1
|
Hoenig T, Eissele J, Strahl A, Popp KL, Stürznickel J, Ackerman KE, Hollander K, Warden SJ, Frosch KH, Tenforde AS, Rolvien T. Return to sport following low-risk and high-risk bone stress injuries: a systematic review and meta-analysis. Br J Sports Med 2023; 57:427-432. [PMID: 36720584 DOI: 10.1136/bjsports-2022-106328] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/03/2023] [Indexed: 02/02/2023]
Abstract
OBJECTIVE Bone stress injuries (BSIs) are classified in clinical practice as being at low- or high-risk for complication based on the injury location. However, this dichotomous approach has not been sufficiently validated. The purpose of this systematic review was to examine the prognostic role of injury location on return-to-sport (RTS) and treatment complications after BSI of the lower extremity and pelvis. DESIGN Systematic review and meta-analysis. DATA SOURCES PubMed, Web of Science, Cochrane CENTRAL and Google Scholar databases were searched from database inception to December 2021. ELIGIBILITY CRITERIA FOR SELECTING STUDIES Peer-reviewed studies that reported site-specific RTS of BSIs in athletes. RESULTS Seventy-six studies reporting on 2974 BSIs were included. Sixteen studies compared multiple injury sites, and most of these studies (n=11) described the anatomical site of injury as being prognostic for RTS or the rate of treatment complication. Pooled data revealed the longest time to RTS for BSIs of the tarsal navicular (127 days; 95% CI 102 to 151 days) and femoral neck (107 days; 95% CI 79 to 135 days) and shortest duration of time for BSIs of the posteromedial tibial shaft (44 days, 95% CI 27 to 61 days) and fibula (56 days; 95% CI 13 to 100 days). Overall, more than 90% of athletes successfully returned to sport. Treatment complication rate was highest in BSIs of the femoral neck, tarsal navicular, anterior tibial shaft and fifth metatarsal; and lowest in the fibula, pubic bone and posteromedial tibial shaft. CONCLUSION This systematic review supports that the anatomical site of BSIs influences RTS timelines and the risk of complication. BSIs of the femoral neck, anterior tibial shaft and tarsal navicular are associated with increased rates of complications and more challenging RTS. PROSPERO REGISTRATION NUMBER CRD42021232351.
Collapse
Affiliation(s)
- Tim Hoenig
- Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Julian Eissele
- Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - André Strahl
- Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Kristin L Popp
- Endocrine Unit, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
- U.S. Army Research Institute of Environmental Medicine, Natick, Massachusetts, USA
- TRIA Orthopedic Center, Bloomington, Minnesota, USA
| | - Julian Stürznickel
- Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Kathryn E Ackerman
- Endocrine Unit, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Division of Sports Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Karsten Hollander
- Institute of Interdisciplinary Exercise Science and Sports Medicine, MSH Medical School Hamburg, Hamburg, Germany
| | - Stuart J Warden
- Department of Physical Therapy, School of Health & Human Sciences, Indiana University, Indianapolis, Indiana, USA
- Indiana Center for Musculoskeletal Health, Indiana University, Indianapolis, Indiana, USA
| | - Karl-Heinz Frosch
- Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Adam S Tenforde
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Harvard Medical School, Cambridge, Massachusetts, USA
| | - Tim Rolvien
- Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| |
Collapse
|
2
|
Egerton T, Donkin D, Kazantzis S, Ware H, Moore S. Conceptualisation of a region-based group of musculoskeletal pain conditions as 'tibial loading pain' and systematic review of effects of load-modifying interventions. J Sci Med Sport 2021; 25:46-52. [PMID: 34366244 DOI: 10.1016/j.jsams.2021.07.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Revised: 07/01/2021] [Accepted: 07/14/2021] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Conceptualisation of a clinically-relevant group of conditions as a region-based, load-related musculoskeletal pain condition ('tibial loading pain') to enable identification of evidence of treatment effect from load-modifying interventions. DESIGN Systematic review and evidence synthesis based on a developed and justified theoretical position. METHODS Musculoskeletal pain localised to the tibial (shin) region and consistent with clinical presentations of an exercise/activity-related onset mechanism, was conceptualised as a group of conditions ('tibial loading pain') that could be reasoned to respond to load modifying interventions. Five databases were searched for randomized controlled studies investigating any load-modifying intervention for pain in the anterior-anteromedial lower leg (shin). Study quality was evaluated (Risk of Bias Tool Version 2) and level of certainty for the findings assessed. RESULTS Six studies reporting seven comparisons were included. Interventions included braces, anti-pronation taping, compression stocking and a stretch + strengthening programme. All included studies were assessed as having unclear or high risk of bias. The review found no evidence of beneficial effect from any of the load-modifying interventions on symptoms, physical performance or biomechanical measures, apart from a possible benefit of anti-pronation 'kinesio' taping. There was very low certainty evidence that kinesio taping improves pain and pain-free hopping distance after one week. The braces were associated with minor adverse effects and problems with acceptability. CONCLUSIONS None of the treatments investigated by the included studies can be recommended. Conceptualisation of the problem as regional, primarily loading-related pain rather than as multiple distinct pathoanatomically-based conditions, and clearer load-modifying hypotheses for interventions are recommended.
Collapse
Affiliation(s)
- Thorlene Egerton
- Physiotherapy Department, The University of Melbourne, Australia; Centre for Health, Exercise & Sports Medicine, The University of Melbourne, Australia
| | - David Donkin
- Physiotherapy Department, The University of Melbourne, Australia; Department of Health Professions, Macquarie University, Australia
| | - Sia Kazantzis
- Physiotherapy Department, The University of Melbourne, Australia
| | - Hannah Ware
- Physiotherapy Department, The University of Melbourne, Australia; The Melbourne Sports Medicine Centre, Australia
| | - Sonya Moore
- Physiotherapy Department, The University of Melbourne, Australia.
| |
Collapse
|
3
|
Hallinan JTPD, Statum SM, Huang BK, Bezerra HG, Garcia DAL, Bydder GM, Chung CB. High-Resolution MRI of the First Metatarsophalangeal Joint: Gross Anatomy and Injury Characterization. Radiographics 2020; 40:1107-1124. [PMID: 32412828 DOI: 10.1148/rg.2020190145] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
The first metatarsophalangeal joint (MTPJ) is vital to the biomechanics of the foot and supports a weight up to eight times heavier than the body during athletic activities. The first MTPJ comprises osseous and cartilaginous surfaces along with a complex of supporting structures, including the dorsal extensor tendons, collateral ligaments, and a plantar plate complex. In contradistinction to the lesser MTPJ plantar plates, a single dominant fibrocartilaginous capsular thickening does not exist at the first MTPJ. Instead, the plantar plate complex comprises a fibrocartilaginous pad that invests the hallux sesamoids and is inseparable from the plantar capsule, the intersesamoid ligament, paired metatarsosesamoid and sesamoid phalangeal ligaments (SPLs), and the musculotendinous structures. Acute injury at the first MTPJ is typically secondary to forced hyperextension-turf toe-and can involve multiple structures. During hyperextension, the resulting forces primarily load the distal SPLs, making these structures more susceptible to injury. SPL injuries are best seen in the sagittal plane at MRI. Radiography can also aid in diagnosis of full-thickness SPL tears, demonstrating reduced sesamoid excursion at lateral dorsiflexed (stress) views. Hallux valgus is another common condition, resulting in progressive disabling deformity at the first MTPJ. Without appropriate treatment, first MTPJ injuries may progress to degenerative hallux rigidus. The authors detail the anatomy of the first MTPJ in cadaveric forefeet by using high-resolution 3-T and 11.7-T MRI and anatomic-pathologic correlation. Injuries to the plantar plate complex, collateral ligaments, and extensor mechanism are discussed using clinical case examples. Online supplemental material is available for this article. ©RSNA, 2020.
Collapse
Affiliation(s)
- James T P D Hallinan
- From the Department of Diagnostic Imaging, National University Hospital, 5 Lower Kent Ridge Rd, 119074 Singapore (J.T.P.D.H.); Yong Loo Lin School of Medicine, National University of Singapore, Singapore (J.T.P.D.H.); Department of Radiology, VA San Diego Healthcare System, San Diego, Calif (S.M.S., G.M.B., C.B.C.); Department of Radiology, San Diego Medical Center, University of California, San Diego, Calif (B.K.H., C.B.C.); Department of Radiology, Hospital do Coração (HCor) and Teleimagem, São Paulo, Brazil (H.G.B.); and Universidade Federal de São Paulo, São Paulo, Brazil (UNIFESP) and Hospital Beneficência Portuguesa de São Paulo, São Paulo, Brazil (D.A.L.G.)
| | - Sheronda M Statum
- From the Department of Diagnostic Imaging, National University Hospital, 5 Lower Kent Ridge Rd, 119074 Singapore (J.T.P.D.H.); Yong Loo Lin School of Medicine, National University of Singapore, Singapore (J.T.P.D.H.); Department of Radiology, VA San Diego Healthcare System, San Diego, Calif (S.M.S., G.M.B., C.B.C.); Department of Radiology, San Diego Medical Center, University of California, San Diego, Calif (B.K.H., C.B.C.); Department of Radiology, Hospital do Coração (HCor) and Teleimagem, São Paulo, Brazil (H.G.B.); and Universidade Federal de São Paulo, São Paulo, Brazil (UNIFESP) and Hospital Beneficência Portuguesa de São Paulo, São Paulo, Brazil (D.A.L.G.)
| | - Brady K Huang
- From the Department of Diagnostic Imaging, National University Hospital, 5 Lower Kent Ridge Rd, 119074 Singapore (J.T.P.D.H.); Yong Loo Lin School of Medicine, National University of Singapore, Singapore (J.T.P.D.H.); Department of Radiology, VA San Diego Healthcare System, San Diego, Calif (S.M.S., G.M.B., C.B.C.); Department of Radiology, San Diego Medical Center, University of California, San Diego, Calif (B.K.H., C.B.C.); Department of Radiology, Hospital do Coração (HCor) and Teleimagem, São Paulo, Brazil (H.G.B.); and Universidade Federal de São Paulo, São Paulo, Brazil (UNIFESP) and Hospital Beneficência Portuguesa de São Paulo, São Paulo, Brazil (D.A.L.G.)
| | - Higor Grando Bezerra
- From the Department of Diagnostic Imaging, National University Hospital, 5 Lower Kent Ridge Rd, 119074 Singapore (J.T.P.D.H.); Yong Loo Lin School of Medicine, National University of Singapore, Singapore (J.T.P.D.H.); Department of Radiology, VA San Diego Healthcare System, San Diego, Calif (S.M.S., G.M.B., C.B.C.); Department of Radiology, San Diego Medical Center, University of California, San Diego, Calif (B.K.H., C.B.C.); Department of Radiology, Hospital do Coração (HCor) and Teleimagem, São Paulo, Brazil (H.G.B.); and Universidade Federal de São Paulo, São Paulo, Brazil (UNIFESP) and Hospital Beneficência Portuguesa de São Paulo, São Paulo, Brazil (D.A.L.G.)
| | - Diego A L Garcia
- From the Department of Diagnostic Imaging, National University Hospital, 5 Lower Kent Ridge Rd, 119074 Singapore (J.T.P.D.H.); Yong Loo Lin School of Medicine, National University of Singapore, Singapore (J.T.P.D.H.); Department of Radiology, VA San Diego Healthcare System, San Diego, Calif (S.M.S., G.M.B., C.B.C.); Department of Radiology, San Diego Medical Center, University of California, San Diego, Calif (B.K.H., C.B.C.); Department of Radiology, Hospital do Coração (HCor) and Teleimagem, São Paulo, Brazil (H.G.B.); and Universidade Federal de São Paulo, São Paulo, Brazil (UNIFESP) and Hospital Beneficência Portuguesa de São Paulo, São Paulo, Brazil (D.A.L.G.)
| | - Graeme M Bydder
- From the Department of Diagnostic Imaging, National University Hospital, 5 Lower Kent Ridge Rd, 119074 Singapore (J.T.P.D.H.); Yong Loo Lin School of Medicine, National University of Singapore, Singapore (J.T.P.D.H.); Department of Radiology, VA San Diego Healthcare System, San Diego, Calif (S.M.S., G.M.B., C.B.C.); Department of Radiology, San Diego Medical Center, University of California, San Diego, Calif (B.K.H., C.B.C.); Department of Radiology, Hospital do Coração (HCor) and Teleimagem, São Paulo, Brazil (H.G.B.); and Universidade Federal de São Paulo, São Paulo, Brazil (UNIFESP) and Hospital Beneficência Portuguesa de São Paulo, São Paulo, Brazil (D.A.L.G.)
| | - Christine B Chung
- From the Department of Diagnostic Imaging, National University Hospital, 5 Lower Kent Ridge Rd, 119074 Singapore (J.T.P.D.H.); Yong Loo Lin School of Medicine, National University of Singapore, Singapore (J.T.P.D.H.); Department of Radiology, VA San Diego Healthcare System, San Diego, Calif (S.M.S., G.M.B., C.B.C.); Department of Radiology, San Diego Medical Center, University of California, San Diego, Calif (B.K.H., C.B.C.); Department of Radiology, Hospital do Coração (HCor) and Teleimagem, São Paulo, Brazil (H.G.B.); and Universidade Federal de São Paulo, São Paulo, Brazil (UNIFESP) and Hospital Beneficência Portuguesa de São Paulo, São Paulo, Brazil (D.A.L.G.)
| |
Collapse
|
4
|
Abstract
Turf toe is a term used to describe myriad injuries to the metatarsophalangeal complex of the great toe, which have been associated with the introduction of artificial turf surfaces in sport. If not diagnosed early and treated properly, these injuries can result in chronic pain and loss of mobility. Accurate injury grading through physical exam and advanced imaging is essential to guide treatment, thereby minimizing long-term complications and maximizing an athlete's recovery and return to play. Levels of Evidence: Level V.
Collapse
Affiliation(s)
- Daniel Chiou
- Warren Alpert Medical School, Brown University, Providence, Rhode Island (DC).,Department of Orthopaedics, Massachusetts General Hospital, Boston, Massachusetts (KLS, GW)
| | - Kristen L Stupay
- Warren Alpert Medical School, Brown University, Providence, Rhode Island (DC).,Department of Orthopaedics, Massachusetts General Hospital, Boston, Massachusetts (KLS, GW)
| | - Gregory Waryasz
- Warren Alpert Medical School, Brown University, Providence, Rhode Island (DC).,Department of Orthopaedics, Massachusetts General Hospital, Boston, Massachusetts (KLS, GW)
| |
Collapse
|
5
|
Chaudhry ZS, Raikin SM, Harwood MI, Bishop ME, Ciccotti MG, Hammoud S. Outcomes of Surgical Treatment for Anterior Tibial Stress Fractures in Athletes: A Systematic Review. Am J Sports Med 2019. [PMID: 29528694 DOI: 10.1177/0363546517741137] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Although most anterior tibial stress fractures heal with nonoperative treatment, some may require surgical management. To our knowledge, no systematic review has been conducted regarding surgical treatment strategies for the management of chronic anterior tibial stress fractures from which general conclusions can be drawn regarding optimal treatment in high-performance athletes. PURPOSE This systematic review was conducted to evaluate the surgical outcomes of anterior tibial stress fractures in high-performance athletes. STUDY DESIGN Systematic review; Level of evidence, 4. METHODS In February 2017, a systematic review of the PubMed, MEDLINE, Cochrane, SPORTDiscus, and CINAHL databases was performed to identify studies that reported surgical outcomes for anterior tibial stress fractures. Articles meeting the inclusion criteria were screened, and reported outcome measures were documented. RESULTS A total of 12 studies, published between 1984 and 2015, reporting outcomes for the surgical treatment of anterior tibial stress fractures were included in this review. All studies were retrospective case series. Collectively, surgical outcomes for 115 patients (74 males; 41 females) with 123 fractures were evaluated in this review. The overall mean follow-up was 23.3 months. The most common surgical treatment method reported in the literature was compression plating (n = 52) followed by drilling (n = 33). Symptom resolution was achieved in 108 of 123 surgically treated fractures (87.8%). There were 32 reports of complications, resulting in an overall complication rate of 27.8%. Subsequent tibial fractures were reported in 8 patients (7.0%). Moreover, a total of 17 patients (14.8%) underwent a subsequent procedure after their initial surgery. Following surgical treatment for anterior tibial stress fracture, 94.7% of patients were able to return to sports. CONCLUSION The available literature indicates that surgical treatment of anterior tibial stress fractures is associated with a high rate of symptom resolution and return to play in athletes, although the high complication rate and potential need for subsequent procedures are important considerations for surgeons and patients.
Collapse
|
6
|
Healy A, Farmer S, Pandyan A, Chockalingam N. A systematic review of randomised controlled trials assessing effectiveness of prosthetic and orthotic interventions. PLoS One 2018; 13:e0192094. [PMID: 29538382 PMCID: PMC5851539 DOI: 10.1371/journal.pone.0192094] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2017] [Accepted: 01/16/2018] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Assistive products are items which allow older people and people with disabilities to be able to live a healthy, productive and dignified life. It has been estimated that approximately 1.5% of the world's population need a prosthesis or orthosis. OBJECTIVE The objective of this study was to systematically identify and review the evidence from randomized controlled trials assessing effectiveness and cost-effectiveness of prosthetic and orthotic interventions. METHODS Literature searches, completed in September 2015, were carried out in fourteen databases between years 1995 and 2015. The search results were independently screened by two reviewers. For the purpose of this manuscript, only randomized controlled trials which examined interventions using orthotic or prosthetic devices were selected for data extraction and synthesis. RESULTS A total of 342 randomised controlled trials were identified (319 English language and 23 non-English language). Only 4 of these randomised controlled trials examined prosthetic interventions and the rest examined orthotic interventions. These orthotic interventions were categorised based on the medical conditions/injuries of the participants. From these studies, this review focused on the medical condition/injuries with the highest number of randomised controlled trials (osteoarthritis, fracture, stroke, carpal tunnel syndrome, plantar fasciitis, anterior cruciate ligament, diabetic foot, rheumatoid and juvenile idiopathic arthritis, ankle sprain, cerebral palsy, lateral epicondylitis and low back pain). The included articles were assessed for risk of bias using the Cochrane Risk of Bias tool. Details of the clinical population examined, the type of orthotic/prosthetic intervention, the comparator/s and the outcome measures were extracted. Effect sizes and odds ratios were calculated for all outcome measures, where possible. CONCLUSIONS At present, for prosthetic and orthotic interventions, the scientific literature does not provide sufficient high quality research to allow strong conclusions on their effectiveness and cost-effectiveness.
Collapse
Affiliation(s)
- Aoife Healy
- School of Life Sciences and Education, Staffordshire University, Stoke On Trent, United Kingdom
| | - Sybil Farmer
- School of Life Sciences and Education, Staffordshire University, Stoke On Trent, United Kingdom
| | - Anand Pandyan
- School of Life Sciences and Education, Staffordshire University, Stoke On Trent, United Kingdom
- School of Health & Rehabilitation, Keele University, Keele, United Kingdom
| | - Nachiappan Chockalingam
- School of Life Sciences and Education, Staffordshire University, Stoke On Trent, United Kingdom
| |
Collapse
|
7
|
Abstract
Tibial stress fractures are common in the athlete. There are various causes of these fractures, the most common being a sudden increase in training intensity. Most of these injuries are treated conservatively; however, some may require operative intervention. Intervention is mostly dictated by location of the fracture and failure of conservative treatment. There are several surgical options available to the treating surgeon, each with advantages and disadvantages. The physician must understand the nature of the fracture and the likelihood for it to heal in a timely manner in order to best treat these fractures in this patient subset.
Collapse
Affiliation(s)
- John J Feldman
- Department of Orthopaedics, University of Tennessee-Campbell Clinic, 49 South 4th Street, Apartment 208, Memphis, TN 38103, USA.
| | - Eric N Bowman
- Department of Orthopaedics, University of Tennessee-Campbell Clinic, 170 Alexander Street, Memphis, TN 38111, USA
| | - Barry B Phillips
- Department of Orthopaedics, Campbell Clinic Orthopaedics, University of Tennesee-Campbell Clinic, 1400 South Germantown Road, Germantown, TN 38138, USA
| | - John C Weinlein
- Department of Orthopaedics, University of Tennessee-Campbell Clinic, 145 Greenbriar Drive, Memphis, TN 38117, USA
| |
Collapse
|
8
|
Zimmermann WO, Helmhout PH, Beutler A. Prevention and treatment of exercise related leg pain in young soldiers; a review of the literature and current practice in the Dutch Armed Forces. J ROY ARMY MED CORPS 2016; 163:94-103. [DOI: 10.1136/jramc-2016-000635] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2016] [Revised: 05/26/2016] [Accepted: 05/29/2016] [Indexed: 01/28/2023]
|
9
|
Graham EM, Burns J, Hiller CE, Nightingale EJ, Simic M. Management for common lower leg stress fractures in athletes. PHYSICAL THERAPY REVIEWS 2014. [DOI: 10.1179/1743288x14y.0000000158] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
|
10
|
Lucas DE, Philbin T, Hatic S. The plantar plate of the first metatarsophalangeal joint: an anatomical study. Foot Ankle Spec 2014; 7:108-12. [PMID: 24572212 DOI: 10.1177/1938640014522095] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The plantar plate of the first metatarsophalangeal (MP) joint is a critical structure of the forefoot that has been identified as a major stabilizer within the capsuloligamentous complex. Many studies have clarified and documented the anatomy of the lesser toe MP plantar plates, but few have looked closely at the anatomy of the first MP joint. Ten cadaveric specimens were examined to identify and document the objective anatomic relationship of the plantar plate, tibial sesamoid, and surrounding osseus structures. The average distance of the plantar plate distal insertion from the joint line into the proximal phalanx was 0.33 mm. The plantar plate was inserted into the metatarsal head on average 17.29 mm proximal from the joint line. The proximal aspect of the sesamoid was 18.55 mm proximal to the distal attachment of the plantar plate to the phalanx. The distal aspect of the sesamoid averaged 4.69 mm away from the distal attachment into the proximal phalanx. The footprint of the distal plate insertion was on average 6.33 mm in length in the sagittal plane. The authors hope that these objective data measures can aid in the understanding and subsequent surgical repair of this important forefoot structure.
Collapse
|
11
|
Behrens SB, Deren ME, Matson A, Fadale PD, Monchik KO. Stress fractures of the pelvis and legs in athletes: a review. Sports Health 2013; 5:165-74. [PMID: 24427386 PMCID: PMC3658382 DOI: 10.1177/1941738112467423] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
CONTEXT Stress fractures are common injuries in athletes, often difficult to diagnose. A stress fracture is a fatigue-induced fracture of bone caused by repeated applications of stress over time. EVIDENCE ACQUISITION PubMed articles published from 1974 to January 2012. RESULTS Intrinsic and extrinsic factors may predict the risk of stress fractures in athletes, including bone health, training, nutrition, and biomechanical factors. Based on their location, stress fractures may be categorized as low- or high-risk, depending on the likelihood of the injury developing into a complete fracture. Treatment for these injuries varies substantially and must account for the risk level of the fractured bone, the stage of fracture development, and the needs of the patient. High-risk fractures include the anterior tibia, lateral femoral neck, patella, medial malleolus, and femoral head. Low-risk fractures include the posteromedial tibia, fibula, medial femoral shaft, and pelvis. Magnetic resonance is the imaging test of choice for diagnosis. CONCLUSIONS These injuries can lead to substantial lost time from participation. Treatment will vary by fracture location, but most stress fractures will heal with rest and modified weightbearing. Some may require more aggressive intervention, such as prolonged nonweightbearing movement or surgery. Contributing factors should also be addressed prior to return to sports.
Collapse
Affiliation(s)
- Steve B. Behrens
- Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Matthew E. Deren
- Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Andrew Matson
- Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Paul D. Fadale
- Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Keith O. Monchik
- Warren Alpert Medical School of Brown University, Providence, Rhode Island
| |
Collapse
|
12
|
Gallo RA, Plakke M, Silvis ML. Common leg injuries of long-distance runners: anatomical and biomechanical approach. Sports Health 2012; 4:485-95. [PMID: 24179587 PMCID: PMC3497945 DOI: 10.1177/1941738112445871] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
CONTEXT Long-distance running (greater than 3000 m) is often recommended to maintain a healthy lifestyle. Running injury rates increase significantly when weekly mileage extends beyond 40 miles cumulatively. With the development of running analysis and other diagnostic tests, injuries to the leg secondary to bone, musculotendinous, and vascular causes can be diagnosed and successfully managed. EVIDENCE ACQUISITION Searches used the terms running, injuries, lower extremity, leg, medial tibial stress syndrome, compartment syndrome, stress fractures, popliteal artery entrapment, gastrocnemius soleus tears, and Achilles tendinopathy. Sources included Medline, Google Scholar, and Ovid from 1970 through January 2012. RESULTS Tibial stress fractures and medial tibial stress syndrome can sometimes be prevented and/or treated by correcting biomechanical abnormalities. Exertional compartment syndrome and popliteal artery entrapment syndrome are caused by anatomic abnormalities and are difficult to treat without surgical correction. CONCLUSION Leg pain due to bone, musculotendinous, and vascular causes is common among long-distance runners. Knowledge of the underlying biomechanical and/or anatomic abnormality is necessary to successfully treat these conditions.
Collapse
Affiliation(s)
- Robert A. Gallo
- Department of Orthopedics and Rehabilitation, Pennsylvania State University College of Medicine, Milton S. Hershey Medical Center, Hershey, Pennsylvania
| | - Michael Plakke
- Department of Orthopedics and Rehabilitation, Pennsylvania State University College of Medicine, Milton S. Hershey Medical Center, Hershey, Pennsylvania
| | - Matthew L. Silvis
- Department of Orthopedics and Rehabilitation, Pennsylvania State University College of Medicine, Milton S. Hershey Medical Center, Hershey, Pennsylvania
- Department of Family and Community Medicine, Pennsylvania State University College of Medicine, Milton S. Hershey Medical Center, Hershey, Pennsylvania
| |
Collapse
|
13
|
Brewer RB, Gregory AJM. Chronic lower leg pain in athletes: a guide for the differential diagnosis, evaluation, and treatment. Sports Health 2012; 4:121-7. [PMID: 23016078 PMCID: PMC3435913 DOI: 10.1177/1941738111426115] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Context: Chronic lower leg pain in athletes can be a frustrating problem for patients and a difficult diagnosis for clinicians. Myriad approaches have been suggested to evaluate these conditions. With the continued evolution of diagnostic studies, evidence-based guidance for a standard approach is unfortunately sparse. Evidence Acquisition: PubMed was searched from January 1980 to May 2011 to identify publications regarding chronic lower leg pain in athletes (excluding conditions related to the foot), including differential diagnosis, clinical presentation, physical examination, history, diagnostic workup, and treatment. Results: Leg pain in athletes can be caused by many conditions, with the most frequent being medial tibial stress syndrome; chronic exertional compartment syndrome, stress fracture, nerve entrapment, and popliteal artery entrapment syndrome are also considerations. Conservative management is the mainstay of care for the majority of causes of chronic lower leg pain; however, surgical intervention may be necessary. Conclusion: Chronic lower extremity pain in athletes includes a wide differential and can pose diagnostic dilemmas for clinicians.
Collapse
|
14
|
Beck BR, Bergman AG, Miner M, Arendt EA, Klevansky AB, Matheson GO, Norling TL, Marcus R. Tibial stress injury: relationship of radiographic, nuclear medicine bone scanning, MR imaging, and CT Severity grades to clinical severity and time to healing. Radiology 2012; 263:811-8. [PMID: 22623695 DOI: 10.1148/radiol.12102426] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
PURPOSE To examine the relationship between severity grade for radiography, triple-phase technetium 99m nuclear medicine bone scanning, magnetic resonance (MR) imaging, and computed tomography (CT); clinical severity; and recovery time from a tibial stress injury (TSI), as well as to evaluate interassessor grading reliability. MATERIALS AND METHODS This protocol was approved by the Griffith University Human Research Ethics Committee, the Stanford University Panel on Human Subjects in Medical Research, the U.S. Army Human Subjects Research Review Board, and the Australian Defense Human Research Ethics Committee. Informed consent was obtained from all subjects. Forty subjects (17 men, 23 women; mean age, 26.2 years ± 6.9 [standard deviation]) with TSI were enrolled. Subjects were examined acutely with standard anteroposterior and lateral radiography, nuclear medicine scanning, MR imaging, and CT. Each modality was graded by four blinded clinicians. Mixed-effects models were used to examine associations between image severity, clinical severity, and time to healing, with adjustments for image modality and assessor. Grading reliability was evaluated with the Cronbach α coefficient. RESULTS Image assessment reliability was high for all grading systems except radiography, which was moderate (α = 0.565-0.895). Clinical severity was negatively associated with MR imaging severity (P ≤ .001). There was no significant relationship between time to healing and severity score for any imaging modality, although a positive trend existed for MR imaging (P = .07). CONCLUSION TSI clinical severity was negatively related to MR imaging severity. Radiographic, bone scan, and CT severity were not related to time to healing, but there was a positive trend for MR imaging.
Collapse
Affiliation(s)
- Belinda R Beck
- School of Physiotherapy and Exercise Science, Centre for Musculoskeletal Research, Griffith University, Gold Coast campus, Griffth, QLD 4222, Australia.
| | | | | | | | | | | | | | | |
Collapse
|
15
|
Kadakia AR, Molloy A. Current concepts review: traumatic disorders of the first metatarsophalangeal joint and sesamoid complex. Foot Ankle Int 2011; 32:834-9. [PMID: 22049873 DOI: 10.3113/fai.2011.0834] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
- Anish R Kadakia
- University of Michigan, Orthopaedic Surgery, 2098 South Main Street, Ann Arbor, MI 48103, USA.
| | | |
Collapse
|
16
|
Moen MH, Bongers T, Bakker EWP, Weir A, Zimmermann WO, van der Werve M, Backx FJG. The additional value of a pneumatic leg brace in the treatment of recruits with medial tibial stress syndrome; a randomized study. J ROY ARMY MED CORPS 2011; 156:236-40. [PMID: 21275357 DOI: 10.1136/jramc-156-04-06] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To study the additional effect of a pneumatic leg brace with standard rehabilitation for the treatment of medial tibial stress syndrome (MTSS) in recruits. METHODS In a single blinded randomized study, 15 recruits (age 17-22) followed a rehabilitation programme consisting of leg exercises and a graded running programme. Recruits performed daily exercises and ran three times a week. The running programme consisted of 6 consecutive phases. One group was, after randomization, additionally provided with a pneumatic leg brace. Follow-up was provided every other week. Days to completing the running programme was the primary outcome measure, the Sports Activity Rating Scale (SARS) score and satisfaction with the treatment were secondary outcome measures. RESULTS In total 14 recruits completed the rehabilitation programme. No differences were found in the number of days until phase six of the running schedule was finished between the brace and the control group (Brace 58.8 +/- 27.7 (mean +/- SD) vs Non-Brace 57.9 +/- 26.2 (mean +/- SD, p = 0.57). Also no differences were found in the SARS scores between the groups. Overall satisfaction with the treatment was 6.4 +/- 1.1 (mean +/- SD) on a 1-10 scale for the brace group and 7.1 +/- 0.7 (mean +/- SD) for the control group (p = 0.06). Comfort of the brace was assessed as 4.8 +/- 1.3 (mean +/- SD) on a 1-10 scale. CONCLUSIONS No additional large effect of the pneumatic leg brace could be found in recruits and wearing of the brace was not feasible, since the wearing comfort was low.
Collapse
Affiliation(s)
- M H Moen
- University Medical Center Utrecht, Utrecht, The Netherlands.
| | | | | | | | | | | | | |
Collapse
|
17
|
Abstract
Stress fractures that occur in the young active population typically represent an overuse injury, and may lead to prolonged periods of restriction from play if they are not treated appropriately. Several risk factors have been identified and must be addressed when treating these patients. Low-risk stress fractures can be successfully treated with activity restriction and a stepwise return to sport. Several pharmacologic and nonoperative treatment modalities have been described. However, high-risk stress fractures are more difficult to treat because they may have an increased rate of delay and nonunion, and often require surgical stabilization. When treating an athlete with a stress fracture, the objective is a safe and quick return to sport; therefore, special considerations must be made in this population, particularly when dealing with the in-season athlete.
Collapse
Affiliation(s)
- Amon T Ferry
- Massachusetts General Hospital, Harvard Medical School, Boston, MA.
| | | | | | | |
Collapse
|
18
|
Coughlin MJ, Kemp TJ, Hirose CB. Turf toe: soft tissue and osteocartilaginous injury to the first metatarsophalangeal joint. PHYSICIAN SPORTSMED 2010; 38:91-100. [PMID: 20424406 DOI: 10.3810/psm.2010.04.1766] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The use of artificial turf in the United States has created a dramatic increase in first metatarsophalangeal joint dorsiflexion injuries. Turf toe has been reported to occur in athletes who participate in sporting activities. An injury to the plantar capsular ligamentous complex can result in acute and chronic pain, resulting in time lost from sports participation for a short- or long-term period. Classification of this injury is based on clinical findings and imaging studies, including plain radiographs and magnetic resonance imaging. The early recognition of this injury is crucial to successful treatment. Nonoperative treatment may often suffice for incomplete injuries; however, surgery may be warranted for a complete plantar plate disruption or injury to one or both sesamoids. In the high-performance or elite athlete, a turf toe or severe dorsiflexion injury can be disabling, and can threaten an athlete's career if not treated properly.
Collapse
|
19
|
Carmont MR, Mei-Dan O, Bennell KL. Stress Fracture Management: Current Classification and New Healing Modalities. OPER TECHN SPORT MED 2009. [DOI: 10.1053/j.otsm.2009.05.004] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
|
20
|
Beck BR, Matheson GO, Bergman G, Norling T, Fredericson M, Hoffman AR, Marcus R. Do capacitively coupled electric fields accelerate tibial stress fracture healing? A randomized controlled trial. Am J Sports Med 2008; 36:545-53. [PMID: 18055921 DOI: 10.1177/0363546507310076] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Tibial stress fractures increasingly affect athletes and military recruits, with few known effective management options. Electrical stimulation enhances regular fracture healing, but the effect on stress fractures has not been definitively tested. HYPOTHESIS Capacitively coupled electric field stimulation will accelerate tibial stress fracture healing. STUDY DESIGN Randomized controlled trial; Level of evidence, 1. METHODS Twenty men and 24 women with acute posteromedial tibial stress fractures were referred from local clinicians. Subjects were randomly assigned active or placebo capacitively coupled electric field stimulation to be applied for 15 hours per day until healed, given supplemental calcium, and instructed to rest from provocative training. Healing was confirmed when hopping to 10 cm for 30 seconds could be achieved without pain. RESULTS No difference in time to healing was detected between treatment and placebo groups. Women in the treatment group healed more slowly than did the men (P = .05). Superior treatment compliance was associated with reduced time to healing (P = .003). Rest noncompliance was associated with increased time to healing (P = .05). CONCLUSION Whole-group analysis did not detect an effect of capacitively coupled electric field stimulation on tibial stress fracture healing; however, greater device use and less weightbearing loading enhanced the effectiveness of the active device. More severe stress fractures healed more quickly with capacitively coupled electric field stimulation. CLINICAL RELEVANCE Although the use of capacitively coupled electric field stimulation for tibial stress fracture healing may not be efficacious for all, it may be indicated for the more severely injured or elite athlete/recruit whose incentive to return to activity may motivate superior compliance.
Collapse
|
21
|
Abstract
Stress fractures can occur because of prolonged exercise and are associated with cyclic loading. Fatigue is the accumulated damage that results from cyclic loading and bone fatigue damage is of special concern for athletes and army recruits. Existing literature shows that the rates of stress fracture for female athletes and female army recruits are higher than their male counterparts. In this study, we used an ex vivo rat model to investigate the fatigue response of female and male bones. We determined the strain versus number of cycles to failure (S/N) for each sex and found that for a certain initial strain (5,000-7,000 microepsilon) female bones have shorter fatigue life. To further characterize the bone response to fatigue, we also determined the creep that occurred during the fatigue test. From the creep data, for a certain strain range, female bones accumulated greater residual strains and reached the critical strain at a faster rate. In summary, this study demonstrates that female rat bones have a lower resistance to fatigue in the absence of a physiological response such as muscle fatigue or osteogenic adaptation. From these results, we hypothesized that creep was the underlying mechanism that accounted for the fast deterioration of female bones during fatigue.
Collapse
Affiliation(s)
- Luisa D Moreno
- Samuel Lunenfeld Research Institute, Mount Sinai Hospital, Toronto, and Department of Mechanical and Materials Engineering, Queen's University, Kingston, ON, Canada
| | | | | |
Collapse
|
22
|
Abstract
Stress fractures are common among female athletes, especially runners. Although both intrinsic and extrinsic factors can contribute to stress injury etiology, the female athlete triad--negative energy balance leading to menstrual irregularity, and reduced bone mineral mass--is a significant contributor to the incidence of stress fractures in the female athlete. When combined with impact weight-bearing activity, this triad puts these women at increased risk for stress fractures. Treatment must focus on reversing identified risk factors, in addition to relative rest, and maintenance of fitness. Most stress fractures heal without complication. High-risk stress fractures should be evaluated and treated by a practitioner with expertise in the care of these injuries.
Collapse
Affiliation(s)
- Elizabeth A Joy
- Department of Family and Preventive Medicine, University of Utah, 375 Chipeta Way, Suite A, Salt Lake City, UT 84108, USA.
| | | |
Collapse
|
23
|
|
24
|
Rome K, Handoll HHG, Ashford R. Interventions for preventing and treating stress fractures and stress reactions of bone of the lower limbs in young adults. Cochrane Database Syst Rev 2005; 2005:CD000450. [PMID: 15846606 PMCID: PMC6769029 DOI: 10.1002/14651858.cd000450.pub2] [Citation(s) in RCA: 72] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Stress reaction in bone, which may proceed to a fracture, is a significant problem in military recruits and in athletes, particularly long distance runners. OBJECTIVES To evaluate the evidence from randomised controlled trials of interventions for prevention or management of lower-limb stress fractures and stress reactions of bone in active young adults. SEARCH STRATEGY We searched the Cochrane Musculoskeletal Injuries Group Specialised Register (April 2004), the Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 1, 2004), MEDLINE (1966 to September week 1, 2004), EMBASE, CINAHL, Index to UK Theses, reference lists of relevant articles and contacted trialists. SELECTION CRITERIA Any randomised or quasi-randomised trials evaluating interventions for preventing or treating lower limb stress reactions of bone or stress fractures in active young adults. DATA COLLECTION AND ANALYSIS We independently selected trials for inclusion, assessed trial quality and extracted data. Only limited data pooling was undertaken. MAIN RESULTS We included 16 trials. All 13 prevention trials involved military recruits undergoing training. Participants of two of the three treatment trials were military personnel. Ten prevention trials tested the effects of various foot inserts and other footwear modifications. While pooling of data was not possible, the four trials evaluating the use of "shock-absorbing" boot inserts versus control found fewer stress injuries of the bone in their intervention groups. However, the only trial showing a significant benefit lacked important information about trial design. A key issue in several trials was the acceptability, in terms of practicality and comfort, of the boot inserts. Two cluster-randomised prevention trials found no significant effect of leg muscle stretching during warm up before exercise. Pooled data from three small but very different trials testing the use of pneumatic braces in the rehabilitation of tibial stress fractures showed a significant reduction in the time to recommencing full activity (weighted mean difference -33.39 days, 95% confidence interval -44.18 to -22.59 days). These results were highly heterogeneous (I squared = 90%), which is likely to reflect the underlying differences of the trials, including differences in the control group interventions and definitions of outcomes. AUTHORS' CONCLUSIONS The use of shock absorbing inserts in footwear probably reduces the incidence of stress fractures in military personnel. There is insufficient evidence to determine the best design of such inserts but comfort and tolerability should be considered. Rehabilitation after tibial stress fracture may be aided by the use of pneumatic bracing but more evidence is required to confirm this.
Collapse
Affiliation(s)
- K Rome
- Teesside Centre for Rehabilitation Sciences, University of Teesside, James Cook University Hospital, Marton Road, Middlesbrough, Tees Valley, UK, TS4 3BW.
| | | | | |
Collapse
|