesives for orthopaedic applications. The required properties for successful bone repair adhesives, which include suitable injectability, setting characteristics, mechanical properties, biocompatibility and an ability to promote new bone formation, are highlighted. Finally, the potential to achieve repair of challenging bone voids and fractures as well as the potential of new bioinspired adhesives and the future directions relating to their clinical development are discussed.
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Affiliation(s)
- Antzela Tzagiollari
- School of Mechanical and Manufacturing Engineering, Dublin City University, D09 NA55 Dublin, Ireland; (A.T.); (T.J.L.)
- Centre for Medical Engineering Research, Dublin City University, D09 NA55 Dublin, Ireland
| | - Helen O. McCarthy
- School of Pharmacy, Queen’s University, Belfast BT9 7BL, UK;
- School of Chemical Sciences, Dublin City University, D09 NA55 Dublin, Ireland
- Biodesign Europe, Dublin City University, D09 NA55 Dublin, Ireland
| | - Tanya J. Levingstone
- School of Mechanical and Manufacturing Engineering, Dublin City University, D09 NA55 Dublin, Ireland; (A.T.); (T.J.L.)
- Centre for Medical Engineering Research, Dublin City University, D09 NA55 Dublin, Ireland
- Biodesign Europe, Dublin City University, D09 NA55 Dublin, Ireland
- Tissue, Engineering Research Group, Department of Anatomy and Regenerative Medicine, Royal College of Surgeons in Ireland, D02 PN40 Dublin, Ireland
- Advanced Manufacturing Research Centre (I-Form), School of Mechanical and Manufacturing Engineering, Dublin City University, D09 NA55 Dublin, Ireland
- Advanced Processing Technology Research Centre, Dublin City University, D09 NA55 Dublin, Ireland
- Trinity Centre for Biomedical Engineering, Trinity Biomedical Sciences Institute, Trinity College Dublin, D02 PN40 Dublin, Ireland
| | - Nicholas J. Dunne
- School of Mechanical and Manufacturing Engineering, Dublin City University, D09 NA55 Dublin, Ireland; (A.T.); (T.J.L.)
- Centre for Medical Engineering Research, Dublin City University, D09 NA55 Dublin, Ireland
- Biodesign Europe, Dublin City University, D09 NA55 Dublin, Ireland
- Advanced Manufacturing Research Centre (I-Form), School of Mechanical and Manufacturing Engineering, Dublin City University, D09 NA55 Dublin, Ireland
- Advanced Processing Technology Research Centre, Dublin City University, D09 NA55 Dublin, Ireland
- Trinity Centre for Biomedical Engineering, Trinity Biomedical Sciences Institute, Trinity College Dublin, D02 PN40 Dublin, Ireland
- Advanced Materials and Bioengineering Research Centre (AMBER), Trinity College Dublin, D02 PN40 Dublin, Ireland
- Department of Mechanical and Manufacturing Engineering, School of Engineering, Trinity College Dublin, D02 PN40 Dublin, Ireland
- Correspondence: ; Tel.: +353-(0)1-7005712
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Abstract
The tarsal navicular is an essential component of the Chopart joint and crucial for most of hindfoot motion. Most fractures are low-energy dorsal avulsions that may be treated nonoperatively. Displaced comminuted fractures require open reduction and internal fixation, sometimes with external fixation, bridge plating, and bone grafting. Diagnosis of stress fractures is commonly delayed. Conservative treatment is associated with good results, but surgery allows for quicker return-to-play in athletes. Nonunion in acute and stress fractures needs open debridement, grafting, and stable fixation. Müller-Weiss disease may present with a fragmented navicular and mimic an acute or a stress fracture.
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Affiliation(s)
- Manuel Monteagudo
- Orthopaedic Foot and Ankle Unit, Orthopaedic and Trauma Department, Hospital Universitario Quirónsalud Madrid, Faculty Medicine UEM Madrid, Calle Diego de Velazquez 1, 28223 Pozuelo de Alarcón, Madrid, Spain.
| | - Pilar Martínez-de-Albornoz
- Orthopaedic Foot and Ankle Unit, Orthopaedic and Trauma Department, Hospital Universitario Quirónsalud Madrid, Faculty Medicine UEM Madrid, Calle Diego de Velazquez 1, 28223 Pozuelo de Alarcón, Madrid, Spain
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7
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Nunley JA, Green C, Morash J, Easley ME. Treatment of Navicular Stress Fractures With an Algorithmic Approach. Foot Ankle Int 2022; 43:12-20. [PMID: 34404262 DOI: 10.1177/10711007211034812] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Navicular stress fractures are becoming increasingly more common. There is no universal consensus on treatment. We provide an algorithm that we feel will be useful in determining treatment. METHODS A retrospective study was performed on all patients having operative treatment of navicular stress fractures during a 10-year period. Acute fractures were treated with open reduction internal fixation. Chronic fractures greater than 3 months were treated with open reduction and internal fixation (ORIF) and iliac crest bone grafting. Chronic fractures with evidence of sclerosis, avascular changes, or those who failed previous surgery were treated with ORIF, iliac crest bone grafting, as well as vascular bone grafting. Patients' pain scores were recorded and a return-to-sports scale was used. Radiographic union was compared among the 3 groups using computed tomographic (CT) scans or radiographs. RESULTS Forty-three patients were identified. Fifteen received ORIF alone, 12 were treated with ORIF and bone graft, and 16 had ORIF with vascularized bone grafting. No difference was found among the median age of the 3 groups. In terms of radiographic healing, 3 patients in the ORIF group received radiographs alone. All other patients had follow-up CT scans. ORIF alone group had 80% union, ORIF with bone graft had 75% union, and ORIF with vascularized bone grafting had 100% union. Return to sports did not show any difference among the 3 groups. CONCLUSION The algorithm dividing navicular stress fractures into 3 distinct groups with different operative techniques helped us address these difficult cases. Vascularized bone grafting certainly appeared to be beneficial for the more difficult cases. LEVEL OF EVIDENCE Level IV, case series.
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Affiliation(s)
- James A Nunley
- Department of Orthopaedic Surgery, Division of Foot and Ankle Surgery, Duke University Health System, Durham, NC, USA
| | - Cynthia Green
- Department of Basic Sciences, Duke University, Durham, NC, USA
| | - Joel Morash
- Specializing in Reconstructive Foot and Ankle Surgery, Queen Elizabeth II Health Sciences Center, Dalhousie University, Halifax, NS, Canada
| | - Mark E Easley
- Department of Orthopaedic Surgery, Division of Foot and Ankle Surgery, Duke University Health System, Durham, NC, USA
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8
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Strassberg J, Ahmed A. Pediatric Sports Injuries. Clin Podiatr Med Surg 2022; 39:89-103. [PMID: 34809797 DOI: 10.1016/j.cpm.2021.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Recreational sports are more popular, with many athletes involved year-round in multiple sports and on multiple teams. Most athletes do not take proper rest, making them more susceptible to stress-related injuries. There are numerous sports-related injuries in the foot and ankle. These issues can be non-traumatic, due to chronic repetitive stresses, or traumatic. Most of these injuries are managed conservatively, and athletes do well and return to play, while some do better with operative management. This article discusses a few of the sports injuries that are common in the leg, foot, and ankle and the recovery process.
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Affiliation(s)
- Joshua Strassberg
- The Pediatric Orthopedic Center, 218 Ridgedale Avenue, Suite 101, Cedar Knolls, NJ 07927, USA
| | - Aamir Ahmed
- Ankle and Foot Doctors of New Jersey, 225 Millburn Avenue, Suite #104B, Millburn, NJ 07041, USA.
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9
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Treatment of Navicular Stress Fracture Accompanied by Os Supranaviculare: A Case Report. Medicina (B Aires) 2021; 58:medicina58010027. [PMID: 35056335 PMCID: PMC8781933 DOI: 10.3390/medicina58010027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Revised: 12/19/2021] [Accepted: 12/22/2021] [Indexed: 11/17/2022] Open
Abstract
Navicular stress fractures (NSFs) are relatively uncommon, and predominantly affect athletes. Patients complain of vague pain, bruising, and swelling in the dorsal aspect of the midfoot. Os supranaviculare (OSSN) is an accessory ossicle located above the dorsal aspect of the talonavicular joint. There have been few previous reports of NSFs accompanied by OSSN. Herein we report the case of a patient with OSSN who was successfully treated for an NSF. A 34-year-old Asian man presented with a 6-month history of insidious-onset dorsal foot pain that occasionally radiated medially toward the arch. The pain worsened while sprinting and kicking a soccer ball with the instep, whereas it was temporarily relieved by rest for a week and analgesics. Plain radiographs of the weight-bearing foot and ankle joints revealed a bilateral, well-corticated OSSN. Computed tomography (CT) revealed a sagittally oriented incomplete fracture that extended from the dorsoproximal cortex to the center of the body of the navicular. The OSSN was excised and the joint was immobilized with a non-weight-bearing cast for 6 weeks, followed by gradual weight bearing using a boot. The 5-month follow-up CT scan demonstrated definite fracture healing. At the 1-year follow-up, the patient’s symptoms had resolved, the American Orthopedic Foot and Ankle Society midfoot score had improved from 61 to 95 points, and the visual analog scale pain score had improved from 6 to 0. We describe a rare case of NSF accompanied by OSSN. Because of the fracture gap and biomechanical properties of OSSN, OSSN was excised and the joint was immobilized, leading to a successful outcome. Further research is required to evaluate the relationship between NSFs and OSSN, and determine the optimal management of NSFs in patients with OSSN.
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10
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Stress Fractures of the Foot and Ankle. OPER TECHN SPORT MED 2021. [DOI: 10.1016/j.otsm.2021.150852] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Abstract
Navicular stress fractures are multifactorial injuries due to chronic overload on the navicular, particularly in young athletes. The navicular is subject to unique stresses and has a complex blood supply, making it susceptible to stress fractures and potentially delayed union or nonunion. Expeditious diagnosis is critical to prevent a delay in treatment and a poor outcome. Advanced imaging is essential in making the diagnosis and monitoring healing. Both nonsurgical and surgical treatments have demonstrated good results. Nonsurgical management consists of a period of immobilization and nonweight bearing, and surgical management typically involves open reduction and internal fixation. Patients need to be appropriately counseled regarding expectations for these challenging injuries.
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Abe K, Hashiguchi H, Sonoki K, Iwashita S, Takai S. Tarsal Navicular Stress Fracture in a Young Athlete: A Case Report. J NIPPON MED SCH 2019; 86:122-125. [PMID: 31130563 DOI: 10.1272/jnms.jnms.2019_86-208] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Approximately 30% of tarsal navicular stress fractures are missed by physicians because plain radiographs often show no diagnostic clues. If early diagnosis and treatment are not obtained, such fractures will become refractory and the patient will no longer be able to actively participate as an athlete. We herein describe our experience treating a 14-year-old female track sprinter with persistent foot pain. Magnetic resonance imaging 6 months after the onset of pain showed a stress fracture of the tarsal navicular bone. Computed tomography showed the tarsal navicular stress fracture as well as sclerosis at the fracture edges. We diagnosed a refractory tarsal navicular stress fracture. Conservative management in the form of non-weight-bearing cast immobilization is the standard treatment for both partial and complete stress fractures of the tarsal navicular bone. However, surgical treatment is required in refractory cases. We treated the herein-described refractory case with 6 weeks of non-weight-bearing cast immobilization. We instructed the patient to perform quad muscle training at the same time as casting. Six weeks later, follow-up computed tomography showed callus formation and disappearance of the fracture line. The patient thus began full weight bearing with daily use of arch support equipment, and we allowed her to gradually return to sports. We gradually increased her activity intensity from jogging to running. She completely and successfully returned to sports after 3 months of treatment.
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Affiliation(s)
- Kazumasa Abe
- Department of Orthopedic Surgery, Nippon Medical School Chiba Hokusoh Hospital
| | - Hiroshi Hashiguchi
- Department of Orthopedic Surgery, Nippon Medical School Chiba Hokusoh Hospital
| | - Kentaro Sonoki
- Department of Orthopedic Surgery, Nippon Medical School Chiba Hokusoh Hospital
| | - Satoshi Iwashita
- Department of Orthopedic Surgery, Nippon Medical School Hospital
| | - Shinro Takai
- Department of Orthopedic Surgery, Nippon Medical School Hospital
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Shaner AC, Spiker AM, Goolsby MA, Kelly BT, Helfet DL. Case report: ischial stress fracture non-union in a college football player. J Hip Preserv Surg 2018; 5:312-318. [PMID: 30393560 PMCID: PMC6206699 DOI: 10.1093/jhps/hny019] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2018] [Accepted: 05/19/2018] [Indexed: 12/31/2022] Open
Abstract
Stress fractures are common injuries associated with repetitive high-impact activities, often in high-level athletes and military recruits. Although predominantly occurring in the lower extremities, stress fractures may occur wherever there is a sudden increase in frequency or intensity of activity, thereby overloading the yield point of the local bone environment. Ischial stress fractures are a rarely diagnosed cause of pain around the hip and pelvis. Often, patients present with buttock pain with activity, which can be misdiagnosed as proximal hamstring tendonitis or avulsion. Here, we report a case of a college football player who was diagnosed with an ischial stress fracture which went on to symptomatic non-union after extensive conservative management. We treated his ischial non-union with open reduction internal fixation utilizing a tension band plate and screws. This interesting case highlights an uncommon cause of the relatively common presentation of posterior hip pain and describes our technique for addressing a stress fracture non-union in the ischium.
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Affiliation(s)
- Adam C Shaner
- Department of Orthopaedic Surgery, Trauma Surgery, Westchester Medical Center, New York Medical College, NY, USA
| | - Andrea M Spiker
- Department of Orthopedic Surgery, Sports Medicine and Hip Preservation, University of Wisconsin – Madison, Madison, WI, USA
| | | | - Bryan T Kelly
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY, USA
| | - David L Helfet
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY, USA
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Saxena A, Behan SA, Valerio DL, Frosch DL. Navicular Stress Fracture Outcomes in Athletes: Analysis of 62 Injuries. J Foot Ankle Surg 2018; 56:943-948. [PMID: 28842101 DOI: 10.1053/j.jfas.2017.06.009] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2017] [Indexed: 02/03/2023]
Abstract
The optimal treatment modalities for navicular stress fractures in athletes is currently unknown for this season-ending injury. The present study evaluated factors that might be significant and affect healing outcomes, specifically focusing on the return to activity (RTA) time and a decreased desired activity (DDA) after treatment in athletes. Such considerations included previous navicular stress fractures, patient demographic data and type of sport, and initiation time of treatment. The data from 59 patients with 62 fractures were prospectively analyzed from May 2005 through July 2016. The results showed a significant correlation between a previous navicular stress fracture and decreased desired activity. The average duration of symptoms before receiving definitive treatment was 8.8 months. Computed tomography as the initial imaging modality correlated positively with a correct diagnosis (1.00). In contrast, magnetic resonance imaging, when used initially, was only 71% accurate. Runners constituted most of the cohort at 38 (61.3%). Ten other athletes were involved in jumping sports. Of the 62 injuries, 21 (33.9%) were in elite or professional athletes, all of whom were able to RTA, with 1 patient, a 38-year-old world record holding runner, having a DDA. Seven refractures (11.2%) occurred an average >5 years after the initial injury, predominantly in those aged <21 years, none with previous surgery. Eight patients (12.9%) developed postinjury arthrosis, including 1 with DDA. Patients who underwent open reduction and internal fixation had a RTA of 4.56 months compared with those who had undergone nonoperative treatment, who had an average RTA of 3.97 months. Seven patients (11.2%) underwent screw removal and required a longer RTA. Overall, of the 62 injuries, the patients with 57 of the injuries (91.9%) were able to RTA at their preinjury level.
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Affiliation(s)
- Amol Saxena
- Podiatrist, Department of Sports Medicine, PAMF-Sutter, Palo Alto, CA.
| | - Shontal A Behan
- Student, California School of Podiatric Medicine, Oakland, CA
| | | | - Dominick L Frosch
- Adjunct Associate Professor, Department of Medicine, University of California at Los Angeles, Los Angeles, CA; Senior Scientist, PAMFRI, Palo Alto, CA
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15
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Paisan G, Magister S, Bridgforth A, Yarboro S. Non-traumatic isolated medial cuneiform fracture: A unique mechanism of a rare injury. SAGE Open Med Case Rep 2017; 5:2050313X17744483. [PMID: 29238575 PMCID: PMC5721952 DOI: 10.1177/2050313x17744483] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2017] [Accepted: 09/21/2017] [Indexed: 11/17/2022] Open
Abstract
We report a case of a 23-year-old woman who sustained a stress fracture to the medial cuneiform. Isolated medial cuneiform fractures are extremely rare with less than 10 cases reported in the literature. The patient initially presented to an urgent care facility complaining of right midfoot pain that occurred while running. Radiographs obtained at the time showed no acute abnormality and the patient was told to resume normal activities. Several weeks later, she presented to urgent care again after exercising, this time unable to bear weight and with swelling and ecchymoses of the right foot. Plain radiographs were again normal, but a high suspicion for injury remained, so a magnetic resonance imaging of the foot was obtained. The advanced imaging showed an acute, non-displaced fracture of the medial cuneiform. Because the fracture was discovered soon after the injury and was non-displaced, she was treated conservatively and at 6-month follow up had returned to all pre-injury activities with no complaints. These rare fractures are often missed at initial presentation because they are usually not evident on plain radiographs. Unless more advanced imaging is obtained to rule out a fracture, a delay of diagnosis can occur resulting in additional morbidity for the patient. Level of clinical evidence: Level 5
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Affiliation(s)
- Gabriella Paisan
- University of Virginia School of Medicine, Charlottesville, VA, USA
| | - Steven Magister
- University of Virginia School of Medicine, Charlottesville, VA, USA
| | | | - Seth Yarboro
- University of Virginia School of Medicine, Charlottesville, VA, USA
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Mandell JC, Khurana B, Smith SE. Stress fractures of the foot and ankle, part 2: site-specific etiology, imaging, and treatment, and differential diagnosis. Skeletal Radiol 2017; 46:1165-1186. [PMID: 28343329 DOI: 10.1007/s00256-017-2632-7] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2017] [Revised: 02/22/2017] [Accepted: 03/13/2017] [Indexed: 02/06/2023]
Abstract
Stress fractures of the foot and ankle are a commonly encountered problem among athletes and individuals participating in a wide range of activities. This illustrated review, the second of two parts, discusses site-specific etiological factors, imaging appearances, treatment options, and differential considerations of stress fractures of the foot and ankle. The imaging and clinical management of stress fractures of the foot and ankle are highly dependent on the specific location of the fracture, mechanical forces acting upon the injured site, vascular supply of the injured bone, and the proportion of trabecular to cortical bone at the site of injury. The most common stress fractures of the foot and ankle are low risk and include the posteromedial tibia, the calcaneus, and the second and third metatarsals. The distal fibula is a less common location, and stress fractures of the cuboid and cuneiforms are very rare, but are also considered low risk. In contrast, high-risk stress fractures are more prone to delayed union or nonunion and include the anterior tibial cortex, medial malleolus, navicular, base of the second metatarsal, proximal fifth metatarsal, hallux sesamoids, and the talus. Of these high-risk types, stress fractures of the anterior tibial cortex, the navicular, and the proximal tibial cortex may be predisposed to poor healing because of the watershed blood supply in these locations. The radiographic differential diagnosis of stress fracture includes osteoid osteoma, malignancy, and chronic osteomyelitis.
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Affiliation(s)
- Jacob C Mandell
- Division of Musculoskeletal Imaging and Intervention, Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, 02115, USA.
| | - Bharti Khurana
- Division of Emergency Radiology, Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Stacy E Smith
- Division of Musculoskeletal Imaging and Intervention, Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, 02115, USA
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17
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Vopat B, Beaulieu-Jones BR, Waryasz G, McHale KJ, Sanchez G, Logan CA, Whalen JM, DiGiovanni CW, Provencher MT. Epidemiology of Navicular Injury at the NFL Combine and Their Impact on an Athlete's Prospective NFL Career. Orthop J Sports Med 2017; 5:2325967117723285. [PMID: 28840151 PMCID: PMC5565004 DOI: 10.1177/2325967117723285] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
Background: Navicular injuries can result in persistent pain, posttraumatic osteoarthritis, and diminished performance and function. Purpose: To determine the epidemiology of navicular fracture in players participating in the National Football League (NFL) Scouting Combine and evaluate the impact of a navicular injury on the NFL draft position and NFL game play compared with matched controls. Study Design: Cohort study; Level of evidence, 3. Methods: Data were collected on players who previously sustained a navicular injury and participated in the NFL Combine between 2009 and 2015. The epidemiology of navicular injury was determined through an evaluation of the number of injuries, surgeries, and collegiate games missed as well as the position played, a physical examination, the surgical technique, and imaging findings. Players with a previous navicular injury (2009-2013) were compared with a set of matched controls. NFL performance outcomes included the draft position, career length ≥2 years, and number of games played and started within the first 2 years. Results: Between 2009 and 2015, 14 of 2285 (0.6%) players were identified as having sustained a navicular injury. A total of 11 of 14 (79%) athletes had sustained an overt navicular fracture, while 3 of 14 (21%) were diagnosed with stress reactions on magnetic resonance imaging. Eight patients who sustained a navicular fracture underwent surgery. There was evidence of ipsilateral talonavicular arthritis in 75% of players with a navicular fracture versus only 60% in the uninjured foot (odds ratio, 1.3; P = .04). Fifty-seven percent of players with navicular injury (72.7% of fractures) were undrafted versus 30.9% in the control group (P = .001). Overall, 28.6% of players with navicular fracture played ≥2 years in the NFL compared with 69.6% in the control group (P = .02). Conclusion: A previous navicular fracture results in a greater risk of developing posttraumatic osteoarthritis. Although only a low prevalence of navicular injury in prospective NFL players was noted, players with these injuries had a greater probability of not being drafted and not competing in at least 2 NFL seasons when compared with matched controls without an injury history to the NFL Combine.
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Affiliation(s)
- Bryan Vopat
- University of Kansas Medical Center, Kansas City, Kansas, USA
| | | | | | - Kevin J McHale
- Cape Regional Medical Center, Cape May Court House, New Jersey, USA
| | - George Sanchez
- Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA
| | | | | | | | - Matthew T Provencher
- The Steadman Clinic, Vail, Colorado, USA.,Steadman Philippon Research Institute, Vail, Colorado, USA
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18
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Dobson JA, Riddiford-Harland DL, Bell AF, Steele JR. Effect of work boot type on work footwear habits, lower limb pain and perceptions of work boot fit and comfort in underground coal miners. APPLIED ERGONOMICS 2017; 60:146-153. [PMID: 28166873 DOI: 10.1016/j.apergo.2016.11.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/29/2016] [Revised: 11/11/2016] [Accepted: 11/14/2016] [Indexed: 06/06/2023]
Abstract
Lower limb injuries are highly prevalent in underground coal mining. Wearing gumboots with inadequate ankle support was thought to contribute to these injuries. Despite the uptake of leather lace-up boots, which provide more ankle support, no recent research could be found investigating the effect of this alternative work boot in underground coal mining. Consequently, this study aimed to determine whether boot type (gumboot, leather lace-up boot) influenced work footwear habits, foot problems, lower limb pain, lower back pain, or perceptions of work boot fit and comfort in underground coal miners. Chi-squared tests were applied to 358 surveys completed by underground coal miners to determine whether responses differed significantly (p < 0.05) according to boot-type. There were no significant between-boot differences in regards to the presence of foot problems, lower limb pain or lower back pain. However, the types of foot problems and locations of foot pain differed according to boot type. Gumboot wearers were also more likely to state that their work boot comfort was either 'uncomfortable' or 'indifferent', their work boot fit was 'poor' and their current boot did not provide enough support. The introduction of more structured leather lace-up boots appears to have positively influenced the support and fit provided by mining work boots, although foot problems, lower limb pain and lower back pain continue to be reported. Further investigation is recommended to identify which specific boot design features caused these observed differences in work boot fit, comfort and locations of foot pain and how these design features can be manipulated to create an underground coal mining work boot that is comfortable and reduces the high incidence of foot problems and lower limb pain suffered by underground coal miners.
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Affiliation(s)
- Jessica A Dobson
- Biomechanics Research Laboratory, School of Medicine, Faculty of Science, Medicine & Health, University of Wollongong, Wollongong, Australia.
| | - Diane L Riddiford-Harland
- Biomechanics Research Laboratory, School of Medicine, Faculty of Science, Medicine & Health, University of Wollongong, Wollongong, Australia
| | - Alison F Bell
- Biomechanics Research Laboratory, School of Medicine, Faculty of Science, Medicine & Health, University of Wollongong, Wollongong, Australia
| | - Julie R Steele
- Biomechanics Research Laboratory, School of Medicine, Faculty of Science, Medicine & Health, University of Wollongong, Wollongong, Australia
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19
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Hong CC, Pearce CJ, Ballal MS, Calder JDF. Management of sports injuries of the foot and ankle: An update. Bone Joint J 2017; 98-B:1299-1311. [PMID: 27694582 DOI: 10.1302/0301-620x.98b10.37896] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2016] [Accepted: 07/05/2016] [Indexed: 12/23/2022]
Abstract
Injuries to the foot in athletes are often subtle and can lead to a substantial loss of function if not diagnosed and treated appropriately. For these injuries in general, even after a diagnosis is made, treatment options are controversial and become even more so in high level athletes where limiting the time away from training and competition is a significant consideration. In this review, we cover some of the common and important sporting injuries affecting the foot including updates on their management and outcomes. Cite this article: Bone Joint J 2016;98-B:1299-1311.
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Affiliation(s)
- C C Hong
- National University Hospital, 5 Lower Kent Ridge Road, 119074, Singapore
| | - C J Pearce
- Jurong Health, NTFGH Hospital, 609606, Singapore
| | - M S Ballal
- Fortius Clinic, 17 Fitzhardinge Street, London W1H 6EQ, UK
| | - J D F Calder
- Fortius Clinic, 17 Fitzhardinge Street, London W1H 6EQ, UK
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Abstract
PURPOSE OF REVIEW Navicular stress fractures are common in athletes and management is debated. This article will review the evaluation and management of navicular stress fractures. RECENT FINDINGS Various operative and non-operative adjunctive treatment modalities are reviewed including the relevance of vitamin D levels, use of shock wave therapy and bone marrow aspirate concentrate (BMAC), and administration of teriparatide. Surgical treatment may be associated with earlier return to sports. The author's preferred treatment algorithm with corresponding images is presented which allows for safe and rapid return to activities in the athletic patient. Future research is needed in evaluating the preventative effects of vitamin D and use of other adjunctive treatments to increase the healing rates of this fracture.
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Affiliation(s)
- Rachel J Shakked
- Rothman Institute, 3300 Tillman Drive, 2nd Floor, Bensalem, PA, 19020-2071, USA.
| | - Emily E Walters
- University of Texas McGovern Medical School, Houston, TX, USA
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Abstract
The incidence of stress fractures in the general athletic population is less than 1%, but may be as high as 15% in runners. Stress fractures of the foot and ankle account for almost half of bone stress injuries in athletes. These injuries occur because of repetitive submaximal stresses on the bone resulting in microfractures, which may coalesce to form complete fractures. Advanced imaging such as MRI and triple-phase bone scans is used to evaluate patients with suspected stress fracture. Low-risk stress fractures are typically treated with rest and protected weight bearing. High-stress fractures more often require surgical treatment.
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