18 / 116
A
sano
LYJ
et
al
.
514
R
ev
A
ssoc
M
ed
B
ras
2014; 60(6):512-517
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
).
25,26
Supination and pronation of
the feet are associated with a significant increase in the
risk of stress injuries (
B
).
27
Recommendation
In cases of suspected stress fractures, intrinsic and extrin-
sic factors that favor the occurrence of injury should be
investigated. The investigation of these risk factors aids
diagnosis and treatment.
W
hat
is
the
differential
diagnosis
?
The main diseases that should be discarded are those re-
sulting from repetitive and excessive effort and that af-
fect the soft tissues that surround the area of bone affec-
ted, such as muscle injuries, bursitis, tendinopathy, splints,
infections, cancer and compartment syndrome (
C
)
28
(
B
).
29
D
oes
female
athlete
triad
affect
stress
fractures
?
Female athletes are more likely to developing stress frac-
tures (
C
).
19
The growing increase of this pathology among
female athletes is related to factors that characterize fe-
male athlete triad: eating disorders, menstrual disturban-
ces and low bone density (
D
).
4,5,8
Greater prevalence of ea-
ting disorders (such as bulimia, anorexia nervosa,
ingestion of laxatives and diuretics) has been found among
female athletes (
D
).
30
Irregularities in the menstrual cy-
cle (hypoestrogenism) correlate with early bone loss, re-
duced mineralization of the osteoid and, consequently,
the prevalence of stress fractures in women (
D
).
22
H
ow
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 di-
vided into two phases: phase I, or modified rest, is cha-
racterized by pain control through the use of anti-inflam-
matory drugs, physiotherapy methods for analgesia and
kinesiotherapy, weight-bearing permitted in daily activi-
ties and maintenance of aerobic fitness without causing
abnormal stress responses in the affected segment. Acti-
vities such as cycling, swimming or running in water are
alternatives for maintaining the athlete’s physical condi-
tioning.
Phase II begins from the moment in which the athle-
te 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 cor-
rection of intrinsic and extrinsic factors (
D
).
3
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 ellipti-
cal machines can be continued to maintain aerobic fitness.
Frequent physical exams are useful to identify the resolu-
tion of symptoms. Nutritional considerations are impor-
tant as dietary deficiencies may contribute to the develo-
pment 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 asso-
ciated with a quicker return to the sport (
B
)
15
(
C
)
49,50
(
D
).
31
Electrical stimulation has also been used for the treat-
ment of stress fractures with satisfactory results (
C
).
32
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 condi-
tion with low impact exercise and correcting risk factors.
W
hat
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 inju-
ries 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 surgi-
cal stabilization (
D
).
8,33
Stress fractures in the navicular bone are often difficult
to diagnose. If untreated, they can result in osteoarthritis
and delayed consolidation (
C
)
34-36
(
B
).
37
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 re-
veals a high occurrence of delayed consolidation, impor-
tance should be given to immediate surgical treatment, es-
pecially when the fracture extends to the navicular body or
up to the second cortex of the navicular bone(
B
).
38
Surgical