yogabook / pathologie / stress fracture

stress fracture (march fracture, fatigue fracture)

Definition of

The stress fracture is a bone-related overuse syndrome; metatarsal bones are usually affected, Os metatarsale II most frequently, otherwise other bones can also be affected, especially in athletes, depending on the sport. First described as a marching fracture in 1855 by the military doctor Breithaupt. Outside of the military, recreational and professional athletes are mostly affected today, W:M up to 10:1. Age peak in children and adolescents in the growth phase and also in recreational athletes who start or restart sport from the age of 40. The lower extremity is affected in 85% of cases. A distinction is made between high-risk and low-risk bone localizations. The high-risk localizations include: Femoral neck, talus, ventral tibia at the medial melleolus, Os Naviculare, Os Metatarsale I, II and V. If one of these bones is affected, immobilization may be necessary, possibly even surgery. It is currently being discussed whether NSAIDs delay healing.

For bone marrow edema without a stress fracture, however, NSAIDs can be given. In the case of low-risk localizations, low-impact sports can be continued, including light athletic training if necessary. An atraumatic bone bruise requires differential diagnosis. In addition to these forms, there are also Schipper’s disease/Schipper’s fracture(fracture usually of a cervical spinal process) and cough fracture. Etiologically, prolonged (often iterated) overloading overtaxes the remodeling of the bones. Small cracks inside the bone, which heal when the load is stopped, can no longer heal and microcracks develop down to the periosteum. If a bone breaks as a result of normal, moderate everyday stress, it is not a stress fracture but an insufficiency fracture. The absence of the mensis in young, ambitious female athletes is an indication of an increased fracture risk.

The preliminary stage of stress fractures are stress reactions of the bone in which there has not yet been a detectable fracture, but these are often not detectable by conventional means. Hormonal data can provide information about a possible stress reaction or the tendency to one, whereby osteogenic hormones are in the foreground. Bone density measurements are also evaluated. However, depending on the intensity and extent of training, stress reactions can also occur in unsuspected hormonal constellations. In contrast to traumatic fractures, stress fractures rarely show a complete interruption of bone continuity. Pain also usually occurs before the actual fracture occurs. Instead of exact fracture lines, defect zones are usually recognizable, which morphologically correspond more to osteonecrosis. It is difficult to predict how long it will take from the first symptoms to the pain-induced inability to bear weight and which triggers are still necessary. Depending on the intensity and extent of the training, it can also take hours or months. Swelling of the periosteum is typical but can also be absent. The pain can creep in or occur spontaneously, and in the case of a fracture it intensifies abruptly.

It is not uncommon for periostitis, tendovaginitis or simply an overload reaction to be misdiagnosed instead of a stress fracture. However, diseases that are also relevant to the differential diagnosis, such as osteosarcoma, sclerosing osteomyelitis, osteomalacia and osteonecrosis, are rarely assumed by general performers. The best detection method for stress fractures and stress reactions is the scintigram, although this is correctly used sparingly for reasons of radiation protection. The criterion of the correct position of the fracture fragments, which is relevant for the healing of traumatic fractures, is given by law in the case of fatigue fractures without complete rupture. Training must at least be reduced appropriately, but everyday activities should be possible as normal. Surgical treatment is not usually necessary, immobilization is not indicated due to the risk of muscular dystrophies and the resulting muscular imbalances, as well as the risk of damage to joints and bones. If a stress reaction or stress facture has occurred, the extent, type and intensity of training, the materials used, the regeneration times and the relevant parts of the musculoskeletal system must be reviewed.

Ursache

1. Overuse

Predisposing

– Behavior

1. Inadequate footwear, hard ground, lack of cushioning of the footwear
2. Inadequate increase in training (especially in sports, running, hiking, marching)
3. Nutritional deficiencies, reduced calcium or vitamin D intake
4. Basketball players: calcaneus, patella, femur, pelvis
5. Runners, especially cross-country skiers: lower leg, metatarsus
6. Jumping sports: Os naviculare, femur, pelvis
7. Racket sports such as tennis (in addition to the lower extremity also the olecranon)
8. Lack of adaptation to the requirement: beginners in sport, recruits
9. Initial or irregular training, leading to a mismatch between muscle strength and osseous resilience

– Musculoskeletal system

1. Malpositions and deformities
2. Osteoporosis and other bone diseases

– Dispositional diseases

1. endocrinological

– Other factors

1. Overweight/weight gain
2. Reduced oestrogen concentrations due to cycle disorders or diet

Diagnosis

1. Clinic and medical history are often sufficient to make a diagnosis
2. X-ray in 2 planes; MRI shows bone marrow edema even before the fracture of the cortical bone, indicates a stop to training and thus minimizes loss of training time. The fracture that occurs is usually in the middle of the bone, not close to the joint. The fresh, non-displaced, non-fragmented fracture may remain inconspicuous on X-ray and only become visible after days or a few weeks due to decalcification.
3. A bone scintigraphy also provides evidence, but is avoided if possible due to the radioactive exposure. MRI provides evidence of the fracture and allows a prognosis of the patient’s ability to bear weight again.
4. Periosteal edema visible on MRI can be an early symptom of an impending stress fracture

Symptoms

1. Slowly increasing dull, later stabbing pain in the midfoot
2. Reduced load-bearing capacity of the foot, especially when rolling, reduced walking distance
3. localized pressure pain
4. Swelling
5. Local signs of inflammation can be an early symptom of an impending stress fracture

Complications

1. clear tendency to recur
2. Relapse in the event of a premature attempt to exercise, resulting in delayed healing

Therapy

1. Immediate relief and immobilization
2. Orthosis
3. Analgesics (NSAIDs), if necessary
4. In most cases, you can start slowly building up the load after 6-8 weeks, full resilience usually after 4-6 months
5. When resuming athletic training: check for orthopaedic abnormalities, technical deficiencies, material deficiencies, training program and workload. The resumption of training must be pain-free, otherwise healing is not yet complete and training must not be resumed too aggressively.
6. Fractures of the tibia and fibula require walking aids for relief
7. For athletes: temporarily switch to sports that provide relief, such as cycling or strength training, depending on the fracture