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S
tress
fractures
in
the
foot
and
ankle
of
athletes
R
ev
A
ssoc
M
ed
B
ras
2014; 60(6):512-517
515
H
ow
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
).
11
The prevention of injuries and prognosis are of par-
ticular importance to competitive athletes as the objec-
tive is not only to start participating again, but to com-
pete 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
).
51
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
).
52
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
).
33
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
).
53
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
).
54
Another Cochrane review found evidence that custom-
-made orthoses for feet were effective in the treatment of
cavus foot pain (
A
).
55
Running shoes with neutral insoles have recently de-
monstrated a statistically significant reduction in plan-
tar pressure in athletes with cavus feet (
A
).
56
In relation to refracture, it is well known that retur-
ning to sport early is an important risk, therefore athletes
should be warned about the complication (
C
).
47,57
In high
level athletes, computerized tomography or magnetic re-
sonance imaging should be considered before returning
to training in order to avoid refracture (
C
).
57
Recommendation
The prevention of stress fractures in athletes is based on
a suitable physician/patient relationship in order to iden-
tify the characteristics of the athlete, correct risk factors
and guide them in relation to symptoms and the impor-
tance of correct treatment to avoid new fractures.
W
hen
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
treatment consists in percutaneous screw fixation with or
without exposure of the fracture site. Generally, bone gra-
phs are reserved for chronic fractures and delayed consoli-
dation and nonunions (
C
).
36
Partially threaded solid or can-
nulated compression screws measuring 4mmare used(
D
).
31
A stress fracture in the fifthmetatarsal diaphysis is defi-
ned as a stress fracture of the proximal zone of the bone im-
mediately distal to the anatomical area of the Jones fracture
(
C
)
41
(
B
).
42
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 hea-
ling time of 21 months, and nonunion may developed in
up to 25% of patients treated conservatively (
C
).
41,44
There-
fore, many authors currently favor surgical intervention for
this fracture, especially in athletes (
D
)
8,31,43
(
C
).
44
Compared
to conservative treatment, surgical treatment offers a quic-
ker healing time, a shorter time for returning to full sports
activity, and a lower rate of complications (
C
).
40
Various surgical treatment methods (bone grafts
(
C
),
24,41
tension bands (
D
)
23
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
)
44,47
(
B
).
45,46
The hybrid technique (fixation with intramedul-
lary screws associated with autogenous cancellous bone
graft) seems to be a reasonable treatment for primary in-
tramedullary fixation(
C
)
24
(
D
).
39
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 mal-
leolus, and the distal end of the fibula depends on several
factors. The presence of a fracture line, deviated fractu-
re and athletic participation in the season may influen-
ce treatment decisions (
D
).
48
There are numerous reports
of surgical intervention for the treatment of stress frac-
tures in the medial malleolus. The presence of a fractu-
re line detectable via radiography, especially in high le-
vel 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
)
15
(
C
).
58
The present authors believe there
are no reports in the literature of surgical fixation of dis-
tal fibular stress fractures.
Recommendation
Surgical treatment is indicated in cases where the fractu-
re occurs in the shear zone, the location most disposed
to delayed consolidation, nonunion or refractures.