CH23: Stress Fractures

壱. Historical Perspective
1. Stress fracture
A. 別名: fatigue fractures or march fractures
B. 最早由 Breithaupt 提出，in unconditioned Prussian military recruits in 1855
C. 機轉: 通常是 weight-bearing bones of the lower extremities，ex: repeated stresses of running
and jumping。但是 potential overuse injuries of the upper extremity has increased
D. 本文文章主要是針對 causes, risks, classification , and treatment 做說明

弐. pathophysiology
1. stress fracture 機轉: material fatigue failure of bone
2. Fatigue failure of bone 分為三個階段: crack initiation, crack propagation, complete fracture
A. crack initiation
 發生處: sites of stress concentration during bone loading
 Stress concentration site: 通常發生在 differential bone consistency such as lacunae or
canaliculi
 單獨 Initiation of the microcrack 並不足以構成 stress fracture, 單獨 microcrack 其實是 bone
remodeling 的第一步,是骨頭汰舊換新的過程之一。
B. crack propagation(傳播):
 當 bone healing 的速度低於 Microcrack initiation 的速度就會產生 crack propagation
 crack propagation 的方向通常平行於 cement line
 propagating parallel to the cement lines 傳遞速度大於 propagating perpendicular to cement
lines
 Continued loading 加上不斷的 crack propagation 最後會成為 clinically symptomatic stress
fracture
C. complete fracture
 補充:cement line

The cement line, which is the interface between the 'fibers' (osteons) and extraosteonal bone matrix,
may impart important mechanical properties to compact bone.

壱. Risk factor
1. 包含 biologic and mechanical factors : sex, age, race, hormonal status, nutrition, neuromuscular
function, and genetic factors
2. predisposing factors: abnormal bony alignment, improper technique/biomechanics, poor running
form, poor blood supply to specific bones, improper or worn-out footwear, and hard training surfaces
3. key modifiable risk factors: 與運動前骨頭狀況(preparticipation condition of the bone)以及
frequency, duration, and intensity of the causative activity 有關
A. 缺少 preconditioning and acclimation to a particular activity 會造成運動員 stress fracture 機會
上升。
弐. Neuromuscular Hypothesis
1. Muscle contraction 對於 stress fracture 有 protective and provocative(刺激)效果
A. Muscle contraction 功用:
 internally generated compressive, tensile, and/or rotational stresses on bone 進而造成
bone microdamage
甲、 例如: 投擲運動中，上臂肌肉對於 humerus 產生的 rotational strain
 facilitating the distribution of externally applied loads
 decrease the amount of energy being directly absorbed by the bones and joints
B. 所以當 muscle fatigue 時，肌肉無法分散骨頭的壓力，進而造成 bone microtrauma 使的
stress fracture 機會上升。

参. caloric insufficiency and the female triad

1. Stress fractures treatment principles: decrease the creation of microcracks and increase repair of
microcracks in bone
A. Decrease creation of microcracks: evaluate the patient's training regimen, biomechanics, and
equipment
B. maximize the patient's biologic capacity to repair microcracks: evaluate the general health of the
patient, including nutritional status, hormonal status, emotional status, and medication use
2. female athletic triad : disordered eating , amenorrhea . osteoporosis
3. Inadequate caloric intake
A. play a role in amenorrhea, which has been linked to an increased incidence of stress fractures
B. “energy drain hypothesis.”: low caloric intake 造成 estrogen and progesterone 製造減少(這類
性荷爾蒙的製造順位變低)，進一步導致 amenorrhea
4. Endocrine and nutritional conditions 會影響 bone formation and resorption，進而影響 stress
fracture
5. Stress fractures associated risk factor :
A. lower fat intake
B. lower caloric intake
C. eating disorders
D. body weight of <75% ideal body weight
 ex: 有研究指出: female track and crosscountry runners had an increased risk of
developing stress fractures if body mass index (BMI) was less than 19.

四. Male Endurance Athlete Tetrad

1. 有文獻指出 male runners may be predisposed to decreased BMD
2. 號發位置: lumbar spine and radius
3. Multifactorial risk factor :
A. Inadequate caloric intake: Decreased energy availability may be the key factor for low BMD
B. Decreased testosterone levels: present in males who participate in prolonged endurance events
C. genetic predilection
伍. vitamin D insufficiency
1. 有文獻研究指出: A prospective study of Finnish (芬蘭)military recruits found that the average serum
 vitamin D
2. 另外一篇 randomized, double-blind, placebo-controlled study 顯示 calcium and vitamin D
intervention could reduce the incidence of stress fractures in female recruits during basic training
3. 一天建議劑量: 800 to 1,000 IU (or perhaps as much as 2,000 IU) of vitamin D3
4. identifying vitamin D de􀂦ciency : Serum 25(OH)D3 level
5. 針對 low BMD or low vit-D level 的 vitD 建議補充劑量: at least 50 nmol/L (20 ng/mL) to as high as 90
to 100 nmol/L (36 to 40 ng/mL) based on the Food and Nutrition Board recommendations.
6. exact role of vitamin D in fracture prevention is still up for debate.

六. Stress Fracture Versus Insufficiency fracture

1. subtle difference between stress fractures and insufficiency fractures
stress fractures insufficiency fractures
相似處 loss of balance between the creation and repair of microdamage in bone
差異處 high loads placed on relatively normal normal loads placed on bone with
bone impaired healing capacity.
example Elderly females. subchondral insu􀂨ciency
fracture of the medial femoral condyle i

七. Diagnosis: Clinical Presentation

1. Pain quality :
A. Onset : Symptom onset is usually insidious, and typically patients cannot recall a specific injury or
trauma to the affected area.
B. 隨著運動量加大而加重，如果產生 complete fracture 連 Normal activity 也會痛
2. PE:
A. reproducible point tenderness with direct palpation of the affected bone site
B. There may or may not be swelling or a palpable soft tissue or bone reaction.
C. 兩個常見 PE:
 fulcrum test : long bone
 single-leg hop test: pelvic and lower extremity stress injuries

fulcrum test:
hopdiagnosis of as
femoral
far as shaft stress
on fractures
八 single-leg test: jump possible a single leg, without losing balance and landing
firmly. The distance is measured from the start line to the heel of the landing leg. The goal is to .
have a less than 10% difference in hop distance between the injured limb and uninjured limb.
Imaging
1. Plain x-rays
A. Specific but not sensitive
 usually negative early on in the course of a stress fracture, especially in the first 2-3
weeks . 2/3 of initial x-rays are negative
 half ultimately prove positive once healing begins to occur
2. diagnostic ultrasound
A. not reliable
3. Bone scintigraphy
A. nearly 100% sensitive for stress injuries of bone, but with lower specific than MRI
B. 應用: useful for tarsal, femoral, pelvic, and tibial plateau stress fractures
C. 與 periostitis 的 bone scan 差別:
periostitis Stress fracture
Phase 顯影差別 often negative in the angiogram positive in all phases of a triple-phase
and blood pool phases and positive technetium scan (angiogram, blood
in the delayed image phase pool, delayed).
顯影範圍 more diffuse distribution along the focal “hot spot”
medial border of the tibia

D. Bone scintigraphy 臨床應用:

 early diagnosis of stress injuries: increased uptake in the affected bone 1 to 2 weeks
before radiographic changes occur
 lagging behind the resolution of clinical symptoms: uptake on bone scan requires 12 to
18 months to normalize
甲、 less helpful for guiding return to activity and/or sports participation
乙、 less useful in the clinical setting for determining prognosis or assessing clinical
union of the fracture.

Bone scintigraphy image of a 20-year-old female rower with left

lower chest pain.
Diagnosis: mid-axial stress fracture of the 6th rib.

Single-photon emission computed tomography bone scan demonstrating increased contrast uptake at the
 site of bilateral pars interarticularis stress fractures at L4 in a 15-year-
old female gymnast.

4. CT:
A. 用在難以診斷的 stress fracture, ex: tarsal navicular stress fractures. pars interarticularis or linear
stress fractures
B. 診斷 stress fracture 癒合程度: demonstrating evidence of healing by clearly showing the
periosteal reaction and the absence of a discrete lucency or sclerotic fracture line
C. determining if the fracture is complete or incomplete
A: Coronal T2 MRI scan of a displaced
(grade IV) navicular stress fracture
in a competitive dancer.

B: After 3 months of nonoperative

treatment, the fracture shows minimal
signs of interval healing on three-
dimensional CT scan and has
developed a nonunion

5. MRI:
A. most sensitive and specific for diagnose stress fracture
B. superior sensitivity and specific over bone scan and CT for associated soft tissue abnormalities
and edema and may delineate injury earlier than bone scan.
C. Sensitivity 跟 bone scan 差不多,但是 more precise in delineating the anatomic location and
extent of injury
D. Image finding: T2 sequences include a band of low signal corresponding to the fracture line,
surrounded by diffuse high signal intensity representing marrow edema
 <example>
This stress fracture of the fibula is seen especially in
athletes runners patients.

九. Classification/Grading
1. 常根據許多 parameter 做分類: size of the fracture line seen on imaging, the severity of pain or
disability, the biologic healing potential of the particular injury or location, the natural history of the
particular fracture, or some combination of these parameters
2. 常分類為“high risk” or “low risk”
A. High risks stress fracture: at least one of the following characteristics
 risk of delayed or nonunion
 risk of refracture
 signficant longterm consequences if they progress to complete fracture.
B. 區分 low risk or high risk 的臨床意義: allows clinicians to quickly determine if they can be
aggressive or conservative with the decision to return an athlete to training or competition
C. <TABLE 23-1>Anatomic Sites for High-Risk Stress Fractures
Femoral neck (tension side)
Patella (tension side)
Anterior tibial cortex
Medial malleolus
Talar neck
Dorsal tarsal navicular cortex
Fifth metatarsal proximal metaphysis
Sesamoids of the great toe

D. <TABLE 23-2>Kaeding–Miller Stress Fracture Classification

Grade Pain Radiographic Findingsa
I - Imaging evidence of stress FX No fracture line
II + Imaging evidence of stress FX No fracture line
III + Nondisplaced fracture line
IV + Displaced fracture (>2 mm)
V + Nonunion
a
: CT, MRI, bone scan, or x-ray.
Modified with permission from Kaeding CC, Miller T. The comprehensive description of stress fractures: a new classification system. J Bone Joint

Surg Am. 2013;95(13):1214–1220.

A. 了解 extent of the fatigue failure or “grade” of the stress fracture 對於制定治療計畫也是相當重

要。
B. Kaeding–Miller Stress Fracture Classification: 根據臨床以及 radiologic finding 來規定 grading!
C. Example:

 A: T2 MRI examples of grade I and grade II stress fractures of the tibia in a female
distance runner. The increased signal intensity in the right tibia representing a stress
reaction was asymptomatic at the time of presentation (grade I). The left tibial stress
reaction was symptomatic with pain (grade II).
 B: Grade III stress fracture of the fifth metatarsal in a 24- year-old male soccer player
(arrow
 C: Grade IV stress fracture of the humeral shaft in a baseball pitcher/football
quarterback
 D: Grade V stress fracture of the ulnar shaft in a 35-year-old woman who used crutches
for 6 weeks following ankle fracture

壱零. High-Risk Stress Fractures Versus Low-Risk Stress Fractures

1. Low-risk stress fractures 常見區域: femoral shaft, medial tibia, ribs, ulnar shaft, and first through
fourth metatarsals
A. tend to be on the compressive side of the bone
B. respond well to activity modification
C. less likely to reoccur, develop nonunion, or have a significant complication should it progress to
complete fracture
2. High-risk stress fracture 區域如<TABLE 23-1>所示
A. Worsening prognosis if they have a delay in diagnosis
 prolong the patient's period of complete rest of the fracture site
 potentially alter the treatment strategy to include surgical fixation with or without bone
grafting
 tend to progress to nonunion or complete fracture, require operative management, and
recur in the same location

壱壱. Management of High-Risk Stress Fractures

1. Treatment decision making based on radiographic findings with less consideration given to symptom
severity
2. immediate goal of treatment: avoid progression and get the fracture to heal.
A. requires either complete elimination of loading of the site or surgical stabilization
B. avoid deconditioning of the athlete while minimizing the risk of a signi_cant complication of
fracture healing(要在訓練跟骨折恢復之間達到平衡,針對 high risk patient 要避免
undertreatment , 針對 Low risk patient 要避免 overtreatment)
 Understanding the classification and grade of stress fractures 對於治療很重要

3. 針對 High risk stress fracture location:

 A. incomplete fracture is present on plain films with evidence of fracture on MRI or CT in a high-risk
location: immobilization and strict non-weight bearing
 Worsening symptoms or radiographic evidence of fracture progression:保守治療無效
馬上考慮手術治療
B. complete fractures at high-risk location:直接考慮手術治療

壱弐. Return to Sports Participation

1. high-risk stress fractures:
A. associated with progression to complete fracture,
B. 通常建議 Complete rest, including weight-bearing restrictions, with or without immobilization or
operative management
C. low-grade injury at a high-risk location 該如何抉擇? 根據 patient's compliance level, healing
potential, and risk of worsening of the injury
D. low-grade stress fracture at a high-risk location=>等 healing
E. low-grade stress fracture at a low-risk location=>可以繼續訓練

壱参. Management of Low-Risk Stress Fractures

1. 針對 Low risk location:
A. Low grade ( gradeI.II): 先減少活動量(根據自己疼痛的程度來減少活動),不行的話在 complete
rest,再不行再考慮手術治療
B. Grade III: 先 complete rest,不行再考慮手術治療
C. High grade:手術治療
2. Return to Sports Participation:
A. Summary: treatment plan should be tailored to the individual's athletic and personal goals with a
thorough discussion of the risks and benefits of continued participation
3. low-risk stress fractures:
A. end of a competitive season, or off season: 通常運動員會有耐心等骨折癒合在開始運動
 relative rest and activity modification to a pain-free level
 建議的運動處方: cross training or aquatic treadmill
B. mid-season: 通常會想要晚點接受治療，會想先把賽季完成再說:
 limiting the athlete to a pain-free level of activity for 4 to 8 weeks

<Figure 23-6>
A 21-year-old male long jumper undergoing
running gait analysis on an aquatic treadmill during
recovery from a navicular stress fracture.

壱四. Upper Extremity Stress Fractures

1. 大部分 stress fracture 都在下肢，上肢比較少
2. less than 10% of all stress fractures and are commonly found in throwing athletes and rowers
3. great majority of these stress injuries are considered low risk and usually require only activity
modification to heal
4. 機轉:
A. shoulder girdle, arm, forearm, and wrist: strain is generated by the rotational torque of swinging
or throwing, as well as by the tension or compression generated by muscle contraction
A. repetitive axial loading: weight-bearing activities of the upper extremity (gymnastics,
cheerleading(啦啦隊)) developed all their stress fractures distal to the elbow
5. 上肢大部分保守治療少數才要手術。
A. Olecranon stress fracture in a competitive thrower , grade I.II 還可以保守治療，gradeIII 建議手
術治療

壱伍. Vertebral Stress Fractures

1. Spondylolysis, or a stress fracture of the pars interarticularis region
A. 機轉: repetitive hyperextension of spine (gymnasts, cheerleaders, divers, weight lifters),
B. Associated condition: L4 and L5 levels are most commonly affected
C. 常見主訴: insidious onset of low back pain ultimately with complaints of significant back spasms
D. often misdiagnosed as lumbar strain
A. 預後: Short periods of rest may temporarily relieve pain, but return to activity typically results in
immediate exacerbation of symptoms
B. PE finding:
 clinical hyperlordosis in addition to pain with palpation over affected vertebral levels,
and exquisite pain and muscle guarding with one and two-leg standing trunk extensions
 elicited by trunk rotation and extension, prone hip extension, and prone trunk
extension.
 Neurologic evaluation is usually normal but occasionally may elicit associated
radiculopathy
C. Radiopgraphic exam:
 Xray :
甲、 low sensitivity
乙、 要照 AP, lateral, and bilateral oblique views
丙、 Positive finding: classic defect of a “collar” on the neck (pars
interarticularis) of the “Scotty dog” is seen on oblique views
丁、 low sensitivity and high radiation exposure

備註:正常的 lumbar spine 會有 scotty dog sign , pars fracture 的會看到 scotty
dog 脖子斷掉
 
SPECT scan
甲、 greater sensitivity and is becoming the gold-standard diagnostic tool
乙、 SPECT and CT help determine the likelihood of healing and may help help
determine the treatment protocol
D. Treatment :
Initial Activity modification and avoidance of lumbar hyperextension
s/s persist 2 to 4 weeks of rest and bracing(nonrigid brace such as corset), 2-4
周後再加上 physical therapy which includes trunk stabilization,
core strengthening, and lumbar spine flexibility exercises
S/S persist>4 thoracolumbosacral orthosis (TLSO) or low-profile rigid antilordotic
weeks Boston brace : unload posterior elements and prevent
hyperextension
Healing 需要 3to 6 months, and a repeat axial-cut CT scan may be
considered to assess the amount of healing
Return to play may be as early as 8 weeks if the patient remains pain free at rest,
in hyperextension

corset brace 示意圖

壱六. Pelvic and Sacral Stress Fractures

1. uncommon and typically involve the pubic rami
2. 好發族群: most often in women, military recruits, long-distance runners or joggers after increases in
duration, frequency, or intensity of impact-loading exercise
3. S/S:
A. pubic rami stress fracture: insidious pain in the inguinal, perineal, or adductor regions that is
relieved by rest
B. Sacral stress fractures: vague, poorly localized pain in the gluteal or groin areas
4. 年輕男性要多考慮 seronegative arthropathies including ankylosing spondylitis
5. PE:
A. Pubic ramus stress fracture : antalgic gait, full range of motion, pain over the pubic rami, or an
inability to stand unsupported on the affected side
B. Sacral stress fracture: pain with hip flexion , abduction, and external rotation in addition to
increased pain when asked to hop
  usually will have normal hip and spine range of motion but complain of deep groin pain
at the extremes of hip motion
6. Xray:
A. initially negative in most cases of both pelvic and sacral stress fractures.
B. Later in the healing process, callus may be present on plain film
7. Bone scan or MRI: help in early diagnosis
8. Treatment:
A. cessation of running and jumping activities, protected weight bearing, and relative rest lasting
from 6 weeks to 8 months
B. Surgery is not typically necessary

< Figure 23-7> 21-year-old female distance runner with right pelvic pain.
A: Anteroposterior pelvic radiograph demonstrating minimally displaced (grade IV) right inferior pubic
ramus stress fracture.
B: Axial-cut T2 MRI demonstrates stress reaction and early healing callus

壱七. Lower Extremity Stress Fractures: femur

1. Lower Extremity Stress Fractures
A. most commonly involved areas :femur shaft, the intertrochanteric region, and the neck
B. tension or superior side of the femoral neck : high-risk site for fracture propagation

壱八. Femoral Neck

1. 常見族群: most frequently in runners, dancers, and military recruits
2. 診斷時機: often delayed for 5 to 13 weeks
3. High risk location: Tension-sided femoral neck stress fractures possess the greatest risk for fracture
progression
4. PE: antalgic gait, pain with palpation in the groin, hip, or anterior thigh as well as pain at the extremes
of hip range of motion.
5. Confirmation of the diagnosis:
A. Xray :
 lags behind symptoms and may not be evident until some healing has occurred .
 high false-negative rate
B. Bone scan or SPECT
  useful for early diagnosis
 false negatives have been reported up to 12 days after symptom onset
C. MRI: sensitive study identifying early marrow edema, which typically resolves in 8 to 12 weeks
6. Management

A. Inferior cortex( compression side):

 restricted weight bearing for 6 weeks or longer
 Weekly radiographs should be obtained until the patient can walk pain free with a cane
 Return to play or other vigorous activity may be delayed up to 2 years
B. Tension side:
 indication for surgical fixation with parallel screws or a sliding hip screw device
 if no displacement , some authors have advocated bed rest as the first-line treatment
without immediate surgery
 早期診斷早期治療才可以減少 nonunion 以及 femoral head necrosis 機率

壱九. Femoral Shaft

1. 好發族群: runners, in particular female runners,
2. 好發位置: junction of the proximal and middle thirds of femoral shaft
3. 常見主訴: recent increase in frequency, intensity, or duration of a repetitive activity
4. PE:
A. antalgic gait with normal knee and hip range of motion.
B. Pain with palpation may be present at the anterior thigh with hopping on the affected leg
reproducing the pain
C. fulcrum or “hanging leg” test : A three-point bending force is then applied to the thigh with the
edge of the table being used as a fulcrum. Pain elicited is indicative of a stress fracture
5. Image:
A. Xray :
 typically negative early in the course of the injury
 Fracture callus and a radiolucent fracture line usually appear 2 to 6 weeks after
symptom onset
B. Bone scan or MRI:
 Necessary for early diagnosis

6. Tx: 通常會先嘗試 nonoperative tx , 效果通常不錯

1 to 4 weeks 1. protected weight bearing with crutches
2. Activity modification with cross training during this time period allows aintenance
of aerobic fitness, skill, and strength
2 weeks 以上如 rehabilitation program with low-impact exercise may be initiated
果不會痛
5-10 weeks Time to full recover
8-16 weeks return to full athletic participation
:

弐零. Knee and Lower Leg Stress Fractures: Patella

1. Rare , but troublesome
2. 好發族群: basketball players, soccer players, and high jumpers
3. Risk factors(for a tension-sided (anterior cortex) stress fracture of the patella):
A. flexion contracture
B. harvest of a patellar tendon graft for ACL reconstruction
4. S/S: anterior knee pain, worse with jumping.
5. PE: point tenderness to palpation of the anterior patella and increased pain with resisted knee
extension
6. Image:
A. Xray : fracture lines in longitudinal or transverse directions, but these must be differentiated from
a bipartite or tripartite patella
B. bone scan or MRI: identifying bone edema can clarify the diagnosis.
7. Tx: 因為 extensor mechanism 有 distraction force , 所以 transverse patella fracture 很容易跑掉
A. Nondisplaced: hinged knee brace with the knee in full extension for 4 to 6 weeks, followed by
progressive range of motion and quadriceps rehabilitation
B. Displaced fractures :ORIF !!!
C. 如果是 Fractures in a longitudinal direction
 most often at the lateral patellar facet
 if displaced, the lateral fragment may be excised

弐壱. Tibial Shaft

1. Incidence : 20% to 75% of all stress fractures in athletes
2. 要區分 medial tibial stress syndrome (shin splints), a compression-sided stress fracture, and a tension-
sided stress fracture
A. most predominant type: low-risk posteromedial cortex (compression side) stress fracture
B. less common type: high-risk “dreaded black line” of the anterolateral cortex of the central shaft

3. 常見運動: running sports such as soccer, track and field, basketball, or ballet,
4. PE:
A. localized pain with point tenderness at the anterior or medial tibiae. Edema, palpable periosteal
thickening, and pain with percussion may also be present
B. “tuning fork test” : high false-negative rate
 <Figure 23-8>
A: A 19-year-old female ballet
dancer with chronic anterior tibial
pain and
stress fracture of the anterior
tibial cortex (arrow). Final
treatment required operative
_fixation with an intramedullary
rod.
B: Cortical thickening remains
evident 6 months after surgery.

5. image:
A. Xray: may be positive if symptoms have persisted for 4 to 6 weeks.
B. Bone scan: demonstrates focal fusiform uptake, which differs from the linear uptake seen with
medial tibial stress syndrome
C. MRI: useful for grading and providing a prognosis for return to play
6. TX:
A. 跟前面差不多,一開始先 control pain , limit activities
B. 不痛了之後再開始復健訓練(cross training with low-impact or nonimpact aerobic training)
 C. Compression-sided injuries 所需復原時間: 2 to 12 weeks
D. Tension-sided injuries 需 4-6Months
 如果需要早點恢復需加其他治療: bone grafting, electrical stimulation, or IM nailing
 Gold standards: IM nailing

弐弐. Medial Malleolus

1. relatively rare
2. 特性: inherently unstable and prone to nonunion
3. 好發於: running and jumping sports
4. History :跟前面差不多( insidious onset of medial ankle pain that is increased with exercise and
relieved by rest)
5. PE: medial malleolar tenderness to palpation and an effusion of the ankle join
6. 需額外評估 foot or lower limb alignment(可能會影響 stress overloading)
A. Varus alignment : cause medial overload
7. Xray : fracture line extends vertically or horizontally from the medial articular surface of the tibial
plafond
8. Treatment:
A. low-demand individuals: no weight bearing and immobilization with gradual rehabilitation
B. high-demand athletes: 要更積極一點, ex: ORIF + malleolar screw
C. nonunion: bone grafting and screw fixation

弐参. Fibula
1. Rare ,因為 fibula weight bearing 比例很低
2. 好發位置: distal third of the diaphysis just proximal to the distal tibiofibular syndesmosis
A. may be associated with overpronation and a valgus hindfoot.
3. S/S: lateral leg and ankle pain with mild swelling and may have a notable limp.
4. PE: Point tenderness can be elicited by palpation of the bone or by performing a syndesmosis squeeze
test.
5. Treatment: 跟前面差不多
A. weight bearing as tolerated in a protective fracture brace, followed by gradual return to activity
once pain and swelling have resolved.
B. return to participation after 3 to 6 weeks of rest
C. Complete healing: 8-12 weeks

弐四. Stress Fractures of the Foot: calcaneus

1. 好發族群: long-distance runners and military recruits
2. S/S: insidious onset of diffuse heel pain with running that may be increased by toe walking or during
the toe-off phase of running
3. PE:
A. positive “heel squeeze” test: compressing the body of the calcaneus between the palms of both
hands
4. Xray:
 A. positive after 2 to 4 weeks
A. sclerotic line with callus perpendicular to the trabecular lines of the calcaneal tuberosity may be
visualized
5. Bone scan and MRI: increased reactive bone in this region as well, confirming the diagnosis
6. Treatment
A. decrease activity and use cushioned heel inserts until symptoms have improved
B. 依然疼痛的話可以考慮 cast or brace and a brief period of non-weight bearing
C. return to sports:3-8 th weeks

弐伍. Tarsal Navicular

1. 好發族群:frequently recognized in jumping and running athletes
2. 特性: high-risk stress fracture!!!
3. S/S: vague midfoot and medial arch symptoms of insidious onset
A. often leading to delayed diagnosis
B. may be delayed from 2 to 7 months.
4. PE: tenderness at the “N spot” (the dorsal aspect of the navicular), but pain may be diffuse rather than
localized
A. 很容易 delay diagnosis!!! midfoot pain in a running or jumping athlete requires a high index of
suspicion and early aggressive management
5. Xray:
A. usually negative
B. Since most fractures occur in the sagittal plane and in the central third of the dorsal navicular
cortex

C. 此區特性:
 poor blood supply predisposing the bone to stress-related injury
 correlated with the plane of maximum shear stress during a combination of plantar
flexion and pronation
 predisposing factor : short first metatarsal, a long second metatarsal, or a
calcaneonavicular coalition
7. Bone scan: confirm diagnosis
8. CT/MRI: necessary to determine the exact location and extent of the fracture and the amount of
healing or to diagnose a nonunion
9. Tx principle : early diagnosis with aggressive treatment
 A. incomplete fractures : non-weight bearing + cast for 6 to 8 weeks + gradual rehabilitation
B. immobilize the fracture site after surgery and until radiographic healing has occurred

弐六. Metatarsal Stress Fractures : 1-4 th

1. 1-4 metatarsal 為 low-risk injuries.
th

A. 1st metatarsal fx 佔 10% .2-5th metatarsal 佔 90%

2. Risk factor :
A. running over 20 miles/week
B. Pes planus deformity increases the impact stress to the medial four metatarsals.
3. 好為位置:
A. Runners: distal shaft
B. ballet dancers : fractures may occur proximally and often involve the medial border of the second
metatarsal due to weight bearing in the “en pointe “position
4. S/S: localized pain and swelling in the absence of trauma and report symptom onset after an increase
in training intensity
5. PE: low arches, overpronation while running, and point tenderness over the involved metatarsal
A. Pain is often exacerbated with inversion of the foot
6. Xray:
A. Weight-bearing AP, lateral, and oblique
B. dancers with second metatarsal pain : internal and external oblique radiographs of the foot
7. Treatment:
A. rest and the use of a stiff-soled shoe or fracture boot: decrease bending stresses across the
midfoot
8. 復健:
A. Gradual reconditioning with progression of repetitive loading such as pool running progressing to
cycling, then land running
A. orthotic devices should be prescribed if abnormal bony alignment or foot biomechanics are
present

弐七. Fifth metatarsal

1. high-risk location
2. prone to nonunion: due to poor circulation
3. three zone:

<Figure 23-9>
 A. Zone I—tuberosity
B. zone II—watershed (avascular) zone at the metaphyseal–diaphyseal junction
C. zone III—proximal diaphysis
4. zone II have the greatest risk for delayed healing due to the limited vascularity of this site.
5. 好發族群: basketball players and runners
6. S/S: insidious onset of lateral foot pain that is worst during and after running or jumping activity
7. PE: point tenderness is elicited at the distal portion of the tuberosity, usually in zone III.
8. Image:
9. Xray: show sclerotic change around the fracture site
10. Bone scan or MRI: may be employed if an occult fracture is suspected
11. TX: should be aggressive
A. Nonathletes: short leg non–weight-bearing cast or fracture brace for 6 to 8 weeks
B. high-demand athletes: IM screw fixation with a 4.0- or 4.5-mm cannulated screw permits faster
return to play
12. 復健:
A. Weight bearing should be initiated 7 to 14 days postoperatively
B. training progressing to full unrestricted activity over 9 weeks
C. Return to sports activities is expected at approximately 3 to 9 weeks postoperatively(zone II or III)

弐八. Sesamoids
1. Rare , difficult to diagnosis
2. 需要 DD 的診斷: sesamoiditis, bipartite and tripartite sesamoids, hallux rigidus, and a painful soft
tissue callus.
3. medial sesamoid is most frequently involved
A. most of the body's weight is transferred through the medial aspect of the 􀂦rst metatarsal during
the toe-off phase of activity
4. S/S: pain localized to the plantar surface of the first metatarsal head which is worse upon weight
bearing and during the toe-off phase of the gait cycle
5. PE: Pain on palpation, pain with resisted active great toe plantar flexion , and pain over the sesamoids
with stretch into full dorsiflexion of the first metatarsophalangeal joint
6. Diagnosis:
A. Xray 難以診斷(尤其是 nondisplaced)
B. bone scan or MRI,
 identify marrow edema
 differentiate stress fracture from a bipartite sesamoid.
7. TX: 手術要放到後線治療,尤其是運動員
A. Initial : Conservative treatment with 6 weeks of non–weight-bearing cast immobilization to
prevent dorsiflexion of the first ray
 Unloading of the first metatarsal head is the primary goal.
 use of orthotic devices in the shoe after casting.
 Union: 4 to 6 months.
 B. Surgical excision is recommended for delayed union or chronic pain
 Removal of the entire medial sesamoid may, however, result in weakening of the flexor
hallucis brevis insertion on the proximal phalanx, resulting in the great toe drifting into
valgus
C. Partial sesamoidectomy
 an alternative to complete sesamoidectomy to effectively resolve symptoms and
maintain normal mechanics of the great toe
弐九. Prevention of Stress Injuries
1. Correction of amenorrhea in females
2. Calcium and vitamin D supplementation
3. use of appropriately designed orthotic devices(如果遇到 biomechanical abnormalities)
4. gait analysis and appropriate running form and technique changes

参零. Biologic Modalities and Future Treatment Options

1. 大概可以分為三種類型: use of electronic bone stimulators, pulsed parathyroid hormone
(teriparatide), and Subchondroplasty
A. Electric bone stimulator:
 Pulsed electromagnetic fields (PEMFs) : creates a magnetic field and a secondary
electric impulse activating a series of enzyme reactions that upregulate growth factors
such as bone morphogenetic proteins, transforming growth factor-β, and calmodulin
 low-intensity pulsed ultrasound (LIPU): direct effect on ion channels for stimulating
bone cell activity via mechanoreceptors
B. pulsed PTH:
 achieve the primary end point of accelerated healing with improved early callus
formation
 animal study : supraphysiologic doses of parathyroid hormone demonstrate increased
fracture site strength and callus quantity, with greater mineralization at the fracture site
C. Subchondroplasty:
 Increase the density and structure integrity of subchondral bone
 Procedure: drilling into subchondral bone with a cannulated guide pin. Under
fluoroscopy, engineered calcium phosphate paste is injected into subchondral bony
defects forming a macroporous scaffold for bone
  Outcome: improvement in the parameters of pain and functional capacity over the first
24 weeks following surgery

参壱. Summary
1. Stress fracture is common injuries particularly in endurance athletes and military recruits
2. 治療方向也要同時考慮 nutritional, hormonal, psychological, and biomechanical factors
3. Management 需考慮多種面向: individualized to the patient or athlete by taking into consideration
injury site (low vs. high risk), grade (extent of microdamage accumulation), the individual's activity
level, competitive situation, and risk tolerance
4. Kaeding–Miller classification System : 病人症狀加 radiologic findings!
5. treatment algorithm 需先區分出 low risk and high risk location
 Low risk High risk
Usually on compression side Usually on tension side
better prognoses, and are unlikely to progress to High rate of nonunion if conservative treatment .
complete fracture often Require operation

参弐. Paper 表格補充:非 rockwood 裡面內容

Ref: Stress Fractures: Classification and Management 2010 .The Physician and Sportsmedicine
A. Figure 5. An algorithm for treatment of stress fractures