So, my first post was primarily looking at modifiable risk factors that I could alter to change the load due to my conservative PT bias. Yet after Laura’s point I started to do some more research to find out when is the best time to refer out for imaging. Based on the articles I read, this is the flow of potential stress fracture management that I came up with:
1. Is this a high-risk stress fracture area? (femoral neck (tension-side), patella, anterior tibia, medial malleolus, talus, tarsal navicular, proximal 5th metatarsal, and great toe sesamoid)
– “These locations all have a region of maximal tensile load in a zone of diminished blood flow that is vulnerable to stress injury, with suboptimal healing potential. Although HRSFs are relatively rare, they have important clinical relevance, because they can keep athletes from participating in sports for long periods of time and can cause significant morbidity if not properly treated. Athletes with HRSFs may require surgical intervention to return to play in a timely fashion. A high index of suspicion and early identification are critical to proper treatment and successful outcomes.” (McInnis 2016)
2. Does the individual have a lot of risk factors for stress fractures?
– Previous history of stress fracture and female sex are risk factors that are strongly supported by the data (Wright 2015)
– Non-modifiable: Bone strength, genetic/nutritional factors, biomechanics, structure, physical fitness, sex, menstrual status
– Modifiable: Training load, footwear, running surface, etc
3. If suspicion is high for stress fracture, then refer out early for MRI. If there is a stress fracture present on MRI, determining the grade of stress fracture will determine the appropriate management.
– MRI stress fracture grades (Nattiv 2015)
Going back to the patient in this case. This has only been going on for 2 weeks. He has a high risk fracture location of anterior tibia. Yet, I would want to know more risk factors before referring to imaging.
(McInnis 2016): High Risk Stress Fractures: Diagnosis and Management, PM R 2016, https://onlinelibrary.wiley.com/doi/full/10.1016/j.pmrj.2015.09.019
(Wright 2015): Risk factors associated with lower extremity stress fractures in runners: a systematic review with meta-analysis, BJSM 2015, https://bjsm.bmj.com/content/49/23/1517.long
(Nattiv 2015) CORRELATION OF MRI GRADING OF BONE STRESS INJURIES WITH CLINICAL RISK FACTORS AND RETURN TO PLAY: A 5-YEAR PROSPECTIVE STUDY IN COLLEGIATE TRACK AND FIELD ATHLETES, AJSM 2015, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4367232/