JIMS 2008

Mauritius Island

14/21 november 2008

 Pr Grard SAILLANT
Pr Yves CATONN
Pr Jacques RODINEAU
Jackson RICHARDSON
Laurent FIGNON
 STRESS FRACTURES
IN SPORTS ACTIVITIES

J. Rodineau
 Many definitions

Based on :
- how it happened
- physiopathology
- imaging
- histology
 Definition *

Modification of the bone structure localized

No real direct trauma
Repeated microtraumas
Sport hyperactivity
Fracture linked with bone density modification
Spontaneous consolidation

* Herv de Labareyre et J. Rodineau (2001)

 History

Metatarsus Breithaupt *
XRay Stechow **

Currently : 10% sport injuries

Lower limb = 95 % cases
Tibia = primary location
* Med Zeit (1855)
** Deutsche Zeit (1897)
 Currently

A pathology more frequent:

Athletes population
Load of training
Athletes ( as an individu) more concerned
Imaging more frequently performed
 Epidemiology

Sport influence
Running (+++)
stress fractures with no specific localisation
Dance, jumping,
specific localization
risk of stress fractures (Bennell et al.) *
0,7 FF for 1000 hours of training
* Am J Sports Med (1996)
 Epidemiology

female > male

Female:
- biomecanic:
. step length
- hormone factors (+++)
- different bone density
 Hormons factors

Before 16 yo : male = female

Secondary amenorrhea is a risk factor

athletes population (+++)
diminution of the bone density

* Am J Sports Med (1996)

Amenorrhea and bone density

Bone density: lower limb < spine

Risk +++ after 6 months of amenorrhea

 Female physiopathology

Hard risk factor:

Caucasian female
Low body weight
Amenorrhea
Low dietary in calcium, Vit D deficiency
Intensive training
 Diagnostic

Should be early diagnosis

Clinic evaluation
. interwiew
. physical examination
Imaging
certify the diagnosis
 Interwiew
How it happened:
. cyclic activity: running, walking
. change of quality or quantity of training
. material (+/-)
Pain:
. progressive, mechanical
. more & more early during the activity
. less & less relieved by rest
 Pain
Normal remodeling

Accelereted remodeling

Bone fragility
Pain during the effort
Stress fracture
Pain permanent
 Clinical exam

Inspection
Palpation
Tests tendinitis
entesopathy
 Imaging

Objective: to be certain of the diagnosis :

How? : Xray +/-

scintigraphy ( bone scan)+, MRI +++
/ expensive in Europe
 X Ray

+ Easy
+ Low cost

- Repeat the X Ray (in the time and the views)

- Difficult to read
 X Ray

Early time: positive 15 %

Late time: positive 50 %
positive diagnostic certain
negative hypothesis
If ve : new X ray after 2/3 weeks
 Scintigraphy
Started in 1971
Exam Gold standard during many years
+ very early diagnosis: hyperfixation
- problem = not specific
- high irradiation exposure
 MRI
Classifications
Fredericson * : 4 grades, Arendt et Griffiths ** :
STIR T1 T2 Rx
Grade 1 +- - Fct invisible
Grade 2 + - + Frct invisible
Grade 3 + + + Frct invisible
Grade 4 + + + Frct visible
* Am J Sports Med (1995)
** Clin Sports Med (1997)
MRI
How to deal with a patient
with a stress fracture ?
Many ways:
- no surgery (+++)
- surgical
Athletes:
= possible surgery
// fracture localization
 Management

First Phase (Diagnostic of Stress frct):

stop completely the activity in cause

continue other activities
PWB or NWB // pain
immobilization // localization
antalgics medicine
+/- oral contraceptive
 Management

Second Phase (Bone remodeling):

go back to the activities without impact

Third Phase (healing):

full activity
mechanical corrections (podiatric, stretching)
 Surgery

For all the cases : delay the time to return to

sport
osteosynthesis (all kind)
 Prevention

Decreasing the distance or the duration

Shoes quality
Insoles (medial arche )
Quality of the surface
Educate coaches to increase awarness
 Physiotherapy

US low frequency ???

Hydrotherapy +
Alter-G ++
Antalgic physiotherapy (ice+++)
Sports rehabilitators
 Conclusion

If treatment : return to sport 2 months

If rest : return to sport 8 weeks