Current Trends in Lower Leg Injuries in the Endurance Runner

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					                                                       General Considerations
Current Trends in Lower Leg                                      Patient history

 Injuries in the Endurance                • Timing and duration of pain
                                              – At start of workout, then subsides
           Runner                             – Develops and worsens into the run
                                              – Arises after workout completed
         Jason Freedman, M.D.
                                          • Training regimen
             April  17, 2010                  – Mileage
                                              – Intensity
                                              – Running surface
                                              – Footwear




     General Considerations                            General Considerations
         Patient foot anatomy                                   Patient anatomy
                                                    Pronation                                             Supination
                                          •   Eversion hindfoot                         •     Inversion hindfoot
                                          •   Abduction forefoot                        •     Adduction forefoot
                                          •   Tibiotalar dorsiflexion                   •     Tibiotalar plantarflexion
                                          •   Medial arch depression                    •     Medial arch elevation
                                          •   Causes tibial internal                    •     Causes tibial external 
                                              rotation                                        rotation




     General Considerations                            General Considerations
               Patient anatomy                              Patient biomechanics
                                                                  Gait Cycle
   Pronation                 Supination




                                                                  from DeLee and Drez's Orthopaedic Sports Medicine




                                                                                                                          1
        General Considerations                                                                        General Considerations
                                                                             Normal                                                                              Overpronation




                                                                  Heel strike                                                                                 Heel strike




                                                                  Transition                                                                                   Transition




                                                                                                                                                                Toe off




                                                                   Toe off

                        www.runnersworld.com                                                                         www.runnersworld.com




        General Considerations                                                                        General Considerations
                                                                    Underpronation
                                                                                              • Foot wear
                                                                                                – Motion control running shoes
                                                                  Heel strike
                                                                                                – Cushion running shoes
                                                                                                – Stability / neutral running shoes


                                                                   Transition




                                                                   Toe off

                        www.runnersworld.com




        General Considerations                                                                        General Considerations
• Foot wear                                                                                   • Foot wear
  – Motion controlled shoe                                                                      – Cushion running shoe
     • Indicated for excessive                                                                     • Indicated for underpronation / 
       pronation / low arch                                                                          high arch
     • Stiffer medial midsole with                                                                 • More cushioning decreases 
       wedge                                                                                         loading rate
     • More compliant lateral sole                                                                 • More flexible forefoot
     • Helps decrease hindfoot                                                                     • Heel designed to encourage 
       eversion                                                                                      more pronation on heel strike



                                               DeLee and Drez's Orthopaedic Sports Medicine                                                 DeLee and Drez's Orthopaedic Sports Medicine




                                                                                                                                                                                           2
        General Considerations                                                                              General Considerations
• Foot wear                                                                                   • Foot wear
  – Stability / neutral running shoe                                                                   • Is there support for specific shoe types?
     • Indicated for normal pronation / 
       arch                                                                                         YES                                                    NO
     • Compromise of motion control 
                                                                                          •Butler AJSM 2006, UNC                      •Knapik AJSM 2010, US Marine Corp 
       and cushioned shoe                                                                 •Butler Gait Posture 2007, Univ. of         •Knapik Am J Prev Med, 2010, US Air Force
     • Positions hindfoot in normal                                                                Evansville                         •Knapik J Strength Cond Res. 2009 US 
       degree of pronation                                                                •Cheung  AJSM 2010, Hong                       Army
                                                                                            Kong                                      •Richards  Br Sports Med J 2009
                                                                                          •Wegner AJSM 2008, Australia                •Ryan Br J Sports Med 2010, Vancouver

                                                                                           Empiric shoe recommendation based on running style: neutral / underpronator / 
                                                                                          overpronator and  location of plantar pressure: heel‐to‐toe / forefoot strike pattern
                                           DeLee and Drez's Orthopaedic Sports Medicine




        General Considerations                                                                              General Considerations
• Orthotics                                                                                   • Orthotics
  – Causes changes in                                                                              – Debate in literature regarding effectiveness
    muscle activation                                                                                  • Mattila Scand J Med Sci Sports 2009, Finland
    patterns to improve gait                                                                                – Military trainees over 6 month period
    mechanics                                                                                               – Overuse injury: orthotic 46.6%, control 38.1%
                                                                                                       • Franklyn‐Miller AJSM 2010, UK
  – Increased shock 
                                                                                                            – Military trainees over 7 week period
    absorption / pressure                                                                                   – Injury rate/hours training: orthotic – 1/4666, control 1/1600
    distribution                                                                                       • Hirschmuller Br J Sports Med 2010, Germany
                                                                                                            – Runners with chronic, unilateral overuse injuries over 8 weeks
                                                                                                            – Pain disability: orthotic – 58% reduction, control – 23% increase




        General Considerations                                                                              General Considerations
• Orthotics                                                                                   • Overuse injuries
                                                                                                   – Up to 90% of long distance runners
  – No differences in custom and pre‐fabricated                                                    – Risk factors for injury
    orthotics                                                                                          •   Pes planus
                                                                                                       •   Pes cavus

                        VS.                                                                            •
                                                                                                       •
                                                                                                       •
                                                                                                           Hyperpronation
                                                                                                           Higher mileage per week
                                                                                                           Year round high intensity training without a break
                                                                                                       •   History of previous injury

 $300 ‐ $500                                   $30 ‐ $60




                                                                                                                                                                                  3
     Lower leg injuries in the endurance 
                                                                    Medial Tibial Stress Syndrome
                   runner
                                                              • “ Shin Splints”
                                                              • Activity related pain 
  • Medial tibial stress syndrome (MTSS)                        along posteromedial
                                                                aspect of lower leg
  • Achilles tendinopathy
                                                              • Incidence: 13 – 17% in 
  • Plantar fasciitis                                           runners
                                                              • New runners
  • Stress fractures                                          • Change in training 
                                                                regimen or terrain




         Medial Tibial Stress Syndrome                                 Medial Tibial Stress Syndrome
                  Etiology and Anatomy                                              Etiology and Anatomy
• Periostitis caused by                                    • Bone stress reaction                                Bone remodeling cycle
  excessive stress on medial                                  – Compressive forces transmitted to concave 
                                                                posteromedial tibia
  border of tibia
                                                              – Initial response of osteoclast bone resorption
• Repetitve stress exerted                                    – Osteoblastic bone formation to resist 
  by:                                                           compressive forces
   • Soleus                              Pell JAAOS 2004   • Chronic stress leads to imbalance and 
   • Flexor digitorum longus                                 weakening of bone
   • Deep crural fascia                                    • Bone mineral density decreased in MTSS
                                                                                                                        www.nucleusinc.com

• Weakened / fatigued                                         – 11% lower than non‐athlete controls
  muscles unable to                                           – 25% lower than athlete controls
                                                              – Density normalized with resolution of symptoms
  dissipate ground reactive 
                                                                        Magnusson AJSM 2003, Sweden
  forces




         Medial Tibial Stress Syndrome                                 Medial Tibial Stress Syndrome
           Symptoms / Physical Examination                                              Diagnostic Imaging

                                                              • X‐rays
  • Activity related  pain along mid to distal tibia               – Usually normal
                                                                                                             Sensitivity
  • Swelling may develop with prolonged                       • Bone scan                                        74%
    symptoms                                                       – Longitudinal uptake pattern

  • Tenderness along posteromedial mid‐distal                 • CT                                               42%
    tibia for several centimeters                                  – Osteopenia, bone cavitations

  • Passive soleus stretch and single heel rise may           • MRI                                              88%
    reproduce symptoms                                             – Periosteal / bone marrow edema

  • Normal neurovascular exam




                                                                                                                                             4
          Medial Tibial Stress Syndrome                                          Medial Tibial Stress Syndrome
                              Treatment                                                                Treatment
 •   Rest (2‐3 weeks), NSAIDs, ice                                      • Extracorporeal shock wave therapy (ESWT)
 •   Training regimen modifications                                         • Rompe AJSM 2010, Germany
                                                                                 – ESWT/home training program vs home training program alone
 •   Cross training                                                              – Completely/much improved: 76% ESWT, 37% control
 •   Physical therapy – massage, e‐stim, iontophoresis, U/S                      – Return to sport: 85% ESWT, 47% control
 •   Boot walker for severe symptoms                                    • Surgery
 •   Change shoes and/or orthotics if indicated                             •   Recalcitrant cases
 •   Eccentric calf exercises, core stability                               •   Minimum 6 months conservative tx
                                                                            •   Posterior fasciotomy
                                                                            •   Yates JBJS 2003, UK
                                                                                 – 69% excellent / good result
                                                                                 – 41% return to pre‐injury level of sport




               Achilles Tendinopathy                                                     Achilles Tendinopathy
                                                                                                         Anatomy

 • Spectrum of involvement                                           • Largest / strongest tendon in 
                                                                       the body
   along Achilles tendon
                                                                     • Forces reach 6 – 8 times body 
 • 11% of runners                                                      weight during running
 • Risk factors                                                      • Confluence of gastrocnemius
                                                                       and soleus
      – Training errors                                              • Encased in paratenon
      – Cavus foot (high arch)                                       • Hypovascular zone 2 – 6cm 
      – Hyperpronation                                                 proximal to insertion
          • Causes shear forces and                                  • Retrocalcaneal bursa between 
            eccentric stresses on tendon                               calcaneal tuberosity and 
                                                                       tendon




                 Achilles Tendinopathy                                                   Achilles Tendinopathy
                        Clinical Conditions                                                             Tendinosis
                                                 Speed BMJ 2001

• Tendinosis                                                            • Non inflammatory mucoid or fatty 
     – Non‐inflammatory 
       condition involving                                                degenerative changes 
       intratendinous
       degeneration                                                     • Disorganized collagen
• Paratenonitis                                                         • Result of repetitive trauma and/or age
     – Isolated inflammation of 
       paratenon
• Insertional tendinitis
     – Inflammatory process 
       within tendinous
       insertion of Achilles
• Retrocalcaneal bursitis                                                  Normal tendon                 Mild tendinosis       Severe tendinosis
     – Inflammation of 
       retrocalcaneal bursa        Multiple conditions can coexist
                                                                                                            Rees AJSM 2009




                                                                                                                                                   5
                Achilles Tendinopathy                            Achilles Tendinopathy
                              Tendinosis                                      Paratenonitis
• May be present without                         • Inflammation limited to 
  clinical symptoms                                paratenon
• Symptoms develop with                          • Medial side more affected
  heavy training                                 • Pain / swelling / redness/ 
   – Tenderness                                    crepitus
   – Thickening                                  • Able  “to run through it” in 
   – Nodules                                       early stages
   – May indicate partial rupture                • Can develop nodules / scar 
     in area of degeneration
                                                   tissue




                Achilles Tendinopathy                            Achilles Tendinopathy
                      Insertional tendinitis                            Retrocalcaneal bursitis

• Inflammatory process at                        • Pain anterior to Achilles 
  tendon insertion on                              between tendon and 
  calcaneus                                        calcaneus
• Seen in older population                       • Seen with Haglund’s
                                                   deformity
  than paratenonitis
                                                 • Bursa becomes inflammed, 
• Tenderness at Achilles                           hypertrophied, adherent to 
  insertion                                        tendon
                                                 • Squeeze test
                                                 • Worse with hill running




                Achilles Tendinopathy                            Achilles Tendinopathy
                        Diagnostic Imaging                                Diagnostic Imaging
• Radiographs                                  • Ultrasound
   – Tendon thickening                            – Tendon thickening
   – Calcification in long standing               – Hypoechoic areas indicate 
     tendinopathy                                   collagen disoranization
   – Calcification in insertional                 – Irregularity in calcaneus in 
     tendinitis                                     insertional tendinopathy
   – Haglund deformity                            – Tendon  tearing


                                                        Normal tendon




                                                                                                  6
                   Achilles Tendinopathy                                                           Achilles Tendinopathy
                           Diagnostic Imaging                                                                  Treatment
• MRI                                                                                 • Correct training errors
  –   Paratenonitis
  –   Tendinopathy                                                                    • Activity modification for mild cases
  –   Insertional tendinopathy                                                           – Cut back mileage 25%; increase 10%/week as 
  –   Retrocalcaneal bursitis
                                                                                           symptoms improve
                                                                                         – Stop interval / hill training
            Normal MRI                                                                • Cross training with cycling / swimming
                                                                                      • Heel pad and/or shock absorbing orthotics




                   Achilles Tendinopathy                                                           Achilles Tendinopathy
                                 Treatment                                                                     Treatment
• Acute inflammatory cases: NSAIDs, cryotherapy                                       • Platelet Rich Plasma (PRP)
• Physical therapy                                                                       – Autologous blood with concentrated platelet levels
• Eccentric stretching                                                                   – Growth factors released from alpha granules 
  – 60‐90% patient satisfaction                                                             • PDGF, VEGF, TGF‐β1, FGF, EGF, IGF‐1
                                                                                         – May initiate and accelerate tendon healing
• Brisement for refractory paratenonitis
                                                                                         – Platelet concentration and volume of blood varies 
  – Distension of space b/w paratenon and tendon       Alfredson AJSM 1998

                                                                                           with different preparation systems
• No steroid injections                                                                  – Preparation syringe cost $150 ‐ 250
  – Consider only for retrocalcaneal                                                     – “Experimental”→ not covered by insurances
     bursiits under ultrasound guidance




                   Achilles Tendinopathy                                                           Achilles Tendinopathy
                                 Treatment                                                                     Treatment

  • Platelet Rich Plasma (PRP)                                                      • Platelet Rich Plasma (PRP)
        – Withdraw patient blood                                                      – Anecdotal evidence of efficacy
        – Centrifuge syringe                                                          – De Cos JAMA 2010 (Netherlands)
        – Transfer PRP to inner syringe                                                  • Double blinded, randomized PRP vs saline injection for chronic 
                                                                                           mid‐Achilles tendinopathy, f/u 24 weeks
        – Ready for injection
                                                                                         • Included eccentric stretching program
                                                                                         • Outcome score improved: PRP 21.7 points, Saline 20.5 points
                                                                                         • No statistically significant difference between groups




                                             Arthrex ACP system (www.arthrex.com)




                                                                                                                                                             7
               Achilles Tendinopathy                                              Achilles Tendinopathy
                              Treatment                                                       Treatment

• Extracorporeal Shock Wave Therapy (ESWT)                             • Extracorporeal Shock Wave Therapy (ESWT)
     – Stimulates healing                                                 – Insertional and non‐
        • Neovascularization                                                insertional tendinopathy
        • Expression of TGFβ‐1, collagen 
          types I and III                                                    • Success rates 50‐70%
        • Stimulation of tenocyte                                            • Trend for better outcomes with 
          proliferation                                                        high‐energy protocols and 
        • Inhibition of pain receptors                                         without use of local anesthesia
     – Low vs. high energy                                                   • Up to 82% when combined 
       protocols                                                               with eccentric stretching 
     – Expensive                                                               program (Rompe AJSM 2009, 
       ($1000+/treatment), not                                                 Germany)
       covered by most insurances




               Achilles Tendinopathy                                              Achilles Tendinopathy
                       Surgical Treatment                                                Surgical Treatment

    Failure of  at least 6 months of                                   • Paratenonitis                             
                                                                         – Excise thickened tissue 
         multiple modalities of                                            adherent to tendon
                                                                         – Open vs. endoscopic
      conservative management
                                                                       • Tendinosis
                                                                                                                    
•   Paratenonitis                                                      • Insertional tendonitis
•   Tendinosis                                                         • Retrocalcaneal bursitis
•   Insertional tendonitis
•   Retrocalcaneal bursitis                                                                             Thermann Knee Surg Sports Traumatol Arthrosc 2009, Germany
                                                                                                                         www.footsurgeryatlas.com




               Achilles Tendinopathy                                              Achilles Tendinopathy
                       Surgical Treatment                                                Surgical Treatment

• Paratenonitis                                                        • Paratenonitis
• Tendinosis                                                           • Tendinosis
    – Incise tendon, debride                                           • Insertional tendonitis
      degenerated tissue                                                 – Split tendon @ insertion
    – Arthroscopic longitudinal                                          – Excise osteophytes ±
      tenotomy                                                             calcaneal prominence
• Insertional tendonitis                                               • Retrocalcaneal bursitis
• Retrocalcaneal bursitis                                                                                                        Schepsis AJSM 1994




                                            www.footsurgeryatlas.com




                                                                                                                                                                     8
             Achilles Tendinopathy                                                          Achilles Tendinopathy
                    Surgical Treatment                                                             Surgical Treatment
•   Paratenonitis                                                            •   Paratenonitis
•   Tendinosis                                                               •   Tendinosis
•   Insertional tendonitis                                                   •   Insertional tendonitis
•   Retrocalcaneal bursitis                                                  •   Retrocalcaneal bursitis
    – Excision of bursa                         Schepsis AJSM 1994
                                                                                 – Excision of bursa
       • Open vs endoscopic                                                           • Open vs endoscopic
    – Resection of Haglund                                                       – Resection of Haglund
      deformity / posterior‐                                                       deformity / posterior‐
      superior angle of calcaneus                                                  superior angle of calcaneus

                                         van Sterkenburg Acta Orthop. 2010
                                                                                                                         www.footsurgeryatlas.com




             Achilles Tendinopathy                                                              Plantar Fasciitis
                    Surgical Treatment

• Rehabilitation                                                             •   80% of patients with inferior heel pain
    – Walker boot post‐operatively                                           •   10% of injuries in runners
    – Light jogging 2 – 3 months                                             •   33% bilateral
    – Running 4 – 5 months                                                   •   Risk factors
                                                                                 –   Pes planus
    – Competitive running 6 months
                                                                                 –   Prolonged standing occupations
                                                                                 –   Excessive pronation
• Outcomes                                                                       –   Tight Achilles tendon
    – 73 – 87% satisfactory outcomes across literature                           –   Poor running technique: increased lordosis
                                                                                 –   Worn out shoes with insufficient arch 
                                                                                     support




                   Plantar Fasciitis                                                              Plantar Fasciitis
                          Anatomy                                                                            Etiology
• Aponeurosis running                                                        • Repetitive microtrauma at origin on calcaneus 
  from inferomedial
  calcaneus to MTP joints                                                      from tensile overload
• Windlass mechanism                                                         • Acute inflammatory fasciitis
• Maintain stability and                                                     • Chronic degenerative fasciosis
  supports arch
                                                                                 – Myxoid degeneration
• Heel forces
    – 100% body weight at heel                                                   – Microtears
      strike                                                                     – Angiofibroblastic hyperplasia
    – 200% with running
    – Calcaneal fat pad begins 
      atrophy @ age 40 yrs
                                          Buchbinder NEJM 2004




                                                                                                                                                    9
                     Plantar Fasciitis                                                                     Plantar Fasciitis
                  Symptoms / Examination                                                                   Diagnostic Imaging
• Inferior heel pain                                               • Radiographs
   – Worse with first steps
   – Improves with activity
   – Worsens during the day with 
     prolonged weight bearing
• Tenderness along medial 
  calcaneal tubercle, plantar 
  fascia
• Passive dorsiflexion of toes 
  exacerbates symptoms
                                                                * Bone spur Incidental – located in flexor digitorum brevis origin, not plantar fascia *




                     Plantar Fasciitis                                                                     Plantar Fasciitis
                       Diagnostic Imaging                                                                  Diagnostic Imaging

• Ultrasound                                                       • MRI
   – Normal < 4 mm thick                                                               Normal                               Plantar Fasciitis

            Plantar fasciitis                          Normal




                          Jeswani Clincal Radiology 2009         McNally SeminMusculoskelet Radiol 2010 




                     Plantar Fasciitis                                                                     Plantar Fasciitis
                                Treatment                                                                      Treatment
– Activity modification                                                    – Stretching
– NSAIDS for acute inflammation                                                   •   Hallmark of conservative treatment
– Physical therapy                                                                •   Achilles stretch
                                                                                  •   Plantar fascia stretch
– Cushioned heel cup
                                                                                  •   Digiovanni JBJS 2006
– Orthotics                                                                               – 2 year follow of patient with chronic (>10months) PF treated with 
   • Prefabricated and customized                                                           stretching protocol
     equivalent outcomes                                                                  – 94% no or less pain than before treatment
                                                                                          – 77% activites/sports without limitation
– Night splint                                                                            – 92% total satisfaction or or satisfaction with minor reservations




                                                                                                                                                                 10
                 Plantar Fasciitis                                         Plantar Fasciitis
                       Treatment                                                 Treatment
• Corticosteroid injections                              • Platelet rich plasma (PRP) injections
   – Area of tenderness                                     – Performed under ultrasound guidance
   – Medial calcaneal                                       – Initiate inflammatory response to 
     tubercle                                                 facilitate healing
   – Effective short term 
     relief                                                 – Small pilot studies demonstrate 
                                                              significant improvement
   – Limited evidence of long 
     term improvement                                       – No definitive clinical studies to date
   – Risk of plantar fascia 
     rupture and fat pad 
     atrophy




                 Plantar Fasciitis                                         Plantar Fasciitis
                       Treatment                                                 Treatment

• Botulinum Toxin A injections                           • Extracorporeal Shock Wave Therapy (ESWT)
   – Endopeptidase prevents release of                      – Can be effective in chronic cases
     intracellular neurotransmitters that                   – Varied results in the literature
     mediate pain                                              • 60 – 80% improvement SWT
   – Acts on plantar fascia and                                • 40 – 50% improvement in 
     surrounding muscles                                         control groups
   – Babcock Am J Phys Med Rehab 2005                       – Rompe JBJS 2010
      • Double blinded randomized trial                        • Randomized, blinded SWT vs. stretching program for acute 
      • At 8 weeks, 56% decreased VAS pain and                   cases PF
        47% increase Maryland Foot Score                       • At 2 and 4 months, stretching group significantly improved
        compared with saline control                           • At 15 months, no significant differences




                 Plantar Fasciitis                                         Plantar Fasciitis
                   Surgical Treatment                                       Surgical Treatment
• 10 – 15% fail conservative management                  • Plantar fasciotomy
• Indicated after 12 months of non‐operative care          – Open
• Plantar fasciotomy                                       – Endoscopic
  – Release only ½ to  ⅔ medial aspect
  – Risk decreasing stability of arch and surrounding 
    ligaments
  – Excellent / good results 70 – 90%



                                                                                                Shazly Arthoscopy 2010 
                                                                                               www.footsurgeryatlas.com




                                                                                                                              11
                    Stress Fractures                                                        Stress Fractures
                                                                                                      Etiology

• 5‐ 16% incidence in runners                                         • Osteoclast resorption outpaces osteoblast formation
• Tibia > tarsal bones >                                              • Weakened bone exposed to repeated strain leads to 
  metatarsals > fibula                                                  microfractures
• Abnormal forces applied across                                      • Stressor persists → complete fracture
  previously normal bone
    – Compared to insufficiency 
      fractures in elderly; normal forces 
      applied to abnormal bone


                                                                                                       www.nucleusinc.com




                     Stress Fractures                                                       Stress Fractures
                             Risk factors                                                          Risk factors

• Extrinsic risk factors                                              • Intrinsic risk factors
    • Training regimen                                                   • Women
       – Raid changes in duration, distance, frequency or intensity          – Lower bone mineral density
                                                                             – Narrower bone width (Stress = Force / Area)
    • Running surface                                                        – Female athlete terrible triad: eating disorder, amenorrhea 
       – Treadmill vs asphalt                                                  (lower estrogen levels), osteoporosis
       – Tibial strain rates 48‐285% higher on asphalt                   • Smaller muscle mass / poor muscle endurance
    • Shoe wear                                                              – Results in less energy absorbed and thus transmitted to bone
       – Limited evidence supporting use of shock absorbing insoles      • Anatomic morphology
       – Change shoes every 300‐500 miles                                    – Pes cavus (high arch) vs pes planus (flat foot)
                                                                             – Leg length discrepancy
                                                                             – Valgus knee alignment




                     Stress Fractures                                                       Stress Fractures
                   Symptoms / Examination                                                     Diagnostic Imaging
•   Insidious onset of localized pain with exertion                   • Plain radiographs
•   Resolves with rest                                                  – Negative early; 15 – 35% sensitivity at presentation
                                                                        – Later findings: Cortical fracture lines, lucency, periosteal 
•   May become constant with persistent activity                          thickening, early callus
•   Focal tenderness / swelling over affected bone                    • 3‐phase bone scan
•   Percussion tenderness                                               – Highly sensitive, ~0% false negative; low specifity 
                                                                      • MRI
•   Tuning fork test
                                                                        – High sensitivity (88‐100%) and specific (86‐100%)
•   Bending /loading tests (fulcrum / leg hop)                          – Less invasive, no radiation, more diagnostic information
                                                                      • CT
                                                                        – Useful to better delineate identified/suspected fracture 
                                                                          lines




                                                                                                                                              12
                     Stress Fractures                     Stress Fractures

• Tibia                                    • Medial malleolus
   – 50% of stress fractures                 – 0.6 – 4.1% of stress 
   – Posteromedial cortex                      fractures
      • Most common
      • Compression side                     – Due to abnormal 
      • Continuation of MTSS; good             weight distribution
        prognosis                                                           Berger Eur J Radiol 2007
                                             – Repetitive 
   – Anterior cortex
                                               impingement on talus 
      •   Less common
      •   Tension side
                                               while running
      •   Hypovascular area                  – Risk of non‐union due 
      •   High risk of propagation, non‐       to high sheer forces
          union




                     Stress Fractures                     Stress Fractures

• Fibula                                   • Calcaneus
   – 4.6 – 21% of stress                     – Common location
     fractures                               – Often missed diagnosis
   – Commonly at distal                      – High index of suspicion 
     end: lateral malleolus                    in posterior heel pain 
   – Due to muscular                           unresponsive to 
     forces; limited role in                   treatment
     weight‐bearing



                                                                              Rosenberg Radiographics 2000




                     Stress Fractures                     Stress Fractures

• Navicular                                • Metatarsal shaft
   – 15 – 30% of stress 
     fractures                               – 10 – 20% of stress 
   – Compressed between                        fractures
     talus and cuneiforms 
     during heel strike                      – 80 – 90% occur in 2nd
   – Central portion most                      and 3rd metatarsals
     affected
      • Area of maximum sheer                – Good prognosis
        stress
      • Decreased area of vascular 
        supply
   – Risk on non‐union if 
     weight bearing allowed

                                                                          Ashman Radiographics 2001




                                                                                                             13
                 Stress Fractures                                         Stress Fractures

• Proximal 5th metatarsal                                 • Sesmoids
    – Rare                                                  – 1‐3% of stress 
    – High non‐union risk, 20                                 fractures
      – 67%                                                 – Functions as pulley for 
    – Watershed area of                                       FHL and FHB, 
      blood supply between                                    stabilizes MTP joint
      metaphyseal and                                       – Repetitive stress and 
      nutrient arteries                                       tensile forces during 
                                                              dorsiflexion
                                                            – High risk of non‐union
                                                                                                         Boden JAAOS 2000




                 Stress Fractures                                         Stress Fractures
                       Treatment                                                 Treatment

• Prevention                                              • Prevention
    – Corrective orthotics                                  – Correct training errors
    – Appropriate shoe wear                                 – Avoid abrupt increases in mileage / intensity
    – Strength training                                     – Periodization
    – Females: proper nutrition/calcium supplements;           • 3 weeks progressive buildup, 1 week less intense 
      address eating disorders/menstrual irregularities          training
                                                            – Cross training




                 Stress Fractures                                         Stress Fractures
                 Conservative Treatment                                   Conservative Treatment

•   Cessation of painful activities                       • Resume training when pain free for 2 weeks
•   Pain control: ice, NSAIDS, “relative rest”            • Gradual increase in distance / intensity
•   Relative rest – reduce training to pain free level    • Most fractures heal over 6 – 8 weeks
•   High risk fractures                                     – Tibia and navicular fractures may take 6 months
    – Non weight bearing                                  • Consider bone stimulator for delayed union
    – Short leg cast / walker boot
• Maintain aerobic conditioning
    – Cycling, swimming, pool running, upper body 
      weights




                                                                                                                            14
                Stress fractures                                     Stress fractures
                 Surgical Treatment                                   Surgical Treatment

• Indications                                         • Tibia fractures
  – Displaced fracture
  – Delayed or non‐union
  – Acutely in elite athletes
  – Persistent pain despite prolonged conservative 
    management




                Stress fractures                                     Stress fractures
                 Surgical Treatment                                   Surgical Treatment

• Medial malleolus fractures                          • Navicular fractures




                Stress fractures                                     Stress fractures
                 Surgical Treatment                                   Surgical Treatment

• Proximal 5th metatarsal                             • Sesmoid fractures




                                                                            Richardson JAAOS 1999




                                                                                                    15
                 Final Points
• Overuse injuries very common in runners                  Thank you
• Training errors usually responsible for injury
•
•
  Proper history and physical examination
  Radiographic studies to confirm and specify 
                                                       Good luck runners!!!
  clinical diagnosis
• Majority of injuries respond to conservative 
  treatment
• Surgical referral for high risk cases and failure 
  of non‐operative management




                                                                              16

				
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