Stress Fractures of the Foot and Ankle
Among athletes, stress fractures are common injuries, many of which occur about the foot and ankle. Typically they develop when a specific bone is subjected to repetitive loads that create microfractures at a rate faster than the body’s ability to compens
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Stress Fractures of the Foot and Ankle Minton Truitt Cooper
Introduction Stress fractures were first described in 1855 by German military surgeon Breithaupt [1]. The condition represents a spectrum ranging from microscopic damage to stress reaction to complete fracture. The vast majority of these conditions affect the bones of the foot and ankle, with approximately 80 % occurring distal to the knee [1]. As with any tissue in the body, a balance exists between the accumulation of damage to bone due to submaximal loads and the host’s ability to repair such damage. Intrinsic factors specific to the host and extrinsic factors are critical to this balance. Intrinsic factors include biomechanical/ anatomical features, metabolic condition (including menstrual patterns), level of fitness, muscular strength and endurance and vascularity. Extrinsic factors include exercise patterns, equipment, and nutrition. The etiology of stress fractures is frequently multifactorial involving both intrinsic and extrinsic factors. These injuries may occur when the balance is altered leading to an accumulation of microscopic damage to a particular bone greater than that for which the host is able to
M.T. Cooper, MD (*) Foot and Ankle Division, Department of Orthopaedic Surgery, University of Virginia Health System, Charlottesville, VA, USA 1200 Lake Avenue, Richmond, VA 23226, USA e-mail: [email protected]
compensate. This commonly occurs in athletic training due to an increase in duration, intensity, or frequency of training, without allowing for sufficient recovery. Stress fractures may be categorized as either high risk or low risk, a distinction that is made based both on the degree of difficulty in obtaining healing as well as the severity of consequences when they do not heal in a timely manner. High risk stress fractures frequently occur in areas of bone that have poor vascularity, often referred to as watershed areas, where the ability to heal may be compromised. Examples include the anterior tibial diaphysis, the proximal fifth metatarsal, and the central one third of the navicular.
Incidence The incidence of stress fractures in the general athletic population has been reported to be approximately 1 %, but may be as high as 20 % in runners. In a study of 295 Israeli army recruits, the incidence of stress fracture was found to be 31 % [2]. Approximately 35 % of these were asymptomatic, and the most common locations were the tibial diaphysis (51 %) and the femur (21 %). In a study of United States military recruits, the most common fracture sites in males were the metatarsals (66 %) and the calcaneus (20 %), whereas females had higher rates of calcaneal (39 %) and tibial (27 %) stress fractures [3]. In a review of 320 athletes who suffered stress
T.M. Philbin (ed.), Sports Injuries of the Foot: Evolving Diagnosis and Treatment, DOI 10.1007/978-1-4899-7427-3_9, © Springer Science+Business Media New York 2014
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fractures, Matheson et al. reported that the tibia was the most common site (49.1 %), follo
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