management of stress fractures - uoa · » stress fxassociated with dietary deficiency before...
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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