Description of the evidence collection method

To develop this guideline, the Medline electronic database (1966 to 2012) was consulted via PubMed, as a primary base. The search for evidence came from actual clinical scenarios and used keywords (MeSH terms) grouped in the following syntax: “Stress fractures”, “Foot”, “Ankle”, “Athletes”, “Professional”, “Military recruit”, “Immobilization”, “Physiotherapy”, “Rest”, “Rehabilitation”, “Conventional treatment”, “Surgery treatment”. The articles were selected by orthopedic specialists after critical evaluation of the strength of scientific evidence, and publications of greatest strength were used for recommendation. The guidelines were drawn from group discussion. The entire text was reviewed by a group specializing in evidence-based clinical guidelines.

Grade of recommendation and strength of evidence

1. Experimental or observational studies of higher consistency.

2. Experimental or observational studies of lower consistency.

3. Case reports (non-controlled studies).

4. Opinions without critical evaluation, based on consensus, physiological studies, or animal models.

Objective

The target audience of this guideline includes orthopedists, physiatrists and sports doctors in order to guide the diagnosis and treatment of athletes with stress fractures in the foot and ankle.

Introduction

Stress fractures were described for the first time in 1855 by Breihaupt among soldiers reporting plantar pain and edema following long marches.¹1 Fitch KD. Stress fractures of the lower limbs in runners. Australian Fam Phys 1984;13:511-5. For athletes, the first clinical description was given by Devas in 1958, based solely on the results of simple X-rays.2 Stress injuries are common among athletes and military recruits, accounting for approximately 10% of all orthopedic injuries.³3 Matheson GO, Clement DB, McKenzie DC, et al. Stress fractures in athletes: a study of 320 cases. Am J Sports Med. 1987;03:46 PM-58.

It is defined as a solution for partial or complete continuity of a bone as a result of excessive or repeated loads, at submaximal intensity, resulting in greater reabsorption faced with an insufficient formation of bone tissue.¹1 Fitch KD. Stress fractures of the lower limbs in runners. Australian Fam Phys 1984;13:511-5.

Although stress fractures may affect all types of bone tissue, they are more common in bones that support bodyweight, especially those in the lower limbs (tibia, 49%; tarsal bones, 25%; metatarsals, 9%).³3 Matheson GO, Clement DB, McKenzie DC, et al. Stress fractures in athletes: a study of 320 cases. Am J Sports Med. 1987;03:46 PM-58. Studies on runners reveal a higher incidence of stress fractures in the tibia, followed by the metatarsals, fibula, femur and navicular bone.⁴4 Bennell KL. Epidemiology and site specificity of stress fractures. Clin. Sports Med 1997;16:179-196.^,55 Amatuzzi MM, Carazzato JG. Medicina do esporte. 1, ed. Ver. São Paulo: Roca 2004;38:363-369.

The locations of stress fractures vary from sport to sport. Runners may develop a stress fracture of the medial malleolus, the distal end of the fibula, calcaneus, lesser metatarsal, and medial sesamoid bone. Classical ballet, aerobic gymnastics, tennis and volleyball athletes mainly present stress fractures in the navicular and sesamoid bones. Basketball athletes have a prominence of the medial malleolus, navicular bone and metatarsal stress fractures, while for footballers lesser metatarsal fractures are more common.⁶6 Haverstock BD. Foot and Ankle Imaging in the Athlete. Clin Podiatr Med Surg 2008;25:249-262.^,77 Bennell KL, Malcolm AS, Thomas AS. Risk factors for stress fractures in track and field athletes: A twelve-month prospective study. Am J Sports Med 1996;24:810-8.^,88 Boden BP, Osbahr DC. High-risk stress fractures: evaluation and treatment. J Am Acad Orthop Surg 2000;8:344-53.

From a biomechanical point of view, fatigue fractures are the result of specific, cyclical and repetitive muscle action until exhaustion, with load transfer to the bone exceeding its adaptation capacity.⁸8 Boden BP, Osbahr DC. High-risk stress fractures: evaluation and treatment. J Am Acad Orthop Surg 2000;8:344-53.^,1010 Sonoda N, Chosa E, Totoribe K, Tajima N. Biomechanical analysis stress fractures of the anterior middle third of the tibia in athletes: nonlinear analysis using a three-dimensional finite elemento method. J Orthop Sci 2003;8(4):505-13. The shear and compression forces stimulate bone transformation according to Wolff’s law, that is, the compression forces promote osteoblast activity and bone deposition leading to a strengthening of bone structures, adapting to the applied load, while shear forces lead to the reverse process of bone resorption by stimulating osteoclast activity. As a result, the majority of stress fractures are located in the areas of shear stress.⁴4 Bennell KL. Epidemiology and site specificity of stress fractures. Clin. Sports Med 1997;16:179-196.^,55 Amatuzzi MM, Carazzato JG. Medicina do esporte. 1, ed. Ver. São Paulo: Roca 2004;38:363-369.^,88 Boden BP, Osbahr DC. High-risk stress fractures: evaluation and treatment. J Am Acad Orthop Surg 2000;8:344-53.

When should we suspect a stress fracture in the foot?

Suspected injury is based on the details from the medical history, general physical examination and orthopedic physical examination. It is important to establish the relationship between the start of painful symptoms and physical activity, generally performed repetitively, abrupt changes in the amount of training and the presence of risk factors (D).⁸8 Boden BP, Osbahr DC. High-risk stress fractures: evaluation and treatment. J Am Acad Orthop Surg 2000;8:344-53.^,1111 Verma RB, Sherman O. Athletic stress fractures: part I. History, epidemiology, physiology, risk factors, radiography, diagnosis and treatment. Am J Orthop 2001;30(11):798-806.^,1212 Knapp TP. Stress fractures: general concepts. Clin. Sports Med 1997;16:339-356.

Initially, pain emerges at the end of the exercises and intensifies over some weeks; it may occur during the entire activity, and be constant during walking. Pain worsens and transforms training into suffering. Training becomes increasingly painful and difficult to continue. Even after some days of rest, returning to activities too early leads to recurrence of the pain (D).⁴4 Bennell KL. Epidemiology and site specificity of stress fractures. Clin. Sports Med 1997;16:179-196.

5 Amatuzzi MM, Carazzato JG. Medicina do esporte. 1, ed. Ver. São Paulo: Roca 2004;38:363-369.^-66 Haverstock BD. Foot and Ankle Imaging in the Athlete. Clin Podiatr Med Surg 2008;25:249-262.^,88 Boden BP, Osbahr DC. High-risk stress fractures: evaluation and treatment. J Am Acad Orthop Surg 2000;8:344-53.

Recommendation

Stress fractures in the feet of athletes should be suspected in the presence of insidious pain associated with increased exercise intensity.

Which complementary exams should be requested for the diagnosis?

After the medical history and clinical exam, plain radiography, bone scintigraphy, computerized tomography and magnetic resonance imaging have been used to aid the diagnosis (D).⁸8 Boden BP, Osbahr DC. High-risk stress fractures: evaluation and treatment. J Am Acad Orthop Surg 2000;8:344-53.^,1111 Verma RB, Sherman O. Athletic stress fractures: part I. History, epidemiology, physiology, risk factors, radiography, diagnosis and treatment. Am J Orthop 2001;30(11):798-806. Despite its low sensitivity, simple radiography is recommended to start the investigation (D).¹²12 Knapp TP. Stress fractures: general concepts. Clin. Sports Med 1997;16:339-356. In more advanced cases, cortical or medullary fracture lines, regional osteopenia, sclerosis and callus formation may be noted. Unfortunately, radiographs are initially negative in 70% of stress fractures and might not show evidence of injury for 2 to 4 weeks after the start of symptoms (C)¹³13 Steinbronn DJ, Bennett GL, Kay DB. The use of magnetic resonance imaging in the diagnosis of stress fractures of the foot and ankle: four case reports. Foot Ankle Int 1994;15(2):80-3. (B).¹⁴14 Kiuru MJ, Pihlajamaki HK, Hietanen HJ, et al. MR imaging, bone scintigraphy, and radiography in bone stress injuries of the pelvis and the lower extremity. Acta Radiol 2002;43:207-212.

Rupture of the bone cortex can be demonstrated through computerized tomography and evidence of periostitis can also be detected in this manner. The sensitivity of computerized tomography is higher than radiography; however, compared with bone scintigraphy and magnetic resonance injury, the sensitivity for revealing stress fractures is low, resulting in a higher rate of false negatives (C).¹⁶16 Murcia M, Brennan RE, Edeiken J. Computed tomography of stress fracture. Skeletal Radiol 1982;8(3):193-5. Owing to the high rate of false negatives using radiographs at the start of the course of stress fractures, additional diagnostic imaging is often necessary. Bone scintigraphy has traditionally been the test of choice in this situation, but has been supplanted by magnetic resonance imaging (B).¹⁷17 Hodler J, Steinert H, Zanetti M, et al. Radiographically negative stress related bone injury. MR imaging versus two-phase bone scintigraphy. Acta Radiol 1998;39:416-420.^,1818 Gaeta M, Minutoli F, Scribano E, et al. CT and MR imaging findings in athletes with early tibial stress injuries: comparison with bone scintigraphy findings and emphasis on cortical abnormalities. Radiology 2005;235:553-561. Despite its sensitivity, bone scintigraphy is not specific and may produce false positive results in 13 to 24% of cases (C).¹³13 Steinbronn DJ, Bennett GL, Kay DB. The use of magnetic resonance imaging in the diagnosis of stress fractures of the foot and ankle: four case reports. Foot Ankle Int 1994;15(2):80-3.

Magnetic resonance imaging has numerous practical advantages over scintigraphy. It provides precise anatomical resolution, can differentiate a stress reaction from a stress fracture, as well as being a noninvasive, multiplanar exam that does not require radiation. It is more sensitive and specific, provides greater information and is capable of detecting pre-radiographic bone changes. The disadvantages include the higher cost, contraindications relating to claustrophobic patients and those with metal implants or surgical materials (C).¹³13 Steinbronn DJ, Bennett GL, Kay DB. The use of magnetic resonance imaging in the diagnosis of stress fractures of the foot and ankle: four case reports. Foot Ankle Int 1994;15(2):80-3.

Follow-up using computerized tomography or magnetic resonance imaging may also be useful to monitor healing of the stress fractures and determining if there is a delay in healing that could require surgical intervention (D).⁶6 Haverstock BD. Foot and Ankle Imaging in the Athlete. Clin Podiatr Med Surg 2008;25:249-262.

Recommendation

In cases of suspected stress fractures, plain radiography of the site of pain should be requested, with diagnosis in the majority of cases via more sensitive and specific imaging exams (magnetic resonance imaging).

What are the factors that favor stress fractures?

Various factors contribute to the pathogenesis of the disease, which may be classified into 2 sub-types: intrinsic and extrinsic. In general, extrinsic factors are related to the type and rhythm of training, the use of unsuitable footwear and sports equipment, precarious physical conditioning, the training location, environmental temperature and insufficient recovery time of previous injuries. Intrinsic factors include age, sex, race, bone density and structure, hormonal, menstrual, metabolic and nutritional balance, sleep pattern and collagen diseases (D)⁴4 Bennell KL. Epidemiology and site specificity of stress fractures. Clin. Sports Med 1997;16:179-196.^,55 Amatuzzi MM, Carazzato JG. Medicina do esporte. 1, ed. Ver. São Paulo: Roca 2004;38:363-369.^,88 Boden BP, Osbahr DC. High-risk stress fractures: evaluation and treatment. J Am Acad Orthop Surg 2000;8:344-53.(C).¹⁹19 Korpelainen R, Orava S, Karpakka J, Siira P, Hulkko A. Risk factors for recurrent stress fractures in athletes. Am J Sports Med 2001;29(3):304-10.^,2020 Blivin SJ, Martire JR, McFarland EG. Bilateral midfibular stress fractures in a collegiate football player. Clin J Sport Med 1999;9(2):95-7.

Prospective and retrospective studies show a higher incidence among Caucasians. When compared to American black and Hispanic individuals, white individuals are more susceptible to stress fractures (D).²²22 Monteleone GP. Stress fractures in the athletes. Orthopedic clinics of north america 1995;26(3):423-432. The same occurs with age: older individuals present a higher incidence of such fractures (B).⁷7 Bennell KL, Malcolm AS, Thomas AS. Risk factors for stress fractures in track and field athletes: A twelve-month prospective study. Am J Sports Med 1996;24:810-8. Stress fractures are less common in children than adolescents and adults (D).²³23 Hulkho A, Orava S. Stress fractures in athletes. Int J Sports Med 1987;8:221-226. In relation to sex, some studies have shown that military women have an incidence 5 to 10 times higher than men (B).⁷7 Bennell KL, Malcolm AS, Thomas AS. Risk factors for stress fractures in track and field athletes: A twelve-month prospective study. Am J Sports Med 1996;24:810-8.

With regard to genetic factors, studies on identical twin military recruits submitted to the same treatment in quantity, duration and intensity reveal fatigue fractures in the metatarsal bones in both (B).⁷7 Bennell KL, Malcolm AS, Thomas AS. Risk factors for stress fractures in track and field athletes: A twelve-month prospective study. Am J Sports Med 1996;24:810-8.

In relation to biomechanical factors, a high longitudinal arch of the foot, difference in the length of the lower limbs and a marked varus foot associated with multiple stress fractures have been observed (B)¹⁵15 Kor A, Saltzman AT, Wempe PD. Medial malleolar stress fractures: literature review, diagnosis, and treatment. J Am Podiatr Med Assoc 2003;93(4):292-7.,²¹21 Giladi M, Milgrom C, Simkin A, et al. Stress fractures: identifiable risk factors. Am J Sports Med 1991;19(6):647-52. (C).¹⁹19 Korpelainen R, Orava S, Karpakka J, Siira P, Hulkko A. Risk factors for recurrent stress fractures in athletes. Am J Sports Med 2001;29(3):304-10.^,20,24

Cavovarus feet have recently been gaining more attention as being a significant risk factor for various conditions of overuse, especially stress fractures. This shape of foot is known for being relatively rigid, with weak capacity for attenuating shock (C).²⁵25 Pearce CJ, Brooks JH, Kemp SP, Calder JD. The epidemiology of foot injuries in professional rugby union players. Foot Ankle Surg 2011;17(3):113-8.^,2626 Raikin SM, Slenker N, Ratigan B. The association of a varus hindfoot and fracture of the fifth metatarsal metaphyseal-diaphyseal junction: the Jones fracture. Am J Sports Med 2008;36:1367. Supination and pronation of the feet are associated with a significant increase in the risk of stress injuries (B).²⁷27 Cain LE, Nicholson LL, Adams RD, Burns J. Foot morphology and foot/ ankle injury in indoor football. J Sci Med Sport 2007;10(5):311-9.

Recommendation

In cases of suspected stress fractures, intrinsic and extrinsic factors that favor the occurrence of injury should be investigated. The investigation of these risk factors aids diagnosis and treatment.

What is the differential diagnosis?

The main diseases that should be discarded are those resulting from repetitive and excessive effort and that affect the soft tissues that surround the area of bone affected, such as muscle injuries, bursitis, tendinopathy, splints, infections, cancer and compartment syndrome (C)²⁸28 Aoki Y, Yasuda K, Tohyama H, Ito H, Minami A. Magnetic resonance imaging in stress fractures and shin splints. Clin Orthop 2004;421:260-7.(B).²⁹29 Dobrindt O, Hoffmeyer B, Ruf J, Steffen IG, Zarva A, Richter WS, et al. Blinded-Read of Bone Scintigraphy, The Impact on Diagnosis and Healing Time for Stress Injuries With Emphasis on the Foot. Clin Nucl Med 2011;36:186-191.

Does female athlete triad affect stress fractures?

Female athletes are more likely to developing stress fractures (C).¹⁹19 Korpelainen R, Orava S, Karpakka J, Siira P, Hulkko A. Risk factors for recurrent stress fractures in athletes. Am J Sports Med 2001;29(3):304-10. The growing increase of this pathology among female athletes is related to factors that characterize female athlete triad: eating disorders, menstrual disturbances and low bone density (D).⁴4 Bennell KL. Epidemiology and site specificity of stress fractures. Clin. Sports Med 1997;16:179-196.^,55 Amatuzzi MM, Carazzato JG. Medicina do esporte. 1, ed. Ver. São Paulo: Roca 2004;38:363-369.^,88 Boden BP, Osbahr DC. High-risk stress fractures: evaluation and treatment. J Am Acad Orthop Surg 2000;8:344-53. Greater prevalence of eating disorders (such as bulimia, anorexia nervosa, ingestion of laxatives and diuretics) has been found among female athletes (D).³⁰30 Barrow GW, Saha S. Menstrual irregularity and stress fractures in collegiate female distance runners. Am J Sports Med 1988;16:209-216. Irregularities in the menstrual cycle (hypoestrogenism) correlate with early bone loss, reduced mineralization of the osteoid and, consequently, the prevalence of stress fractures in women (D).²²22 Monteleone GP. Stress fractures in the athletes. Orthopedic clinics of north america 1995;26(3):423-432.

How should stress fractures be treated?

The treatment of stress fractures varies according to some of the fracture’s characteristics, such as location, type, and evolution time. A general plan can be established divided into two phases: phase I, or modified rest, is characterized by pain control through the use of anti-inflammatory drugs, physiotherapy methods for analgesia and kinesiotherapy, weight-bearing permitted in daily activities and maintenance of aerobic fitness without causing abnormal stress responses in the affected segment. Activities such as cycling, swimming or running in water are alternatives for maintaining the athlete’s physical conditioning.

Phase II begins from the moment in which the athlete no longer presents complaints of pain, which generally occurs within 10 to 14 days from the start of symptoms. A gradual return to the sport is allowed based on the correction of intrinsic and extrinsic factors (D).³3 Matheson GO, Clement DB, McKenzie DC, et al. Stress fractures in athletes: a study of 320 cases. Am J Sports Med. 1987;03:46 PM-58.

Most stress fractures can be treated conservatively. This implies immobilization in a boot, without sustaining the foot until the symptoms have disappeared, generally around 6 to 8 weeks. Impact activities are avoided, but low impact workouts such as swimming, cycling, and elliptical machines can be continued to maintain aerobic fitness. Frequent physical exams are useful to identify the resolution of symptoms. Nutritional considerations are important as dietary deficiencies may contribute to the development of stress fractures. Recent data recommends early surgical treatment of fractures with a high risk of stress to elite athletes owing to the high risk of dislocation and non-consolidation. Early surgical treatment is also associated with a quicker return to the sport (B)¹⁵15 Kor A, Saltzman AT, Wempe PD. Medial malleolar stress fractures: literature review, diagnosis, and treatment. J Am Podiatr Med Assoc 2003;93(4):292-7.(C)⁴⁹49 Palamarchuk HJ, Sabo M. Fibular stress fracture in a female runner: a case report. J Am Podiatr Med Assoc 1998;88(1):34-6.^,5050 Hootman JM, Dick R, Agel J. Epidemiology of collegiate injuries for 15 sports: Summary and recommendations for injury prevention initiatives. J Athl Train 2007;42(2):311-319.(D).³¹31 Brockwell J, Yeung Y, Griffith JF: Stress fractures of the foot and ankle. Sports Med Arthrosc 2009;17(3):149-159.

Electrical stimulation has also been used for the treatment of stress fractures with satisfactory results (C).³²32 Benazzo F, Mosconi M, Beccarisi G, Galli U. Use of capacitive coupled eletric fields in stress fractures in athletes. Clinical Orthopaedics and Related Research 1995;310:145-149.

Recommendation

The treatment of stress fractures in the feet and ankles of athletes is, in most cases, conservative, through the use of analgesic methods, relative rest, not bearing weight, immobilization of the limb, maintaining physical condition with low impact exercise and correcting risk factors.

What are the indications for surgical treatment?

Despite greater awareness about this injury, the treatment of stress fractures in the foot and ankle continue to be a particularly problematic issue, including the navicular bone, fifth metatarsal and medial malleolus. These injuries are often not diagnosed and may occur at a higher frequency than that actually observed. For example, the navicular bone has a risk of delayed healing because of the poor areas of blood supply, and stress fractures of the medial malleolus have a high rate of dislocation and lack of consolidation. These injuries frequently require surgical stabilization (D).⁸8 Boden BP, Osbahr DC. High-risk stress fractures: evaluation and treatment. J Am Acad Orthop Surg 2000;8:344-53.^,3333 Robert B, Anderson MD, Kenneth J, Hunt MD, Jeremy J, McCormick MD. Management of Common Sports-related Injuries About the Foot and Ankle. J Am Acad Orthop Surg 2010;18: 546-556.

Stress fractures in the navicular bone are often difficult to diagnose. If untreated, they can result in osteoarthritis and delayed consolidation (C)³⁴34 Lee A, Anderson R. Stress fractures of the tarsal navicular. Foot Ankle Clin 2004;9:85-104.

35 Saxena A, Fullem B, Hannaford D. Results of treatment of 22 navicular stress fractures: a new proposed radiographic classification system. J. Foot Ankle Surg 2000;39:96-103.^-3636 Torg J, Pavlov H, Cooley L, et al. Stress fractures of the tarsal navicular: a retrospective review of twenty-one cases. J. Bone Joint Surg 1982;64:700-712.(B).³⁷37 Khan K, Fuller P, Brukner P, Kearney C, Burry H. Outcome of conservative and surgical management of navicular stress fractures in athletes. Eighty-six cases proven with computerized tomography. Am J Sports Med 1992;20:657-666. A large number of stress fractures in the navicular bone may show differences in the outcomes of surgical and nonsurgical treatments for various types of injuries. Given that the published data reveals a high occurrence of delayed consolidation, importance should be given to immediate surgical treatment, especially when the fracture extends to the navicular body or up to the second cortex of the navicular bone (B).³⁸38 Saxena A, Fullem B. Navicular stress fractures. A prospective study on athletes. Foot Ankle Int 2006;27(11):917-21. Surgical treatment consists in percutaneous screw fixation with or without exposure of the fracture site. Generally, bone graphs are reserved for chronic fractures and delayed consolidation and nonunions (C).³⁶36 Torg J, Pavlov H, Cooley L, et al. Stress fractures of the tarsal navicular: a retrospective review of twenty-one cases. J. Bone Joint Surg 1982;64:700-712. Partially threaded solid or cannulated compression screws measuring 4 mm are used (D).³¹31 Brockwell J, Yeung Y, Griffith JF: Stress fractures of the foot and ankle. Sports Med Arthrosc 2009;17(3):149-159.

A stress fracture in the fifth metatarsal diaphysis is defined as a stress fracture of the proximal zone of the bone immediately distal to the anatomical area of the Jones fracture (C)⁴¹41 Dameron TB. Fractures and anatomical variations of the proximal portion of the fifth metatarsal. J Bone Joint Surg Am 1975;57:788. (B).⁴²42 Landorf KB. Clarifying proximal diaphyseal fifth metatarsal fractures: the acute fracture versus the stress fracture. JAPMA 1999;89:398. These fractures frequently occur in athletes and are included in the ‘high risk’ group owing to the difficulty of obtaining consolidation and the high rate of nonunion and refracture. These fractures may have a prolonged healing time of 21 months, and nonunion may developed in up to 25% of patients treated conservatively (C).⁴¹41 Dameron TB. Fractures and anatomical variations of the proximal portion of the fifth metatarsal. J Bone Joint Surg Am 1975;57:788.^,4444 Kavanaugh JH, Brower TD, Mann RV. The Jones fracture revisited. J Bone Joint Surg Am 1978;60:776. Therefore, many authors currently favor surgical intervention for this fracture, especially in athletes (D)⁸8 Boden BP, Osbahr DC. High-risk stress fractures: evaluation and treatment. J Am Acad Orthop Surg 2000;8:344-53.^,3131 Brockwell J, Yeung Y, Griffith JF: Stress fractures of the foot and ankle. Sports Med Arthrosc 2009;17(3):149-159.^,4343 Brown SR, Bennett CH. Management of proximal fifth metatarsal fractures in the athlete. Curr Opin Orthop 2005;16:95. (C).⁴⁴44 Kavanaugh JH, Brower TD, Mann RV. The Jones fracture revisited. J Bone Joint Surg Am 1978;60:776. Compared to conservative treatment, surgical treatment offers a quicker healing time, a shorter time for returning to full sports activity, and a lower rate of complications (C).⁴⁰40 Chuckpaiwong B, Queen RM, Easley ME, et al. Distinguishing Jones and proximal diaphyseal fractures of the fifth metatarsal. Clin Orthop Relat Res 2008;466:1966.

Various surgical treatment methods (bone grafts (C),²⁴24 Popovic N, Jalali A, Georis P, et al. Proximal fifth metatarsal diaphyseal stress fracture in football players. Foot Ankle Surg 2005;11:135.^,4141 Dameron TB. Fractures and anatomical variations of the proximal portion of the fifth metatarsal. J Bone Joint Surg Am 1975;57:788. tension bands (D)²³23 Hulkho A, Orava S. Stress fractures in athletes. Int J Sports Med 1987;8:221-226. and intramedullary screws) have been proposed. Fixation with intramedullary screws is the method recommended for the treatment of stress fractures by the majority of authors in the literature (C)⁴⁴44 Kavanaugh JH, Brower TD, Mann RV. The Jones fracture revisited. J Bone Joint Surg Am 1978;60:776.^,4747 Larson CM, Almekinders LC, Taft TN, et al. Intramedullary screw fixation of Jones fractures: analysis of failure. Am J Sports Med 2002;30:55. Sherbondy, PS. Sebastianelli, WJ. Stress Fractures of the Medial Malleolus and Distal Fibula. Clin Sports Med 2006;25:129-137. (B).⁴⁵45 Pecina MD, et al. Surgical treatment os diaphyseal stress fractures of the fifth metatarsal in competitive athletes. Long-term follow-up and computerized pedobarographic analysis. J Am podiatr med assoc 2011;101(6):517- 522.^,4646 Kelly IP, Glisson RR, Fink C, et al. Intramedullary screw fixation of Jones fractures. Foot Ankle Int 2001;22:585. The hybrid technique (fixation with intramedullary screws associated with autogenous cancellous bone graft) seems to be a reasonable treatment for primary intramedullary fixation (C)²⁴24 Popovic N, Jalali A, Georis P, et al. Proximal fifth metatarsal diaphyseal stress fracture in football players. Foot Ankle Surg 2005;11:135.(D).³⁹39 Rosenberg GA, Sferra JJ. Treatment strategies for acute fractures and nonunions of the proximal fifth metatarsal. J Am Acad Orthop Surg 2000;8:332. A recent systematic review (B)59 concluded that intramedullary fixation with screws promotes successful union in all types of Jones fractures when compared to non-surgical treatments.

The treatment of stress fractures in the medial malleolus, and the distal end of the fibula depends on several factors. The presence of a fracture line, deviated fracture and athletic participation in the season may influence treatment decisions (D).⁴⁸48 Miller MD, Marks PH, Fu FH. Bilateral stress fractures of the distal fibula in a 35-year-old woman. Foot Ankle Int 1994;15(8):450-3. There are numerous reports of surgical intervention for the treatment of stress fractures in the medial malleolus. The presence of a fracture line detectable via radiography, especially in high level athletes, or deviation of the fracture is reported as an indication for surgical intervention. Surgical treatment consists in closed or open reduction and internal fixation with screws (B)¹⁵15 Kor A, Saltzman AT, Wempe PD. Medial malleolar stress fractures: literature review, diagnosis, and treatment. J Am Podiatr Med Assoc 2003;93(4):292-7.(C).⁵⁸58 Roche AJ, Calder JD. Treatment and return to sports following a Jones Fractures of the fifth metatarsal: a systematic review. Knee Surg Sports Traumatol Arthrosc 2012. The present authors believe there are no reports in the literature of surgical fixation of distal fibular stress fractures.

Recommendation

Surgical treatment is indicated in cases where the fracture occurs in the shear zone, the location most disposed to delayed consolidation, nonunion or refractures.

How can stress fractures in athletes be prevented?

The best manner of treating stress fractures is prevention. The attending physician is responsible for knowing their athlete well, seeking to detect concurrent intrinsic and extrinsic factors for the injuries caused by microtrauma from repetition, and correcting them (D).¹¹11 Verma RB, Sherman O. Athletic stress fractures: part I. History, epidemiology, physiology, risk factors, radiography, diagnosis and treatment. Am J Orthop 2001;30(11):798-806.

The prevention of injuries and prognosis are of particular importance to competitive athletes as the objective is not only to start participating again, but to compete at a high level, preventing long term consequences. Injury prevention strategies and programs are a vital part of the education and training of athletes at all levels (C).⁵¹51 Ohta-Fukushima M, Mutoh Y, Takasugi S, Iwata H, Ishii S. Characteristics of stress fractures in Young athletes under 20 years. J Sports Med Phys Fitness 2002;42(2):198-206.

It is important to educate athletes that continuous pain lasting 3 weeks is a warning sign for the body, and that early diagnosis leads to quicker recovery (B).⁵²52 Schwellnus MP, Jordaan G, Noakes TD. Prevention of common overuse injuries by the use of shock absorbing insoles: A prospective study. Am J Sports Med 1990;18(6):636-641.

Changes in footwear and the surface for practicing training may help to reduce the number and severity of injuries in relation to the feet and ankles of athletes (D).³³33 Robert B, Anderson MD, Kenneth J, Hunt MD, Jeremy J, McCormick MD. Management of Common Sports-related Injuries About the Foot and Ankle. J Am Acad Orthop Surg 2010;18: 546-556.

Worn footwear may have a role in increased injury rates. Use of light and flexible shoes with less support of the midfoot may places the athlete at risk, as these may offer less protection against potentially harmful forces in the foot (A).⁵³53 Rome K, Handoll HHG, Ashford R. Interventions for preventing and treating stress fractures and stress reactions of bone of the lower limbs in young adults. Cochrane Database of Systematic Reviews 2005;18(2):CD000450.

A Cochrane review in 1999 declared that ‘the use of shock absorbing inserts in footwear probably reduces the incidence of stress fractures in military personnel’ (A).⁵⁴54 Hawke F, Burns J, Radford JA, du Toit V. Custom-made foot orthoses for the treatment of foot pain. Cochrane Database of Systematic Reviews 2008;16(3):CD006801. Another Cochrane review found evidence that custom- -made orthoses for feet were effective in the treatment of cavus foot pain (A).⁵⁵55 Wegener C, Burns J, Penkala S. Effect of neutral-cushioned running shoes on plantar pressure loading and comfort in athletes with cavus feet: a crossover randomized controlled trial. The American Journal of Sports Medicine 2008;36:2139-46.

Running shoes with neutral insoles have recently demonstrated a statistically significant reduction in plantar pressure in athletes with cavus feet (A).⁵⁶56 Wright RW, Fischer DA, Shively RA, et al. Refracture ofproximal fifth metatarsal (Jones) fracture after intra- medullary screw fixation in athletes. Am J Sports Med 2000;28:732.

In relation to refracture, it is well known that returning to sport early is an important risk, therefore athletes should be warned about the complication (C).⁴⁷47 Larson CM, Almekinders LC, Taft TN, et al. Intramedullary screw fixation of Jones fractures: analysis of failure. Am J Sports Med 2002;30:55. Sherbondy, PS. Sebastianelli, WJ. Stress Fractures of the Medial Malleolus and Distal Fibula. Clin Sports Med 2006;25:129-137.,⁵⁷57 Shabat S, Sampson KB, Mann G, et al. Stress fractures of the medial malleolus: review of the literature nd report of a 15-year-old elite gymnast. Foot Ankle Int 2002;23(7):647-50. In high level athletes, computerized tomography or magnetic resonance imaging should be considered before returning to training in order to avoid refracture (C).⁵⁷57 Shabat S, Sampson KB, Mann G, et al. Stress fractures of the medial malleolus: review of the literature nd report of a 15-year-old elite gymnast. Foot Ankle Int 2002;23(7):647-50.

Recommendation

The prevention of stress fractures in athletes is based on a suitable physician/patient relationship in order to identify the characteristics of the athlete, correct risk factors and guide them in relation to symptoms and the importance of correct treatment to avoid new fractures.

When can the patient return to sport?

The decision to return to sport is based on the location of the injury and its corresponding potential for healing and risk of significant complication (D).⁶⁰60 Brukner P, Bradshaw C, Bennell K. Managing common stress fractures: let risk level guide treatment. Physician Sports Med 1998;26(8):39-47. It is useful to divide stress injuries into high and low grades. This simplification provides an approximate assessment of the healing time, with high reliability (C)³⁵35 Saxena A, Fullem B, Hannaford D. Results of treatment of 22 navicular stress fractures: a new proposed radiographic classification system. J. Foot Ankle Surg 2000;39:96-103. (D).⁸8 Boden BP, Osbahr DC. High-risk stress fractures: evaluation and treatment. J Am Acad Orthop Surg 2000;8:344-53.^,99 Boden BP, Osbahr DC, Jimenez C. Low-risk stress fractures. Am J Sports Med 2001;29:100-111.

Healing time is defined as the time required to return to full activity without any symptoms. This time was significantly greater in scintigraphy with high grade stress injuries compared with low grade ones. This grading of stress injury provided by scintigraphy was a significant indicator for the time until full recovery (B).²⁹29 Dobrindt O, Hoffmeyer B, Ruf J, Steffen IG, Zarva A, Richter WS, et al. Blinded-Read of Bone Scintigraphy, The Impact on Diagnosis and Healing Time for Stress Injuries With Emphasis on the Foot. Clin Nucl Med 2011;36:186-191.

Low risk stress fractures generally heal when the athlete is limited to activities without pain, over a period of 4 to 8 weeks. This healing period is an ideal time to assess the modifiable risk factors that could decrease the change of injuries recurring. A gradual increase in activity (daily life activities) should begin after the athlete is free from pain and the site is not injured (D).⁶¹61 Arendt E, Griffiths HJ. The use of MR imaging in the assessment and clinical management of stress reactions of bone in high-performance athletes. Clin Sports Med 1997;16:291-306. In a study by Arendt and Griffith (D),62 returning to full activity from initial stress injuries (3.3 to 5.5 weeks) was significantly quicker than for more serious injuries (11.4 to 14.3 weeks).

For stress fractures in the navicular bone, the time for returning to sports activities and condition for returning to competitions is around 4 months (B).³⁸38 Saxena A, Fullem B. Navicular stress fractures. A prospective study on athletes. Foot Ankle Int 2006;27(11):917-21. Khan et al. (B)³⁷37 Khan K, Fuller P, Brukner P, Kearney C, Burry H. Outcome of conservative and surgical management of navicular stress fractures in athletes. Eighty-six cases proven with computerized tomography. Am J Sports Med 1992;20:657-666. reported on the time to returning to full activity among 55 patients with stress fractures of the navicular bone treated conservatively. The treatment of 6 weeks without bearing weight enabled 86% of the patients to return to full activity in an average period of 5.6 months after injury.

Considerations related to returning to training for athletes with high risk stress fractures are more difficult than in low risk fractures. In general, returning should only be recommended after suitable treatment and when the injury has completely healed, given that high risk fractures have the most frequent complications, such as delayed consolidation and refracture (D).⁸8 Boden BP, Osbahr DC. High-risk stress fractures: evaluation and treatment. J Am Acad Orthop Surg 2000;8:344-53._,⁶⁰60 Brukner P, Bradshaw C, Bennell K. Managing common stress fractures: let risk level guide treatment. Physician Sports Med 1998;26(8):39-47.

Recommendation

Returning to practicing sports should be conducted gradually after consolidation of the fracture, which depends on the grade and location of the fracture, with greater rest time required for high risk fractures.

Other guidelines at www.projetodiretrizes.org.br

References

Publication Dates