Nagging Injuries in the Athlete:Tibial, 5th Metatarsal and Navicular

Stress Fractures

Kenneth J. Hunt, M.D.

2014 COA Annual Meeting

Monterey, CA

Disclosures

I have no potential conflicts of interest with regard to this presentation

Stress Fractures in the foot, ankle and lower

extremity are very common in elite athletes

Nagging Injuries in the Athlete

Stress fracture:

A partial or complete bone fracture that

results from repeated application of stress of

a lower magnitude than the stress required

for bone to fail in a single loading

Nagging Injuries in the Athlete

Many occur as an acute injury after

build-up of stress

Nagging Injuries in the Athlete

• Annual incidence of stress fractures in

athletes estimated 2% to 21%.

• Track and field

– Distance runners

– Sprinters

• Basketball

• Tennis

• Volleyball

• Soccer

Who gets them?

Stress Fractures in the Athlete

• Up to 20% of Sports Medicine Visits

• 80% are in Foot/Legs

• “High Risk” stress fx:

– Tibia

– Navicular

– Proximal 5th Metatarsal (Jones)

Fredericson et al. 2006. Top Magn Reson Imaging

High risk of displacement, non-union or

refracture, requires surgical decision-making

The Burden

Risk Factors

• Intrinsic risk factors:

– Muscle fatigue/poor conditioning

– Weakness/strength imbalance

– Menstrual/hormonal irregularities

– Lower limb malalignment

– Foot structure (cavovarus)

– Height - Tall stature

– Genetic predisposition

Unmodifiable

Stress Fractures

Pes planus = FlatfootPes cavus = High arch foot

Risk FactorsStress Fractures

Varus Valgus

• Extrinsic risk factors

– Excessive volume or intensity of training

– Change in training regimen

– Change in training surface

– Worn-out training shoes

– Cigarette smoking

– Inadequate nutrition –

• calories, calcium, vitamin D

– Medications-

• chronic steroid use

Risk FactorsStress Fractures

• Female Athlete Triad:

– Disordered eating

– Amenorrhoea/oligomenorrhoea

– Osteopenia

• 50% increase in stress

fracture risk

Risk FactorsStress Fractures

Barrack et al., 2014 AJSM

High Risk Stress Fractures

• Tibia

– Posterior cortex

– Anterior tibial cortex

– Medial malleolus

• Navicular

• 5th Metatarsal (Jones fracture)

High Risk

Low risk

High Risk Stress Fractures

• Tibia

– Posterior cortex

– Anterior tibial cortex

– Medial malleolus

• Navicular

• 5th Metatarsal (Jones fracture)

High Risk

Low risk

Tibia Stress Fractures

• Most common stress fx in active population

– Military recruits

– Running and jumping athletes (very little data)

• Up to 75% of chronic leg pain in athletes

• Posteromedial cortex is most common location

Pathophysiology

• Disrupted bone homoeostasis and inadequate repair in the face of repetitive overload

Pathophysiology

• Disrupted bone homoeostasis and inadequate repair in the face of repetitive overload

• Wolff’s law

– Remodeling of microdamageJulius Wolff

Pathophysiology

• Disrupted bone homoeostasis and inadequate repair in the face of repetitive overload

• Wolff’s law

– Remodeling of microdamage

• Repeated pull of the gastrocnemius/soleus complex contributes to failure the bone

– Proximal third in young patients

– Mid/distal 1/3 junction in runners

Tibia

Soleus

Post

Tib.

Clinical Features

• Pain with activity

– Especially longer periods

• Mild discomfort persistent pain

• Eventually unable to participate/train

• Pain persists after cessation of activity

– Night pain

• Exam:

– Tenderness at midshaft tibia (medial border)

– Swelling, erythema, warmth

Radiographs

• Normal in early stages

• Lucency followed by Cortical thickening at

2-3 weeks

99Tc Bone Scan versus MRI

• Bone scan pos at 2-8 days

• MRI more sensitive and specific

MRI CT Bone Scan

Sensitivity 88% 42% 74-90%

Specificity 95-100% 89-100% 33-47%

Treatment

• Phase 1

– Rest from aggravating activities

– Ice, NSAIDs, Diet

– Usually No immobilization

– Pool, elliptical, weights

• Phase 2

– Graduated return when pain-free

– Shoe wear and running surface

– Functional orthotics, bracing • Shock absorption

• Correct mechanical imbalance

Low Risk

Treatment

• Other modalities

– Bisphosphonates • Stewart et al., 2005, CJSM

– Bone stimulators

• Effective in delayed unions

• Theoretical in stress fx

• No evidence in stress fractures

Low Risk

High Risk Stress Fractures

• Tibia

– Posterior cortex

– Anterior tibial cortex

– Medial malleolus

• Navicular

• 5th Metatarsal (Jones fracture)

High Risk

Low risk

• More common in jumpers

– Rare in distance runners

• Poor vascularity and repetitive loads

• Dreaded black line on radiograph

– Non-union

– Bone scan may be normal

Tibial Stress FracturesAnterior Cortex

• More common in jumpers

– Rare in distance runners

• Poor vascularity and repetitive loads

• Dreaded black line on XR

– Non-union

– Bone scan may be normal

• MRI Scan

– Confirm location/extent

– Acuity

Tibial Stress FracturesAnterior Cortex

• Treatment– Immobilize NWB 6-8 weeks

– Pneumatic leg brace

– Electric stim up to 10 hrs per day

• Return to sport

– Radiographic healing

– Resolution of symptoms

• Surgery if no healing at 4-6 months

– Sooner in elite athletes?

Tibial Stress FracturesAnterior Cortex

Treatment

• Surgical treatments

– Excision and bone grafting (Green 1985 AJSM)

– Drilling of defect (Rettig AJSM 1988)

– Reamed IM Nailing (Varner et al., 2005 AJSM)

• 11 tibia stress fractures (failed non-op)

• All fractures healed (mean 3 months)

• Return to sport by 4 months

High Risk Stress Fractures

• Tibia

– Posterior cortex

– Anterior tibial cortex

– Medial malleolus

• Navicular

• 5th Metatarsal (Jones fracture)

High Risk

Low risk

Medial Malleolar Stress Fractures

• Running/jumping athletes

– Repeated dorsiflexion, pronation and rotation

– Insidious onset of medial ankle pain

Medial Malleolar Stress Fractures

• History

– Pain over medial malleolus

– Swelling, no loss of ROM

• Radiographs

– May be negative up to 2 months

– Bone scan or MRI

– CT scan to confirm fracture

Clinical Features

Medial Malleolar Stress Fractures

• Modified rest 3-8 weeks

– Transition to boot when pain-free

– Gradual return to activity

• Complete healing averages 6 months

• Surgery

– Any displacement

– Fracture line on x-ray in high level athlete

Treatment

• Plate and screws

• Graft for non-union

• 4-6 weeks NWB

• Return to sport - 4.2 months

• No level 1 or 2 studies

Fracture

Medial Malleolar Stress FracturesTreatment

• Associated impingement lesion common

– Jowett et al (2008, FAI)

• Advanced imaging can usually detect

• Consider arthroscopy to remove

Medial Malleolar Stress FracturesTreatment

High Risk Stress Fractures

• Tibia

– Posterior cortex

– Anterior tibial cortex

– Medial malleolus

• Navicular

• 5th Metatarsal (Jones fracture)

High Risk

Low risk

• Diagnosis

– Running athletes

– “Ankle pain”

– Navicular Tenderness• The “N” spot

Navicular Stress FractureEvaluation

• X-rays often normal

Navicular Stress FractureRadiographs

• Imaging

– Bone scan/MRI

– Positive before fracture appears

Navicular Stress FractureRadiographic Imaging

• Imaging

– Early CT scan if

stress fracture is

suspected

Navicular Stress FractureRadiographic Imaging

• CT scan

– Determines whether complete or incomplete

– Surgery planning

Navicular Stress FractureRadiographic Imaging

• Central hypovascular region– Only in 20% of patients

– 60% with normal vascularity

Navicular Stress FractureBlood Supply

McKeon et al. 2012 FAI

“Incomplete”

Navicular Stress FractureTreatment

“Complete”I: Dorsal cortex

II: Extends to N-C joint

III: Extends to plantar cortex

“Incomplete” Stress Fx

• In the athlete these

tend to progress

screw fixation

– 1-2 screws

Navicular Stress FractureTreatment

“Incomplete” Stress Fx

• 20 yo basketball

player

• Negative x-rays

Navicular Stress FractureTreatment

“Incomplete” Stress Fx

• 20 yo basketball

player

Navicular Stress FractureTreatment

“Incomplete” Stress Fx

• 20 yo basketball

player

Navicular Stress FractureTreatment

“Incomplete” Stress Fx

• 20 yo basketball

player

• Post-op

– 6 weeks NWB

– Early ROM

– Return to play 4-6

months

Navicular Stress FractureTreatment

“Incomplete” Stress Fx

• 20 yo basketball

player

• Post-op CT

Navicular Stress FractureTreatment

“Complete” Stress Fx

• In Athletes – without delay

• Open bone grafting and screw

fixation

• Often need to debride joints

Navicular Stress FractureTreatment

“Complete” Stress Fx

• In non-athletes

• Fixation is preferred by most

• Role for conservative management?

• Torg et al., 2010 AJSM

– Non-op best for both

complete and incomplete

Non-op: 96% success

Surgery: 82% success

Navicular Stress FractureResults

Nagging Injuries in the Athlete

• Posteromedial diaphysis

• Anterior tibial cortex

• Medial malleolus

• Navicular

• 5th Metatarsal (Jones fracture)

High Risk

Low risk

What is a Jones Fracture?

Definition=

• A fracture of the 5th

metatarsal at the

metaphyseal-diaphyseal

junction in the region the

4/5 intermetatarsal

articulation

Vascular water-shed region

Non-operative

Treatment

– 72-76% heal by 5

months

– Many fail to heal or

refracture

Jones FractureThe Problem

Quill et al. 1995. Orthop Clin North Am

Surgical Treatment

• Indications

– Athlete

• Acute/stress fx

– Nonunion

– Refracture

In Sports Medicine- Our Threshold to

operate is decreasing!

Jones FractureTreatment

Operative goals

• Expedite healing

• More rapid recovery

• Accelerated rehab

• Decrease refracture risk

Jones FractureTreatment

Operative technique

• Screw fixation

– Percutaneous (no big

incision)

Jones FractureTreatment

Operative technique

• Percutaneus approach

• (+/-) Bone graft or

substitute

Jones FractureTreatment

Insert Screw “High and Inside”

HIGH & INSIDE

Jones Fracture

Surgical treatment

• Option to inject

bone graft or

BMA + DBM

Aggressive postoperative management– Weight bearing at 2 weeks

– Begin running in modified shoewear at 6 weeks (if clinically nontender)

– Avg. return to play 8 weeks

Jones FractureTreatment

Post-Operative BracingClamshell Orthosis

Post-Operative BracingClamshell Orthosis

Post-Operative BracingCustom Orthoses

Gait Analysis

Gait Analysis

No Orthotic W/ Orthotic

Jones Fractures

• Beware of Cavus Foot

Pitfalls

Jones Fractures

• Beware of Cavus Foot

• Beware of Medial Cortex Penetration

– Use multiple fluoro views

Pitfalls

Jones Fractures

• Beware of Cavus Foot

• Beware of Medial Cortex Penetration

• Beware of poor start point

Pitfalls

• Treatment of Refractures and non-unions

• Revision Fixation

• Larger diameter screw

• ICBG, or BMA + DBM

Jones FractureTreatment

• 21 Elite Athletes

• Mean Age: 27 yrs

• Union: 100%

• Ave Return 12 weeks

– (8 weeks for primary)

Hunt et al. 2010 (Am J Sports Med)

Jones FractureTreatment

Meta analysis - mostly Level 4 data

• Return to sport ranged from 4 to 18 weeks

• Non-operative treatment: union rate 76 %

• Surgical treatment: union rate 96 %

• Non-unions:

– Treated non-operatively had a union rate of 44%

– Treated surgically had union rate of 97 %

Roche and Calder, KSSTA (2013) 21:1307–1315

Jones FractureTreatment

• Stress Fractures are very common

• Be aware of risk factors – good history

• Pay attention to alignment – correct as needed

• Get the imaging you need

• Remember that sometimes surgery is the more

conservative treatment

SummaryNagging injuries in the Athlete

Thank You

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