Physical Medicine and Rehabilitation for Stress Fractures Treatment & Management

Updated: Sep 10, 2019
  • Author: Stephen Kishner, MD, MHA; Chief Editor: Consuelo T Lorenzo, MD  more...
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Treatment

Rehabilitation Program

Physical therapy

See Deterrence. The foundation of treatment for symptomatic stress injury is activity modification. To create an environment conducive to healing the stress injury, interrupting the cycle of repetitive overload is essential. For athletes, this typically results in time lost from competition and intensive training. For most stress fractures, the period of relative rest may be expected to last from 4-12 weeks. Factors influencing the duration of the activity restriction include the anatomic site of the stress injury, the extent of the stress injury, and the anticipated demands on the athlete upon return to play. During the period of restricted activity, the clinician should evaluate the athlete for modifiable risk factors that might have contributed to the development of the stress fracture.

Training errors (eg, too much, too soon) are a common contributing factor to bone stress injury. One generally espoused (although inadequately validated) principle is that the athlete's training regimen (ie, volume of sport-related activity) should not increase by any more than 10% from one week to the next.

Runners should replace their shoes every 500 km to ensure adequate midsole cushioning. Shoes should be selected with attention to the athlete's foot structure. Flexible flatter feet should be fitted with shoes that provide optimal support and motion control (possibly including orthoses), whereas rigid highly arched feet should be fitted with shoes that provide maximal cushioning. [30]

Rehabilitation of the individual with a stress fracture should include a program of muscle strengthening and generalized conditioning. Strong, well-conditioned muscles help to dissipate GRFs that otherwise would be transmitted to bones and joints along the kinetic chain.

Fitness training during the rehabilitation period should include cross-training so that excessive loading of the affected bone is avoided. A brief period of restricted weight bearing may be indicated if the athlete initially experiences intolerable pain while walking. Occasionally, bracing and even casting may prove beneficial. Aquatic exercise programs are effective for maintaining the athlete's cardiorespiratory conditioning while effectively eliminating weight bearing.

If pain persists or becomes further limiting, analgesics may be helpful. Nonsteroidal anti-inflammatory drugs (NSAIDs) are prescribed frequently, but some clinicians believe that these agents should be relatively contraindicated in this setting. NSAIDs inhibit the production of prostaglandins, which are demonstrated to be involved in normal bone remodeling and fracture healing. Although animal studies have shown reasonably conclusively that NSAIDs inhibit fracture healing, the evidence from human studies is somewhat contradictory in this regard. If used at all, NSAIDs should therefore be used cautiously with a full understanding of their potential adverse effects.

The intravenous administration of the bisphosphonate pamidronate has been reported to benefit athletes with stress fractures, and it may hold some promise as an adjunctive treatment for symptomatic bony stress injury.

In addition to pharmacotherapy, physical therapy modalities, such as ice or interferential current, may be used to help treat symptoms. No compelling evidence exists in the literature to suggest that adjunctive therapeutic modalities (eg, electrical stimulation, pulsed ultrasonography, laser therapy) have a significant role to play in the routine treatment of bony stress injury.

As the fracture heals and symptoms subside, advance the athlete's program accordingly to permit progressively greater loading of the affected structure. Functional progression from walking to running to sport-specific skills permits the athlete to regain fitness and confidence prior to the resumption of training and competition. Additional recommendations for treatment are included in the following brief overviews of 4 common types of stress fracture.

Pars interarticularis stress fractures (ie, spondylolysis)

Stress fractures of the pars interarticularis (shown below) are common in athletes who participate in sports demanding repetitive lumbar hyperextension, truncal rotation, or axial loading. Once considered a congenital variation, spondylolysis is probably an acquired condition in most cases. Genetic predisposition undoubtedly plays a role in the development of spondylolysis. For example, the prevalence of spondylolysis among the Inuit population is roughly 50%, and whites appear to be at greater risk for developing pars defects than African Americans.

This image is of a 17-year-old male wrestler with This image is of a 17-year-old male wrestler with a 2-month history of left-sided low back pain, worse with extension. Total body scintigraphy findings were unremarkable. Courtesy of Michael Spieth, MD, and Nandita Bhattacharjee, MD, MHA; Marshfield Clinic Department of Radiology.
Same patient as in the above image. Single-photon Same patient as in the above image. Single-photon emission computed tomography (SPECT) images demonstrate abnormal delayed uptake in the posterior elements of L5. Courtesy of Michael Spieth, MD, and Nandita Bhattacharjee, MD, MHA; Marshfield Clinic Department of Radiology.
Same patient as in the above 2 images. Subsequent Same patient as in the above 2 images. Subsequent MRI revealed an area of bright signal in the left pars interarticularis of L5 on T2-weighted images, confirming the diagnosis of acute unilateral spondylolysis. The patient was treated successfully with activity restriction and bracing with a lumbar corset for 3 months, at which point he was asymptomatic. Plain film imaging at follow-up (not shown) was unremarkable, with no evidence of spondylolysis on oblique views. Courtesy of Michael Spieth, MD, and Nandita Bhattacharjee, MD, MHA; Marshfield Clinic Department of Radiology.

Soler and Colderon found that while the prevalence of spondylolysis among a broad cross-section of elite Spanish athletes was similar to that found in the general population (8%), the highest prevalence (27%) was among athletes participating in the throwing track-and-field events (eg, javelin, discus, shot put). [31] Roughly 17% of rowers and 14% of gymnasts were found to have spondylolysis. Approximately 13% of weightlifters were affected. The most common level of involvement was L5 (84%), followed by L4 (12%). More than one level was involved in only 3% of cases. The condition was bilateral approximately 78% of the time. Of the athletes found to have spondylolysis, 50-60% reported low back pain. Males and females appeared to be affected equally, although females were more likely to have associated spondylolisthesis than men. Other studies estimate the prevalence of spondylolysis among athletes from 15-63%, with the highest prevalence among weightlifters.

Clinically, symptomatic individuals typically report localized axial low back pain. The pain may be provoked by lumbar extension, particularly while bearing weight on the ipsilateral lower limb. Hamstring inflexibility is a common finding among individuals with spondylolysis. Curiously, young children diagnosed with pars defects tend to be asymptomatic.

The clinical diagnosis may be confirmed radiographically. Conventional radiography is often unrevealing, but, if present, the fracture line is usually best visualized on oblique views. Nascent or recently completed stress fractures of the pars may be detected by scintigraphy. Single-photon emission computed tomography (SPECT) is extremely sensitive and provides reasonable anatomic detail. MRI is also a justifiable first-line imaging procedure, and it offers the additional benefit of permitting concurrent evaluation of the lumbar intervertebral disks and other potential spinal pain generators. In their 2006 study, Sairyo and colleagues were able to correlate the presence of high water-weighted (T2) signal in the pedicle with the early stage of ipsilateral pars interarticularis stress injury as judged by CT, suggesting that MRI may permit early detection of stress injury and potentially enhance the outcome of treatment. [32]

Radiographically documented pars defects that are cold on bone scans probably represent remote injuries and have little chance of bony union. If symptomatic, individuals with cold defects may be treated with NSAIDs or other analgesics and should be instructed in a program of on-going home exercises to strengthen the muscle groups that provide dynamic stabilization of the lumbar spine.

The recommended treatment for acute spondylolysis has evolved considerably over the past decade and remains somewhat controversial. As with other stress fractures, the central tenet of treatment is relative rest with appropriate activity modification. Although some clinicians recommend bracing to minimize extension and resultant shear forces across the affected segment, some evidence from biomechanical studies indicates that lumbosacral bracing may actually increase intersegmental motion at the lumbosacral junction. Therefore, the prevailing opinion appears to be that bracing should be used only for individuals who remain symptomatic despite attempting to limit their activities, or for those who require a physical/tactile reminder to avoid provocative activities.

Once symptoms permit, the individual should begin a rehabilitation program of flexibility training and dynamic lumbar spinal stabilization. The program should emphasize pain-free functional progression. Once the athlete can perform sport-specific skills without symptoms, he or she may return to training and competition. Unilateral spondylolysis tends to have a more favorable clinical outcome than bilateral spondylolysis. For a more detailed discussion, see the article Lumbar Spondylolysis and Spondylolisthesis.

Femoral neck stress fracture

Stress fractures of the femoral neck [4, 33] can occur either on the superior or inferior aspect of the neck. Older individuals tend to develop fractures on the superior (or distraction) side of the neck, while younger people are more prone to fractures on the inferior (or compression) side of the neck. In both populations, the patient typically presents with activity-related pain in the groin, hip girdle, or anterior thigh. Physical examination may reveal pain with passive hip range of motion, particularly internal rotation. Conventional radiography and bone scanning are usually sufficient for the physician to confirm or exclude the diagnosis. However, MRI, with its sensitivity and high anatomic detail, is being used with increasing frequency.

For patients diagnosed with early stress reaction or a nondisplaced stress fracture of the femoral neck, treatment consists of avoidance of weight bearing on the affected lower limb until symptoms resolve. Subsequently, the individual is permitted to resume partial weight bearing as tolerated, progressing over time to unprotected weight bearing, to walking, and, finally, to running. Full functional progression may take months to complete. Serial radiographs obtained periodically help confirm that healing is progressing. If the patient is found to have a significant cortical defect or if the fracture is displaced, surgical fixation is required prior to beginning a program of rehabilitation.

Snyder et al, in a review of randomized and quasi-randomized, controlled trials, found evidence that the use of insoles can reduce the incidence of femoral and tibial stress fractures in soldiers during military training. [34] It was uncertain from their investigation whether the same would be true for athletes.

Tibial stress fracture

The tibial shaft is the most common site of stress fractures. Unfortunately, shin pain is a frequent complaint among athletes and can result from a variety of causes, including tibial periostitis (ie, shin splints) and exertional compartment syndromes (a potentially serious condition). A careful history is helpful in distinguishing these entities. Pain that occurs early in the exercise program and then improves with ongoing activity suggests periostitis. Pain precipitated by exercise that worsens progressively with continued activity may herald a stress fracture.

A 17-year-old female dancer with a 2-week history A 17-year-old female dancer with a 2-week history of left shin pain. Plain film imaging was unremarkable. Three-phase bone scanning demonstrated an area of linear uptake in the posterior medial aspect of the left tibia on blood pool images, but delayed images were considered normal. This scintigraphic pattern is consistent with medial tibial stress syndrome (shin splints), but not with stress fracture. Courtesy of Michael Spieth, MD, and Nandita Bhattacharjee, MD, MHA; Marshfield Clinic Department of Radiology.
This image is of an 18-year-old female soccer play This image is of an 18-year-old female soccer player with a 3-week history of left leg pain, which was worse at night and with activity. Upon examination, she reported tenderness in response to palpation over the midtibia. Bilateral pes planus was noted. Plain film radiography failed to demonstrate a fracture. Bone scanning revealed a focal area of delayed uptake on the posterior medial aspect of the proximal third of the left tibia, confirming the diagnosis of stress fracture. Courtesy of Michael Spieth, MD, and Nandita Bhattacharjee, MD, MHA; Marshfield Clinic Department of Radiology.

Physical examination typically reveals localized tenderness over the medial aspect of the tibia. Tibial stress fractures may be more common among athletes with rigid cavus feet. Excessive subtalar pronation can also predispose an athlete to tibial stress fractures. The clinical diagnosis can be confirmed by conventional radiography, although one study suggests that this imaging modality shows evidence of stress fracture or periosteal reaction in only 10% of cases. Scintigraphy and/or MRI may be useful for confirming the suspected clinical diagnosis.

Treatment consists of activity restriction to minimize symptoms (ie, a period of non weight bearing may be necessary) before engaging in a program of increasingly demanding strengthening and conditioning exercise, leading to an eventual return to play in 8-12 weeks. Interestingly, 3 studies have demonstrated that use of a pneumatic leg brace allowed athletes to recover more quickly than athletes treated with activity restriction alone. [35, 36, 37] It may be that compression of the leg's soft tissues helps to unload the tibia during weight-bearing activities, thereby minimizing further microdamage and facilitating bony repair.

Long-term studies of military recruits with tibial stress fractures did not show any limitations in their physical abilities. [38]

Cortical stress fractures of the anterior tibial midshaft should be treated with care because they tend to heal more slowly (average of 6 mo) and are prone to delayed union or nonunion. In such cases, electromagnetic stimulation may potentially be helpful in promoting healing. Some authors recommend immobilization as initial therapy. Failure of nonoperative care warrants consideration of surgical intervention. Options include reamed intramedullary nailing and internal fixation with bone grafting. Postoperative recovery time averages 6 months.

Second metatarsal stress fracture

The metatarsals are the second most frequent stress fracture site and are especially common among military recruits, distance runners, and ballet dancers. The second metatarsal (see the image below) is injured most frequently, followed in order by metatarsals 3, 1, 4, and 5. Although the idea is somewhat controversial, foot structure may contribute to an individual's relative risk of developing lower limb overuse injuries in general and stress fractures in particular.

This is a 55-year-old female industrial worker wit This is a 55-year-old female industrial worker with a 1-week history of right foot pain. Plain film imaging was unremarkable. Bone scanning revealed a stress fracture of the second metatarsal. Courtesy of Michael Spieth, MD, and Nandita Bhattacharjee, MD, MHA; Marshfield Clinic Department of Radiology.

One prospective study of military recruits found that flat flexible feet were associated with a significantly higher rate of metatarsal stress fractures, while individuals with cavus feet were more prone to developing tibial stress fractures. The authors reasoned that flexible feet dissipate more GRF than do rigid cavus feet, thereby subjecting the intrinsic foot structures to greater loads and transmitting less GRF proximally than would a rigid cavus foot. The relative length of the first and second rays appears to have no relationship to the development of second metatarsal stress fractures.

The diagnosis of second metatarsal stress fracture can be made clinically, given an appropriate history of activity-related forefoot pain and the finding of focal tenderness over the second ray on palpatory examination. Treatment consists of relative rest, with return to play permitted once the individual can perform sport-specific skills without pain. Orthoses may be useful to help prevent recurrence of the injury. Custom-molded orthoses provide optimal support and may help correct biomechanical deficits, but studies have shown that over-the-counter shock absorbing insoles are equally effective in preventing lower limb stress injuries. Stress fractures at the base of the second metatarsal appear to be prone to delayed healing and may be treated best with a period of immobilization.

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Medical Issues/Complications

Concern about complications is warranted when stress fractures are displaced or do not demonstrate adequate healing, despite time and appropriate interventions. Displaced stress fractures of the femoral neck, for example, have a high prevalence of complications, including avascular necrosis and pseudoarthrosis, due to the nature of the blood supply to the femoral neck. Other complications of stress fractures may include nonunion, malunion, posttraumatic arthrosis, and persistent disabling pain. [39]

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Surgical Intervention

In most cases, stress fractures can be managed successfully with conservative measures. High-risk displaced stress fractures, however, require surgical intervention to ensure proper healing. Surgical procedures most typically involve open-reduction internal fixation and pinning of the associated fracture sites. [40] Postoperative recovery time averages 6 months. [41]

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Consultations

Consider consultation with an orthopedic surgeon for high-risk stress fractures. Affected female athletes who exhibit signs of eating disorders may benefit from a consultation with dietitian, psychologist/psychiatrist, or both.

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