Long-term results of medical treatment for lower extremity stress fractures

Objective: to assess the long-term results of medical treatment for lower extremity stress fractures.

Subjects and methods. Fifty-five patients who had received a medical treatment cycle in the European Clinic of Sports Traumatology and Orthopedics (ECSTO) in the period 2010 to 2016 were followed up. The patients' mean age was 37 (range 15—65) years. Among them, there were 36 (65%) females and 19 (35%) males. The long-term results of treatment were assessed using the Foot and Ankle Ability Measure (FAAM) scale (ADL + sport modules) and the Lower Extremity Functional Scale (LEFS) scales.

Results and discussion. Assessing the degree of stress adjustment according to magnetic resonance imaging (MRI), on visiting, in accordance with the classification proposed by E.A. Arendt et al., revealed grades 2, 3, and 4 injuries in 10 (18%), 14 (26%), and 16 (29%) patients, respectively. The median time from the moment of visiting before assessment according to the orthopedic scales was 3 years (1 to 7 years). The second and third metatarsals underwent stress adjustment in 25 (47%) patients. The cause of stress adjustment was most often running (38%), less often walking (29%), playing sports (18%), fitness (9%), and other types of physical activity (6%). Assessing the scores for the FAAM ADL and FAAM sport subscales showed that the median was 100 [96; 100]% and 100 [91; 100]%, respectively. Estimating the scores for the LEFS scale revealed excellent, good, and satisfactory results in 48 (87%), 6 (11%), and in 1 (2%) patients, respectively.

Conclusion. The most common cause of lower extremity stress fractures is running. These changes respond well to medical treatment, which includes injured limb overuse, physiotherapy, and individual ankle-foot orthosis.

1. Robertson GA, Wood AM. Lower limb stress fractures in sport: Optimising their management and outcome. World J Orthop. 2017;8(3):242. doi: 10.5312/wjo.v8.i3.242

2. Changstrom BG, Brou L, Khodaee M, et al. Epidemiology of stress fracture injuries among US high school athletes, 2005-2006 through 2012-2013. Am J Sports Med. 2015 Jan;43(1):26-33. doi: 10.1177/0363546514562739

3. Behrens SB, Deren ME, Matson A, et al. Stress fractures of the pelvis and legs in athletes: a review. Sports Health. 2013 Mar;5(2):165-74. doi: 10.1177/1941738112467423

4. Pegrum J, Crisp T, Padhiar N. Diagnosis and management of bone stress injuries of the lower limb in athletes. BMJ. 2012 Apr 24;344:e2511. doi: 10.1136/bmj.e2511

5. Iwamoto J, Takeda T. Stress fractures in athletes: review of 196 cases. JOrthopaedSci. 2003;8(3):273-8. doi: 10.1007/s10776-002-0632-5

6. Barros A, Karmali S, Rosa B, GonHalves R. Stress fractures in older athletes: a case report and literature review. Clin Case Rep. 2017 Jun;5(6):849-54. doi: 10.1002/ccr3.954

7. Boden BP, Osbahr DC, Jimenez C. Low-Risk Stress Fractures. Am J Sports Med. 2001 Jan;29(1):100-11. doi: 10.1177/03635465010290010201

8. Mayer SW, Joyner PW, Almekinders LC, Parekh SG. Stress fractures of the foot and ankle in athletes. Sports Health. 2014 Nov;6(6):481-91. doi: 10.1177/1941738113486588

9. Yankin AV, Krasnoyarov GA, Markevich PS. Anthology of stress fracture. Byulleten ’ Vostochno-Sibirskogo Nauchnogo Centra Sibirskogo Otdeleniya Rossijskoj Akademii Medicinskih Nauk = Acta Biomedica Scientifica. 2012;2(84):148-51 (In Russ.).

10. McInnis KC, Ramey LN. High-risk stress fractures: diagnosis and management. PM&R. 2016 Mar;8(3):S113-24. doi: 10.1016/j.pmrj.2015.09.019

11. Murray SR, Reeder MT, Udermann BE, Pettitt RW. High-risk stress fractures: pathogenesis, evaluation, and treatment. Compr Ther. 2006;32(1):20-5. doi: 10.1385/COMP:32:1:20

12. Arendt EA, Griffiths HJ. The use of MR imaging in the assessment and clinical management of stress reactions of bone in highperformance athletes. Clin Sports Med. 1997 Apr;16(2):291-306. doi: 10.1016/S0278-5919(05)70023-5

13. Martin RL, Irrgang JJ, Burdett RG, et al. Evidence of Validity for the Foot and Ankle Ability Measure (FAAM). Foot Ankle Int. 2005 Nov;26(11):968-83. doi: 10.1177/107110070502601113

14. Berger FH, de Jonge MC, Maas M. Stress fractures in the lower extremity. Eur J Radiol. 2007 Apr;62(1):16-26. doi: 10.1016/j.ejrad.2007.01.014

15. Binkley JM, Stratford PW, Lott SA, Riddle DL. The Lower Extremity Functional Scale (LEFS): scale development, measurement properties, and clinical application. North American Orthopaedic Rehabilitation Research Network. Phys Ther. 1999 Apr;79(4):371-83. doi: 10.1093/ptj/79.4.371

16. Liong SY, Whitehouse RW. Lower extremity and pelvic stress fractures in athletes. Br J Radiol. 2012;85(1016):1148-56. doi: 10.1259/bjr/78510315

17. Oliveira US de, Labronici PJ, Joao Neto A, et al. Bilateral stress fracture of femoral neck in non-athlete — case report. Rev Bras Ortop Engl Ed. 2016 Nov;51(6):735-8. doi: 10.1016/j.rboe.2016.10.013

18. Tenforde AS, Sayres LC, McCurdy ML, et al. Identifying Sex-Specific Risk Factors for Stress Fractures in Adolescent Runners. Med Sci Sports Exerc. 2013 Oct;45(10):1843-51. doi: 10.1249/MSS.0b013e3182963d75

19. Shindle MK, Endo Y, Warren RF, et al. Stress fractures about the tibia, foot, and ankle. J Am Acad Orthop Surg. 2012;20(3):167-76. doi: 10.5435/JAAOS-20-03-167

20. Espregueira-Mendes J, Costa A, Pessoa P, van Dijk CN. Stress Fractures: Current Concepts. In: Injuries and Health Problems in Football. Springer; 2017. P. 461-71.

21. Mallee WH, Weel H, van Dijk CN, et al. Surgical versus conservative treatment for high-risk stress fractures of the lower leg (anterior tibial cortex, navicular and fifth metatarsal base): a systematic review. Br J Sports Med. 2015 Mar;49(6):370-6. doi: 10.1136/bjsports-2013-093246

22. Torg JS, Moyer J, Gaughan JP, Boden BP. Management of Tarsal Navicular Stress Fractures: Conservative Versus Surgical Treatment: A Meta-Analysis. Am J Sports Med. 2010 May;38(5):1048-53. doi: 10.1177/0363546509355408

23. Finestone A, Milgrom C. How Stress Fracture Incidence Was Lowered in the Israeli Army: A 25-yr Struggle. Med Sci Sports Exerc. 2008 Nov;40(Suppl 1):S623-9. doi: 10.1249/MSS.0b013e3181892dc2