Management of Stress Fractures of the Lower Leg

CharlesJ.Gatt,Jr.,MDChair,DepartmentofOrthopaedicSurgery

RutgersRobertWoodJohnsonMedicalSchoolNewBrunswick,NJ

• Ihavenodisclosures

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Questions:

• Howcommonarestressfracturesofthelowerleg?

• Whatfactorscontributetostressfracture?• Whatarethetreatmentoptions?

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The Problem

• Morethan3.5millionchildrenundertheageof14treatedannuallyforsportsinjuries.(Source:SafeKidsUSA)

• Overuseinjuriesaccountforhalf ofallsportsinjuriesinmiddleschoolandhighschool.(Source:SafeKidsUSA)

• Highschoolathleticsaccountformorethan2millioninjuriesannually,including• 500,000doctorvisits• 30,000hospitalizations(Source:CentersforDiseaseControl)

• GrowingUpTodayStudy– Prospectivecohortstudy– 6831girlsaged9-15years

• 3.9%developedstressfractures• Running,cheerleading,gymnastics,basketball• Increasedageatmenarche,familyhx ofosteoporosis

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• Overallstressfx rateof1.54per100,000athlete-exposures» RatehighestinboysandgirlsCCandgymnastics» Girlshadalmosttwicetherelativeriskasboys

• 99%managednon-surgically• Majorityresultedin≥3wks timelostfromsport

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www.stressfxregistry.net

• Highschoolathletes• 75athletictrainerscontributingdata.• 11differentstates• Onlinedatabase• Quickandeasy

www.stressfxregistry.net

• 263stressfracturesover2.5years• Females:Males1.35:1• Females

– Avg age15– Firsttimeoutforsports– Decreasingincidencewithincreasedage

• Males– Avg age16– 10/11thgrade

www.stressfxregistry.net• Interestingfindings

– Avg subjectivepaincomplaint7/10• Boys6.6,girls7.2

– Track- 65%intibia– 54%StartStopsports– Tibia3xmorecommonthananyotherbone– 19%indicatedtheyhadapriorstressfracture– 45%notedtheyhadpriorhx shinpain>4weeks– Somesortofchange(73%)– Slept1hourlessthancontrols(7vs8hours)– Weighttrainedlessthancontrols

Keep in Mind:

• Adolescentbonedifferentthanadultbone– Lessmineralized– Notasstrong– Moreflexible

• Undergoingaxialgrowth• Willachieve92%oflifetimebonebyage19• Primetimetodevelopbonestrength• Primetimetooverloadtheprocess!

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Typical case

• 14yearoldfemale• 9thgradecrosscountryrunner,6weeksintoseason• Progressivelyworseningleftshinpainover2weeks,notrauma

• Worseafterrunning,nopainwithambulation• Tendertopalpationposteromedialtibiaatjunctionofmiddleanddistalthirds

• Noswelling,ecchymosis

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Case management

• Stoprunning?A.YesB.NoC.Needfurtherworkuptomakedecision

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• Howlong?A.1weekB.2weeksC.4weeksD.6weeks

Case management

• X-ray?A.YesB.No

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• MRI?A.YesB.No

Shin pain evaluation• Keyscreeningquestions

» Howlonghaveyouhadshinpain?» Rateyourworstpainduringactivity(1-10)?» Whendoyouhaveshinpain?» Doyoulimpatanytime?» Haveyouhadanychangesintrainingrecently?» Howmanyhoursperweekdoyouspendparticipatingin

sports?» Howmanyservingsofdairydoyougetinday?» Priorstressfracture» Menstrualdysfunction» Diet

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Shin pain evaluation• Physicalexamination

» Palpation– tibiaandfibula» Fulcrumtest» Singleleghop

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Radiographs

• APandlateralviewsoftibia&fibula• Limitedutilityofx-rays

» Only10-29%ofinitialx-raysarepositive

» Onfollowup,thesensitivityofx-raysincreasesto40-54%

» (Greaneyetal.,1983&Zwas,1987)

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Radiographs

• APandlateralviewsoftibia&fibula

• Periostealreactionposteromedialtibiaatsiteoftenderness

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Management

• Mildfindings, negativex-ray» Shortdurationpain,pain<5, (-)hoptest» Exercisemodification:decreaseimpactaerobictraining

» poolrunning,non-impactaerobictraining» Maycompeteaslongassymptomsdonotworsen

» Don’tgiveupsport

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Advanced imaging

• 31patientshadclinicalexam,x-ray,bonescan,andMRI• Similarsensitivities(reportedupto100%)• MRIhigherspecificity• SeverityonbonescanandMRIwerehighlycorrelated

» Alsomatcheddegreeofclinicalsymptoms• MRIprovidedmoreinformation

» Periostealedema,bonemarrowedema,fractureline

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MRI Grades

• OriginallydescribedbyFredericson etal.(1995)• Modifiedovertheyears• SimplifiedbyDobrindt etal.(2012)intotwogrades

» Lowgrade:bonemarrowedemainSTIRimages,possiblyinT2-weightedimages

» Highgrade:bonemarrowedemainT1- andT2-weightedimagewithorwithoutafractureline

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Examples

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Grade1 Grade2Grade3 Grade4

edema- mild moderatesevere fractureline

Are MRI grades clinically relevant?

• Reviewed68stressfracturesincollegeathletesover10years» 1%overallincidence

• Returntosporttimevariedaccordingtogradeofinjury» Grade1:3.3wks Grade2:5.5wks» Grade3:11.4wks Grade4:14.3wks

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Can we predict severity or duration of injury?

• Comprehensiveannualevaluations• 211athletessustained61stressfractures• LowerBMDandhigherMRIgradewereindependentpredictorsof

longerrecovertime

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Bone Density

• Case-controlstudyof25athleteswithstressfxmatchedto25controlathleteswithsimilarexercisehistory

• Comparedwithcontrols,stressfracturecaseshad» SignificantlylowerDEXA» Greaterlikelihoodofmenstrualirregularity» Similarcaloricintake» Lowercalciumintake

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Diet• Riskfactors(Moranetal.,2012)

» Stressfx associatedwithdietarydeficiencybeforeinductionandduringbasictrainingforelitecombatrecruits» Calcium&vitaminD

• VitaminDlevelsinathletes(Farrokhyar etal.,2014)» Overall56%inadequate» Prevalenceincreasedathigherlatitude,indoorsports,winter

andearlyspringseasons• Supplements(Lappe etal.,2008)

» Largestudyofnavyrecruitsrandomizedtoreceivedeither2000mgCaand800IUVit Dorplacebo

» 5.9%incidenceofstressfx per8wks» 21%fewerfx inthesupplementgroup

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Long term implications

• 175femalesstudied(14- 25y/o)» Eumenorrheic athleteshadhighestBMD

» Amenorrheic athletesBMDsimilartonon-athletes» AAhighestincidenceoffx anddisorderedeating» AAwith≥2fxs,loweststiffnessandfailureload

» Probableincreasedlifetimeriskforfragilityfx• RecommendcheckingDXAonadolescentswith>1stressfx

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Stress fractures

• Treatment– Xray neg +MRpos,<GrIV - activitymodification

• Poolrunning,non-impactaerobictraining• Competitiononly• SymptomsMUSTNOTWORSEN• COMMUNICATION

– Xray positiveorGradeIVMRI• Rest,potentialprotectedweightbearing,immobilization

Stress fractures

• Treatment– Pulsedultrasound,pulsedEM,calcitonin– Nogooddatatosupportuse

– Rue,etal2007• 43tibialstressfx• Randomized,blindedpulsedUSvsplacebo• Nodifferenceinsymptomrelief,returntoplay

Orthopedics. 2004 Nov;27(11):1192-5.

Validation of shin pain scoring systemNussbaum, Gatt, Bechler, Hosea, Swan

• IRBapprovedprotocol• CalculateshinpainscorebasedonhistoryandPE• Correlatewithx-rayandMRIfindings

• Potentialbenefit– Decreaseduseofradiographicstudies– Aidinreturntoplaydecisions

Validation of Shin Pain Scoring SystemInitial findings:

• 75subjects– 150shins(130notedsymptomatic)• 83%positivefindings(125/150)

– 84%GradeIIorabove• 66/125- 52%GradeII• 39/125- 16%GradeIII• 3/125- 12%GradeIV

• 70%BilateralFindings(53/75)*SignificantnumberwithpositivefindingsonMRI

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Validation Shin Pain Scoring System6 month Follow up

• 36Responses• 17/36(47%)wereout>8weeks• 14/36(39%)Stillhaveregularshinpainw/activity

– (1GrI,7GrII,4GrIII,2Normals)• 13/36(36%)Haveoccasionalshinpain

– (2GrI,9GrII,2GrIII)• 27/36(75%)Stillhaveshinpain>6months• 9/36(25%)Notedtheywerefullyrecovered

– (1GrI,5GrII,3GrIII)*Highlightsprolongedhistoryandcomplexityofshinpain.

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Why worry?

• 19yearoldfemal• DivisionINCAAvolleyball player• Progressivelyworseningleftshinpain,notrauma• Worseafterjumping,occasionalpainwithambulation• Tendertopalpationanteriortibiaatmiddlethird• Noswelling,ecchymosis

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Why worry?

• Jumpingathlete• Painoveranterior

tibialcrest• Painwithfulcrumtest• “Dreadedblackline”

onlateralx-ray

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Considering the findings• Doweneedtorestmore?• Gaitmodification?• Reconsidertraininghours/demands• Minimizethechanges

– RuleofToo’s – TooFast,Toohard,toosoon,toooften• StrengthenandconditionforthedemandsofthesportPRIORtotheseason• Supplementation

– ParticularlyVit DandCa+• Orthotics?• Sleepmore• Identifymenstrualissues• Reviewthediet

– Addmorecolor• Decreasementalstress

– School,sport,parents,friends

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Summary:• Shinpainisabigprobleminadolescentpopulation– Lookforredflags

• Pain>6/10,positivehoptest,priorhistory,change

• Tibiaismostcommonbone• Complexproblem

– IntrinsicandExtrinsicFactors• Earlyidentificationiskey

Thank you