We're going to talk about high-grade stress fractures, a little bit more related to some of the more important ones and critical ones, but kind of want to get into a few important pieces about how to diagnose and how to manage these. No significant disclosures from myself or any member of our family. Little bit of an outline. We're going to talk about how to take some history that's pertinent to finding out information about these kind of stress fractures, a couple pieces about physical exam, we'll go through some stress fracture types, but really at the end we're going to also go into managing them and how do you help counsel somebody on return to run and when is that appropriate. So we're going to try to run this gamut of these different important features. So things to remember, we're going to do some basics just to keep us all on the same page, that a stress fracture is really a continuum where you'll see some silent stress reaction. Even after running a marathon, you can see some bone edema and it doesn't have to have symptoms or be painful, and then you'll get stress reaction all the way through the cortical break or so you see a fracture line in the marrow. If you see somebody give you an MRI scan and they say stress reaction without a stress fracture, really what they're meaning is there's bone edema, so it is a lower-grade stress fracture, but they don't see a fracture line. So that's something to always make sure you're looking at when you have a reading, and it's always important just to make sure you look at those MRIs yourself because sometimes you don't know the frame of reference the radiologist is reading from. Just remember a couple other pieces. So your body responds to loading by having to adapt, and in bone, what you're going to get is as you apply a force through a bone, it's going to dig a little of the bone out and then backfill it in stronger, and that's its way of adapting. If you don't allow sufficient recovery, that you keep increasing that volume or doing it in a way that your body can adapt to, that's when we see this micro damage occur inside the trabecular part of a bone, and you get micro fractures that you're going to see on the edema in the MRI scan. So it's insufficient recovery, but remember that can be two things. You can have abnormal force being exerted on normal bone, like too much force too quickly even though the bone looks normal, but you can also have lower bone density. Think about your female athlete triad or Red S-type of patients or somebody with lower nutrition or lower bone vitamin D levels, that you can have even normal levels of force, but the bone might be abnormal, and it reaches that critical breakdown point. So you're thinking about forces and bone. One is normal and one is abnormal, and how do they intersect together? Muscle is a very important component because your muscle is going to act as a shock absorber, and when you think about running, right, running is all about dissipating force, and when you're doing exercise, whether you're playing tennis or you're playing soccer, force is being absorbed by the body, and it has to dissipate it somewhere. So you think about flexibility. So you use ankle dorsiflexion. If you have enough dorsiflexion that you can dissipate force that gets absorbed by the muscle, it doesn't have to get exerted into the bone. Same thing with your great toe. If you have good extension of the great toe, about 50 degrees or more, you're going to be allowed to transfer force by dissipating it in flexibility. If not, if it's really tight, if at dorsiflexion, they're just even at neutral, well, since the muscle couldn't absorb it, it's going to get transmitted to the ends. Where does the muscle originate and where does it insert? And anywhere a muscle inserts, you can get a stress fracture breakdown because that increased force that wasn't absorbed from flexibility has to be imparted somewhere. It doesn't just go away. So it's always important to remember that everywhere a muscle inserts, you can develop a stress fracture because it's exerting a pull and force on a bone. You'll get posterior stress fractures from the soleus. We've seen them in the shoulder and the elbow and the ribs and multiple other places because there's not enough flexibility to allow force dissipation from that elasticity. It puts it in the bones. Always look at things like flexibility, particularly in your lower extremity athletes. Look at dorsiflexion around the ankle. If they're too tight and they can't go into dorsiflexion, they're going to get early transition of force to the forefoot. You're going to get early forefoot loading, which leads to forefoot injuries, but also you've got ramped up forces in the Achilles and gastro soleus complex as well. So it's very important to look at how muscle is involved in dissipating and absorbing shock or force, or is it not doing its job and it's going into the bone instead. Things that are really important from a risk factor perspective are, especially in running and a lot of athletics, are transitions. When somebody comes in with an injury, look at the two to six or eight weeks in advance. What changed? The volume, the type, the intensity, the distance. I imagine if it happened at UF, it's happened all over the country where we had athletes that weren't doing anything over the summer, and then they came back to school. And if their sports started up, they went from zero to a hundred right away. And you start to see overuse injuries and things starting to break down. Also make sure that you're asking all the appropriate questions. So you have a situation where there could be abnormal bone, like menstrual cycle regularities. Are they new to running? Do they have a low bone density to begin with? If it's an older runner or a history of an eating disorder, we think I might have compromised bone at the same time. So you really want to get a good history, particularly on transitions and what is their overall experience level with running. In your first six months, you're most likely to have an injury. But again, this can translate to any sport where they weren't properly habituated to the activity before they really ramped it up high. When you're looking at things with these types of injuries, stress fractures typically have an insidious onset. You can get them in one bout, but typically you're starting to see, they notice it at the end of exercise. It throbs and aches like a toothache when they're resting at the end of the day. So always ask them that question. Was it dull and then become sharp? Does it progress to non-sport activities like just walking around? Does it become earlier during an activity? So those are kind of chronicity things that go into thinking, maybe I've got a stress fracture rather than something like a shin splint or a tendon injury. So things like the longer they walk, the more it hurts. That generally will point to more of a bone issue as opposed to, it's tight and crampy when I wake it up. And then as I walk, it loosens up more like a tendon or a muscle would. But really ask that question at the end of the day when you're resting, do you notice this throb or a toothache? If they say yes, your red flag should go up for something like a stress fracture. Do they have a point of maximal tenderness or not? And can they reach it? When you get to the femoral shaft kind of a stress injury, they can feel it in the leg, but they can't push on it. They can't get deep enough. Same thing for a femoral neck stress fracture. It's deep, they can't get their hands on it. An interesting exam item is to have them hop on one leg. Generally, when you look at a tibia, like for a stress fracture, if they hop on it and it hurts and you press on it, it hurts as a stress fracture until you prove it's not. So hopping on one leg is a great way to draw out lower extremity stress fractures. Spine extension for a PARS. Fulcrum test with a person prone and supine are both important if you think it's a femoral shaft stress fracture. You want to get that femur so it's two-thirds of the way off of the table, put one hand on the iliac crest and the other hand on their knee and push down, flip them over and do the same thing. We've been finding that the posterior femoral shaft stress fractures come out more when the person is supine rather than prone, which has been interesting. And then tuning fork. You can use a tuning fork. We published a paper on that a few years ago. Any pain with a tuning fork has a reasonable probability of bringing out a stress fracture. We typically don't use them much anymore, but it does have some efficacy if they have pain when you apply a tuning fork. X-rays. Most places require us to get an X-ray before we go to advanced imaging. Most of them are never positive. It might take several weeks to start to see a little period of pain. There are things that you can see, but if you have a negative X-ray, it doesn't make you feel better or worse other than the fact that you don't have a true cortical break most likely. So if somebody says you have a negative X-ray, that means you don't have a stress fracture. That's completely not true because most of the time it's not a positive exam to begin with. So you can get an X-ray. Negative doesn't make you feel any better, but if you see it on an X-ray, it usually means you have a pretty high grade one to work from. Bone scans can be utilized. This is one what would look like right here, this little black dot showing up. Generally what that is though, it's telling you there's an area of bone turnover, but it doesn't tell you exactly what it is. So you typically have to follow that up with an MRI scan anyway. Some places still based on their insurance companies will still make you do a bone scan, and then you still have to follow it up to figure out exactly what that is that's made that turnover. One useful thing is looking at the phases can tell you about how old it might be. The other useful part of a bone scan is if somebody has multiple areas of pain, then you can use it to figure out, am I dealing with multiple stress fractures? Like if you have them very far apart that one MRI wouldn't be able to capture them both or they're on both sides, you can use a bone scan to figure out how many stress fractures you may be dealing with and then kind of search it down from there. MRI, so if you get this light up here, this is kind of what you'd be looking for in this proximal tibia, and that's what it would look like on MRI scan. We typically use a Fredrickson criteria. You can use the 4A and 4B. It basically is just giving you a gradation. It takes longer for the threes and fours, those higher grade to heal compared to the ones and twos. And just make sure you know the convention of the radiologist who's reading it, and then what convention you're using when you're putting it in your note and how you're reading it. I typically use the Fredrickson four stage criteria. We do have some of our newer radiologists using 4A and 4B. Just make sure you know what you're all talking about from a terminology perspective. Now, if you look at non-critical, they basically heal without complication if you give them relative rest within about six to eight weeks. Critical are the ones we're gonna talk a lot about are these higher grade ones because they have risk of non-union, displacement, can be intra-articular, and really have to look at prolonged immobilization and what types of exercises can you bring on and when. So this is kind of where the meat of this goes. Think about non-critical stress fractures. One of the big ones that we were running into recently is femoral shaft. In the calendar year of 2019, we treated 11 femoral shaft stress fractures at UF, probably the most we had seen. And what characterizes those quite a bit is this dull aching thigh pain. And if you have a runner, we're gonna keep using running as a model. If you have a distance runner, they're not gonna get a quad strain unless they're doing speed work or something else. It is a low velocity movement. So it doesn't strain the quad. So why would they have a dull aching pain in their thigh? Typically, you've got to start looking at stress fracture as the most likely cause. Medial tibia is commonly confused with shin splints. Now it can start as a shin splint because you might notice pain at the beginning of exercise and then it kind of goes away. That's getting worse over time. Generally, you're starting with a shin splint and you're converting to a stress fracture. These have very common reasons for developing. Fibula is commonly thought to be a perineal tendonitis because people push on the side of your leg and it hurts. If you're gonna palpate it, make sure you're pushing on the fibula and not the tibia. I mean, the fibula and not the perineal tendons. And it's different than the tibia because remember 90% of your weight goes through the tibia, only about 10% through the fibula. To get a stress fracture there, you have rotation. You have somebody who is running externally rotated. It's the outside leg if they run track and they're going around corners. They have a weak hip. So they got a lot of femoral inter rotation causing rotation at the tibia. So if you get a fibular stress fracture, they're easier to treat because of the ability to get weight bearing sooner. But you gotta think harder because if you don't take out where the rotation came from, they're just gonna get hurt again. Most of these are thought to be a tendonitis for so long and they don't really inhibit the person running much. By the time we get them, most of them have cracked all the way through and you can see them on an X-ray. They're generally in that distal part of the fibula, about six centimeters or so above the lateral malleolus. If you're pushing on the bone and it hurts and it's not so much on the tendon, you gotta think fibular stress fracture. Pubic rami is another one that will see you quite a bit. They'll talk about a deep sort of a groin kind of a pain. Again, because it's confused with a strain so often, by the time we get them, we'll see a lot of them show up on X-ray or certainly with advanced imaging. But just start thinking about the story. Does it make sense? Why would this person have a groin strain? What would they do that possibly caused it? And what does it sound like? And does it throb and ache later? Is it with certain movements or weight bearing and not others? Look at your physical exam, but don't be too confused by what they sound like. Think about, does it make sense for this athlete to have it? Calcaneus, people say everything with foot pain seems to be plantar fasciitis. And I'm gonna show you what that, why that would be confused for that later on. So we're gonna kind of go over some of these as we go or why they'd be confused with something else. If it's non-critical, I mean, really you could use crutches of pain with ambulation. If it's lower like tibia to boot, you could use a boot instead of crutches. You really don't have to make a non-critical stress fracture, put them on crutches. All of those can be ambulatory. So pretty much except for an anterior tibia, you can make all these people in a boot. The only ones you would put if they were non-critical and put them on crutches, something like a femoral shaft because you can't put a boot that high and you do have to get them off of that for a few weeks. And I'll show you that protocol a little bit later. You try to figure out what can I do from a cross-training perspective? Because when you pull running away from somebody or whatever they're doing, they start to get a little antsy if they can't exercise. So what you wanna think about, can they do water, cycle, elliptical, anti-grav, or can they do upper body strength training core exercises? So what can I give this person to do that keeps them in shape and keeps them from going crazy? Because the longer I have them out, the more likely they are to not listen to what I'm saying and try to do something different. Then we do a gradual return. So we do a little bit of walking and some strengthening. If they don't have palpation, generally, then we can start them with impact. I'm gonna show you what that looks like in a minute. We use therapy to correct biomechanical errors, particularly if it's a fibula, strengthening and correct training errors. So we're gonna use our therapy as time to make sure that it doesn't happen again. And we're gonna look a lot on the mechanics and a lot of their training errors to get fixed. And most of our lower extremity athletes are just too weak, particularly around the hips. So we've spent a lot of time strengthening the hip. Now, this is our list of critical stress fractures. So these are the ones we're gonna spend a little bit more time on. And we're also gonna talk about how grade can make a difference. So femoral neck, this is the one that you can't miss. Okay, so tension side, you'll see here is a crack through this because that's gonna have a bowing force trying to distract this apart, just like you see on the anterior tibia. Compression side is the one that makes you feel a little bit better because you're likely not gonna end up ever being surgical, but we still have to pay a lot of attention to how we're going to treat them. The tension side is typically the one that ends up getting a surgical consult. So this is our femoral neck. So this is our T1 and our T2. And this does have that crack going through. So we would call that a four. Now, how are we gonna treat this person? And what are we gonna do? Well, it's essential that we get them off of that weight. So what they're gonna start thinking is they have this pain. It's kind of deep in the groin. I think like hip flexor strain. I've seen a lot of people come in with, I've been working on therapy or doing something for my hip flexor, and they're just not listening to the story. Pain that's getting worse, changes of transition, throbbing and aching at night. So we're gonna go non-weight bearing. And generally the non-weight bearing period can be up to about six to eight weeks. I've had it go a little longer in people with bone density issues. And it can be shorter if it's really a low grade. So some of the ones that are shorter can start ambulating even sooner. And then we're gonna transition them off crutches. Non-impact cross training following this protected rest. One of the reasons why is you've got to think about where the stress fracture is. You can have them here, but if they're the basal cervical kind, which comes down towards the lesser trochanter, the reason you can't have a person like that doing deep water running is since the hip flexor inserts on it, every time they flex their hip, they're pulling on it. And if you think about everywhere a muscle inserts, you can get a stress fracture. You basically would be having the hip flexor pulling on it every time. So it's important to look at it and see where it is. If it's here, there's not as much muscle activity pulling on it. If you see a trail down here into that basal cervical region, just remember you can't have them do some of the other non-weight bearing exercises or hip extension or hip flexion and such is because they're yanking on it every time. And those are gonna take longer. So we do non-impact cross training initially a lot of strengthening will get involved, cycling, elliptical, try to keep up their cardiorespiratory endurance. 12 weeks we're gonna re-image. If it's normal, then we start impact and return to run. We start with a jump landing, single leg, double leg, jump rope, plyometrics, walking, walk jog, and then to running. If there's a cortical break or there's 50% of the femoral neck on the tension side, we will have ortho take a look and there are strict non-weight bearing. But for the most part, less than 50% on the compression side, they're gonna do just fine with protected weight bearing. So we typically follow this type of a pathway just to make sure that we have sufficient bone healing. And these are one of the few that we will MRI once they're clinically healed because we wanna make sure it's actually healed. If you go to the point where they're not very painful and then you say, okay, we're gonna start impact again. You could go right back to where you were. And because this is the one stress fracture, we just can't miss because missing it and breaking their femoral neck is so critical. We do spend, we're a little more conservative, but it makes sure that we get people back safely. Anterior tibia is one of those where you'll see these little black lines form. If you don't, you can go to a CT scan. They don't image quite as well on an MRI scan. It's more common in our jumping and leaping sports. And these are the breaks that can lead to catastrophic failure of the anterior tibia because it's a bowing force. They'll be tender right along that anterior tibia. Really focus in on the x-ray to see if you can see anything that looks like a black line. If there is, get them into the CT scanner. The crazy thing about these is they don't seem to hurt as much as the medial tibia, even though they're more critical. We find the same thing with the navicular bone is you wish it would have hurt more to make people stop. I believe Dr. Zaremsky, I think it might've been his patient, if not our partner, Dr. Herman had a basketball player with six to eight black lines on their x-ray before we were able to shut them down. It was somewhat horrifying to see, but eventually got all that sort of healed down. So generally you're looking at three to six months of healing so you make sure the person understands that. And if it's not healing, then we might look at a surgical consult. We do get a bone stimulator. Sadly, insurance makes us wait three months to get the bone stimulator. Sometimes we can convince them to get it at eight weeks, but you have to show non-healing before they'll let you move further. Medial malleolus is an interesting one. You'll see it, but it doesn't always show up as nicely as this fracture that I put here. It's like a person who seems to think what you've got is an anterior ankle impingement or maybe they thought they twisted or sprained their ankle and you've got them in therapy and they're just not getting better. Or what you're noticing is there's swelling around the anterior part of their ankle. So not as lateral, not as medial, it's kind of anterior. And there's a lot of pain when they're walking. You've tried booting them and they're just not getting better. And so if you MRI scan it, you find this fracture line in there. That's got us more times than we would like. Essentially what you're looking for is somebody that you're treating like an ankle sprain or an impingement and they're not getting better. They typically aren't gonna give you this nice look. It's generally a little bit more subtle inside the bone. But if you're treating them and you're doing everything right and they're not getting better, it looks like sprain versus impingement. Get the MRI scan and see if there's truly a fracture line underneath, particularly if they did something with a lot of jumping and landing. And that's where we're seeing it more often is not necessarily in a horizontal kind of running type of population, but something where there's jumps, landings, and quick turn seems to be what break this down. Talis, this is actually a patient of mine from this past fall. She came in thinking that she had injured her ankle when she was running and slipped on a curb. She had this insidious onset of ankle pain that wouldn't get better. And then she kept trying to run on it. Talis is pretty critical because you think about, there's your tibia. Talis is the first bone you stand on. And she decided by the time she came in, she couldn't put her heel on the ground and she had cracked her talis all the way through. You wish she had actually come in and seen us earlier. The fun part about this, this X-ray was negative. So the X-ray didn't show anything. And then we ended up finding this on the MRI scan because we put her in a boot and thought, let's just get a scan and see how bad things look in there. And that's what we ended up finding. So tail or neck is rare, lateral body is most common. And essentially what you're getting is you get a little bit of overpronation allowing impingement of the process on the calcaneus. Because of the seriousness of this one, because it does bear all the weight, you don't want to have that dome flattened and hers extended into that, right to the ligaments and subtalar joint, that can cause a lot of instability. You make them non-weight bearing. And then what you've got to do is get to the business of correcting, why did this happen in the first place? Unless they jumped off the top of a building, this is basically because of mechanical forces that can't be absorbed because of this overpronation impact. So you correct that and they generally do pretty well. There's a period of non-weight bearing that goes into it because that's a pretty critical injury to heal. Like I said, she had jumped off of a four foot sign taking a little picture on vacation in Carolina and got a sharp pain. Our guess is she was working on it and when she jumped, she decided that's when she pushed it all the way through. Navicular is again, one of those insidious pain that's worse when you with push off or jumping or change of direction. Here's our talus right here and there's our navicular and there's our stress fracture. Think about the navicular sits at the nice top of a dome or an arch. So it's always feeling this compression. So if you don't have strong enough foot intrinsics or you're doing a lot of jumping, you can basically have it start to get crushed in between the talus and the cuneiforms and it will start to break down. Because of that middle third is very critical with a poor blood supply. This is one where it's non-weight bearing. Now I have eight weeks in here, but it can be longer. But generally what we're gonna do is non-weight bearing for eight weeks. And then we do two to four week transition in a boot. And then you can go to a mid, a semi-rigid kind of a heat moldable orthotic that you can get online and support the arch so they don't keep pushing down into it. There is a great review article by Torg that goes back about 10 years now. And he goes through the various ways to treat a navicular stress fracture. So if you do a non-weight bearing in a cast for six weeks, and then if it's still tender, you go for two more, most times the fact that we're just going to eight. So if you do that with a cast transition, the semi-rigid orthotic, your return to full activity on average is five months. And you have a 96% chance of getting that to heal. If you do walking in a boot, which is kind of the far end, you have a 46% chance of getting them to heal. If you do surgery, interestingly enough, because surgery has complications, you had an 82% chance. So if you did cast, but did it for four weeks, your chance was somewhere in the middle. So the highest rate of healing, according to the Torg article, was non-weight bearing in a cast for six to eight weeks, but no less than six. And this progression and average return to play was about five months. But I would behoove everybody to look at that article because you'll be able to quote it. You'll be able to describe it. So if you get a parent, an athlete, or anybody that says, why are you doing it this way? Well, this pathway has a 96% chance that I'm going to get you back to full activity. And that's a pretty good chance. And you say, what about the others? They're in that same table. And it goes down with each lesser type of weight bearing that you do. So I would make sure that you looked at that article and had that something that you could pull out of your memory at any time. It does help get the navicular people sort of on par with what you're trying to do. Proximal fifth. So when you're doing proximal fifth, you want to measure in from here. And it's 1.5 to three centimeters in. It's about what's called, basically called the zone of badness. If it's within this range in here, that's our zone of badness that will help differentiate it from your avulsion fractures back here and your shaft fractures out here. That's generally casted. We're going to do sort of serial casting and keep reassessing, keep imaging to make sure that it's healing. If it's not, you can have really good success if you put a bone stimulator on it. If it's still not healing, even after a good trial of bone stimulator, then you can go to ortho. Ortho comes in early with your competitive athletes because they'd rather just put a screw in it and get back to play, rather than waiting to see if it will heal on its own and then potentially failure. Just to make sure you know the difference between it and the avulsion and its distance, okay? So this is about the distance you want to be thinking from here to in this zone and know is it in the zone of badness or not. All right, femoral shaft. It's not critical, but it's critical if you miss it because the femur is a pretty big, important bone. And one of our young athletes had a stress fracture that went from down here above the knee to all the way up here. It lit up the almost entire length. We were wondering how she was still walking around on it with the size that it had taken over. So again, think about why would they have a quad strain? If it's a low velocity movement like running and not sprinting, they wouldn't. You can't reproduce it with palpation. They do have a pain with a hop. They probably will refuse to do it because they know it's going to hurt. But just think of, again, like mechanism's important. And this is where you want to make sure you're doing that fulcrum test, the prone and supine. It's gluteal at times if it's where the gluteal muscle inserts. So we've had several posterior femoral shaft stress fractures. They're a little higher. They're more up in here. And an interesting thing they all say is it hurts when they sit down. So if they say it hurts when it sits down, your mind is going to instantly think about ischial bursitis. It's a little bit lower than that, although it can radiate, but you palpate the ischial bursa and it doesn't hurt. And you fulcrum and it does. Think posterior femoral shaft stress fracture because that's right where the gluteal muscle's inserting. There aren't a lot of data on how to treat a femoral shaft stress fracture. So we will use the fulcrum test and hop just like this article from 2006. So what they basically described is phases. Your symptomatic phase to asymptomatic and on. So you start with non-weight bearing for three weeks. You bring them back, you hop them, you fulcrum them. It hurts, they go back up to the top. You bring them back at three weeks. You fulcrum them, you hop them. It hurts, they go back. Once that's normal, then they get to this phase. And this is where you get them, you wean them off of crutches and you start with some basic strengthening. You bring them back, they're still fine. They didn't have a relapse of symptoms. And then you can start your pathway of strengthening to impact and back to normal exercise. So this is what we've been using for a long time. Like I said, that one year we did 11 of them in one year. In fact, one person was bilateral femoral shaft stress fractures and we've had good success using this. There are other ways to try and do it. They're all based on case reports. One where they had a person in an alter G and they had an athletic trainer at a college working with the patient every single day. If you can spend every single day with the patient and monitor them on a day-to-day basis, you might be able to move through this a little quicker. But this is a system that's worked really well from us from that article. Calcaneus is commonly mistaken to be plantar fasciitis. You want to do the calcaneal squeeze and you want pain under both fingers. If you're not sure if they could perceive that, push on one side and then push on the other. The only thing in between your hand is bone. So make sure the pain is both medial and lateral. And here's why. So when you look at where calcaneal stress fractures typically go, they point up here at the Achilles and Achilles bursa. And they point down here at the plantar fascia. So if you spend your life pushing up from the bottom and it hurts, well, of course it's going to hurt because you're pushing on the stress fracture. Where it shouldn't hurt if it's plantar fasciitis is pushing over here. Most of the time when they start, they're going to start up here. So I'll even rub my finger on a line where I know it's supposed to occur. Medial and lateral and do it to the opposite side to see if there's a difference in pain level. If you're fortunate enough to get it to appear on an X-ray, it will look like that. And sometimes it starts from over here. Sometimes what you'll find is, if you remember the principle of anywhere a muscle insert a stress fracture can form, is remember you got four layers of muscle inserting on the plantar aspect of your foot, right in the same place as the plantar fascia does, which is right here. If they pull hard enough, you'll start to get a stress fracture. So you push here and thinking, it sounds like plantar fasciitis. You send them to plantar fasciitis treatment. They're not getting better. You scan it and you find you had both. You had inflammation in the plantar fascia musculature and a stress fracture forming right here from fatigue breakdown. So always think if I'm doing everything right, and so is the patient and they're not getting better, what am I missing? What you might be missing is that stress fracture right in this area here. Very stable. You can run this thing over the truck and it's not going anywhere. So we put them in a boot and then you can transition to a heel cup. It basically don't make them non-weight bearing unless it even hurts a lot when they're in the boot. That's generally for three to seven days they'll end up with crutches. So a couple of things to think about. 36 year old lady has heel pain and this is kind of a giveaway. She comes in telling me she's got Achilles tendonitis and plantar fasciitis. And I think, okay, so what do I want to know? Well, she was trying to run her first half marathon, had to walk after mile four. Well, she was a novice runner and she ran four races in the past month. Two 5Ks, a 10K and the half marathon. And before she was only doing two to three miles a week. She came in walking on her toe and couldn't put her heel down. So that's her scan. Her imaging showed this little line here that you can look for. And then she had this really cool stress fracture that went right from the plantar fascia area all the way to Achilles. So that's why she thought she had Achilles tendonitis and plantar fasciitis and kept going until she couldn't put her foot down. She kept this copy in her purse for a year while she did rehab and went back to running to make sure she reminded herself never to do that again. So always keep your mind open for pushing in that area. Don't just jump to plantar fasciitis or Achilles. Make sure you check that bone in the middle and listen to the story that they're telling you. This is a person training for half marathon and was diagnosed with pes anserine bursitis, sent to PT, but pain is getting worse. So we get this X-ray and we see this. Now it is where the growth plate area is. So you see some normal sclerosis but this was a little too fulminant and that's the MRI scan. So what you want to think about in a runner, pain in the pes anserine region is a stress fracture till you prove it's not. A couple of our fellows at UF are gonna be presenting a case series of 40 patients consecutively that came in with pes anserine pain that were runners and the majority of them, overwhelming majority ended up having stress fractures. So if you have a young athletic person, particularly a runner and they have pain here in the pes anserine region, it's a stress fracture till you prove that it's not. Now why it's typically medial, 60 to 80% of your weight goes to the medial side, the other 20 to 40 on the lateral. What makes one of our cases really interesting that we're presenting as a case study is they had bilateral lateral femoral proximal tibial stress fractures. And that came down to a rotational mechanics and their form. So it had a really cool biomechanical principle behind it. But if they're tender there, you can think about the fact that it's a stress fracture. Generally with these, you're gonna try to reduce impact so you can boot them. It's not quite like a tibial plateau fracture. You can think we don't usually offload them with an offloader. Sometimes you can use crutches, particularly if they're bilateral, it causes a lot of discomfort. But just think about that. Every time somebody come in and they're tender there and they're young and they're athletic, think stress fracture first. Sacral stress fractures are interesting. They present with sort of this posterior tenderness. They talk about this pain in the buttocks. It might radiate to the groin and the thigh to make it a little bit more difficult to find. Can sound like a lumbar or a dick if the anterior sacral parameter involved. Exam is largely nonspecific. If you're lucky, you'll find one maximum point of tenderness right out on the wing. One legged hop might produce pain, but doesn't always favor. Might, but it doesn't always. It can mimic sacroiliitis. You can think SI joint dysfunction. What you wanna look at is what does it sound like? When do they have it? And if I'm gonna use therapy, does it get better or does it not? But generally when they have a little bit of tenderness, it's gonna occur right out here in this picture. You can see the white of the stress fracture here on the sacrum. And then down here, it's right there in this part of the sacrum. So, and that's what it would look like on a bone scan, that bit of white that pops up. It's interesting. And the reason I'm bringing it up is they're not critical. Generally, when you get them, they've been there a while and they're at a higher grade because everybody thought it was muscular and they did everything they could muscular wise until they just can't get better, just can't take it. Maybe they can't walk, but they know they can't run because they can't do any impact. Consider it to be an insufficiency type of fracture. It broke down because of a, either we have somebody with poor bone quality. Generally, the majority of the ones you're gonna find have menstrual cycle irregularities, eating disorders, low calcium and vitamin D to break down a sacrum is not the easiest thing to do. The other thing you can look for that will characterize them if the bone is normal or even it's abnormal is they have a lot of shear stress and rotation in the pelvis. So you're gonna find weak gluteus medius, you're gonna have a weak supporting musculature and they are rotating, rocking kind of all over the place. They created a lot of shear through the pelvis and caused the bone to break down. So even if you're gonna correct any of the underlying issues, you're always gonna have to fix strength and shear stress that's going through the pelvis to cause that sacrum to break down. It's very stable. So if they can walk on it, they can walk, sometimes use crutches for a few days to make it feel a little bit better. You'll do non-weight bearing for a while in terms of cross training or even non-impact. So you can actually get them training pretty early, but sometimes it takes too long to correct the biomechanics and nutrition and training errors. Return to run can be pretty simple all the way to months out. You just have to get to the cause since it's a relatively rare thing to find, it should spark in your mind, why did they get this? And you're gonna have to check all their hormonal profile, their bone and all the mechanics that went into it. But treat it like an insufficiency fracture. Let's talk a little bit about how do I plan for a race? Cause you're always gonna get this or an event. So we're gonna use a race. How long does it take? Well, your first marathon, you generally plan a year out, but you're gonna need base training six months, three months for a full and a half. So let's take a tibial stress fracture, for instance. So we do eight weeks of non-running to get this thing to heal. So we, remember bone can only heal at such a rate. So they might feel great at four weeks or you get the person who's cycling. They say, I rest for three weeks, it feels better. I go back to running, it hurts. I rest for four weeks, I go back to running, it hurts. Cause the lack of pain is that the bone is healing. It doesn't mean that it's healed. It really needs a good six or eight weeks to heal, not just feel better pain-wise where it's healing. So if we do eight weeks of non-running and then we do a six week return to run program, and then we do just six weeks of base training. So we give them credit here as the three months of base training. And then they do a 12 week training program and many half marathons are four months instead of three months. If we just did this and everything went great from the day that I diagnosed them to their next half marathon at best is eight months. After they stopped crying and catastrophizing cause they signed up for a race in a month, you've got to help them understand that this is how long it takes. This is the pathway. We're gonna get you back, but we're gonna get you back better and stronger. Now, if it's an avicular, remember how long that takes. We got to add three months. If it's a femoral neck, you got to add six to eight weeks. So people are instantly gonna ask you, when are they gonna run again? When can they race again? And by calculating these things out and I'll even sit there in front of them and do it. I'll say, okay, so here we are today. You're gonna rest for six weeks and then we're gonna do strengthening for four. And then we're gonna do this and then you just add up the weeks and then they can see it. So I'll do it in front of them so they can see that process. Few things about the principles of returning to run is remember what got you here? What is it that I have? Is it bone, ligament or tendon that's injured? What was the problem? Was it their training? Was it their biomechanics? Was it something with the equipment or shoes they were using? Always manage expectations. They hear what they wanna hear. If you say six to eight weeks, all they heard was six. So always make sure that you're explaining it and say it several times because the first time they're catastrophizing and they're not listening. So if I say it three or four times, you hope it sinks in. Under promise and over deliver. So if you tell them eight weeks and they're better in six, you're a hero. If you tell them six and they're better in eight, you're the goat. And not the Tom Brady kind of a goat, Dr. Zaremski, the actual animal goat. And remember that your timeline is influenced by their compliance. When I said eight months, I said eight months at best. Well, because that's average. What if they're not doing any of their home exercises? What if they wanna skip a stage in their return to run and go faster? What if they don't do anything you wanted from a weight-bearing perspective? Like, you know what the heck with you during my thermonextress fracture? I'm gonna walk around on this thing and oh my gosh, why isn't it getting better? So that's what I will also tell them is I'll get them through it. We're gonna get where we need to go, but you need to do everything I'm asking of you. And if they're not getting better because they're not doing what you said, then what do they want from me? My timeline is really dictated by their compliance to the program. And make sure that you have them understand they have a role to play. And that the onus is on them and personal responsibility is very important in this pathway. If you're not doing what I'm asking, don't come to me and wonder what else we can do. If you're doing everything I ask and you're not where we are, where we need to be, there's a piece of the puzzle we don't have that then we have to figure out. So some conclusions. In a history, always listen for patterns that make sense. Does it sound like a stress fracture based on the chronicity of it, the change in some sort of a transition? Is it throbbing and aching? All those kinds of things. Always rule out the worst injury before assuming a simple one. It is really easy to say shin splints. Are you sure? Or quad strain or you've got a calf strain. So calf strains will appear with posterior tibial stress fractures. They have a calf strain, but they can't figure out why. It's just this posterior aching in my calf. And then the longer I run, the more it hurts and it's throbbing and aching later. It probably have a posterior tibial stress fracture. Why would it be in that area in the first place? Where do the forces go? You think about why does it appear in the distal third of a tibia? Well, it's wide at the malleolus, it gets more narrow and then it widens again. So as force gets into a narrow area, you got more force for less surface area, that's where bone breaks down. Think about the femur. Why is it breaking down at that point in the shaft? Because that's where it's getting narrow. Is there a muscle inserting on it? Like the posterior part of the tibia where you have the soleus insertion. Is there a muscle insertion? Is it where forces go? Is there a lack of flexibility imparting forces in a place they shouldn't be? That lack of ankle dorsiflexion will point you to a lot of ills because if they're not dissipating force at the level of the ground through that flexibility of that elastic tissue, force has got to go somewhere, they're going up. And then you're going to start to see breakdown of the tissue or early forefoot overload because of lack of dorsiflexion going to give you metatarsal stress fractures, metatarsalogist, sesamoid injuries, things along those lines. So always look at the, if they don't have good flexibility around important segments of the joint and the kinetic chain, force has to go somewhere and that will help break it down. Remember the repetitive load cycles and are we having normal forces on abnormal bone or abnormal forces, or normal forces, abnormal bone, normal bone, abnormal forces, you get the idea. When is relative rest versus absolute necessary? I try to give people as much as I can to keep doing to make them happy because it might be their compensation is exercise. So I don't want to take it completely away if I don't need to. So what can I have them do? What care can I give them to help them feel like they're still doing something along the way? And just remember, never schedule a race during rehab because it will make them push a timeline and do stupid things that you wouldn't want somebody to do while they're having to listen and keep in a nice confined pathway. If they've got a race hanging out there and they don't think the training is going fast enough, they will accelerate it and commonly then people get themselves into trouble.

2nd Edition, CASE 12

2nd Edition

Foot and Ankle

stress fractures

diagnosis

management

biomechanics

risk factors

imaging

personalized treatment

prevention strategies