Imaging Imaging is needed to definitively diagnose stress fractures. Both magnetic resonance imaging (MRI) and bone scans are used, with MRI considered more sensitive (McClure & Oh, 2022). Treatment Stress fractures are managed conservatively in runners with rest, immobilization, activity modification/cross training, and guidance for return to running (Stress Fractures, 2022). As symptoms diminish, therapy can be used to address any strength, flexibility, and neuromuscular issues that have been identified. Healthcare Consideration: Rest is recommended for management of stress fractures. However, runners often find it difficult to take time away from running. It is important to communicate that running on a stress fracture can delay healing and lead to further injury. In addition, it can lead to compensatory running mechanics, which in themselves can lead to injury (Carter, 2024). Case Study: Ross Johnson Mr. Johnson is a 22-year-old male training for his first marathon. He recently joined a running club that has a marathon training program. Before this, Mr. Johnson only ran “up and down the basketball court.” He complains of pain along the medial aspect of his tibia and states that he knows he has “shin splints” and that he is “an overpronator.” Questions What is a risk factor for medial tibial stress syndrome that is mentioned in this case study? What test can you use to evaluate Mr. Johnson’s pronation in standing? Answers The risk factor for medial tibial stress syndrome that is mentioned in Mr. Johnson’s case is less experience as a runner. The test that can be done to assess for pronation in standing is the navicular drop test. Case Study: Catherine Clark Ms. Clark is a middle-aged runner who enjoys running about 20 miles per week with her women’s running club. She presents with right heel pain that is worst when she first gets out of bed in the morning. She has looked online and knows she has plantar fasciitis. She is surprised that she has this injury as she has been able to run without injury for many years. In reviewing her medical history with her, she reports that she is in the process of returning to running after a surgery a few months ago to fix her right bunion. While examining her foot, you can see tha t she has markedly limited right great toe extension. Questions What effect does limited great toe extension have on foot mechanics, and how might that predispose this client to plantar fasciitis? Answers Great toe extension is needed for optimal windlass mechanism function. The windlass mechanism stabilizes the arch of the foot during propulsion. A lack of great toe extension and, thus, dysfunction of the windlass mechanism puts extra stress on the plantar fascia.
Marappa-Ganeshan, 2023) as is a previous history of stress fracture (Hadjispyrou et al., 2023). Body mass index, either underweight (BMI below 19 kg/m2) or overweight (BMI greater than 25 kg/m2) in combination with poor muscle development is a risk factor for stress fractures (Hadjispyrou et al., 2023). Extrinsic risk factors include irregular running surface, running shoes older than 6 months, poor footwear, and deficient vitamin D and calcium. (May & Marappa- Ganeshan, 2023) as is a training mileage of more than 20 miles per week (Hadjispyrou et al., 2023). Biomechanical factors Johnston et al. (2021) found that athletes with stress fractures have higher arches, more leg length discrepancies, and increased forefoot varus. May & Marappa-Ganeshan (2023) identified genu valgum and a short leg as biomechanical risk factors for stress fractures. Symptoms Stress fracture symptoms will manifest themselves approximately 3 weeks after an abrupt increase in training. In runners, the most common sites for stress fractures are the tibia followed by the foot and femur (Hadjispyrou et al., 2023). Pain is of insidious onset and initially occurs after activity. But as the stress fracture worsens, the runner will report pain for a longer period of time after activity, with activity, and upon waking up in the morning (May & Marappa-Ganeshan, 2022). Runners with femoral stress fractures will complain of pain in the groin while those with medial tibial stress fractures will complain of pain along the medial aspect of the distal tibia Typically, examination findings are limited with stress fractures. Point tenderness is usually present at the injury site. Focal edema may occur (May & Marappa-Ganeshan, 2022). An antalgic gait pattern may be seen. Limited and/or painful hip and/or knee range of motion may be present with femoral stress fractures (May & Marapp- Ganeshan, 2022). Tenderness with palpation along the medial aspect of the tibia is typical with tibial stress fractures (McClure & Oh, 2023). Special tests A tuning fork is sometimes used to diagnose stress fractures of the tibia. The rationale for its use is that the vibrating tuning fork will elicit pain when applied to the stress fracture site because the vibrations will irritate the microfractures. A study by May et al. (2021) assessed potential tibial stress fractures with a tuning fork and compared the results to magnetic resonance imaging (MRI) findings. They concluded that the tuning fork is an ineffective tool for diagnosing tibial stress fractures (May et al., 2021). One leg hop test Hopping on the involved leg can assist with diagnosing tibial stress fractures and can help differentiate them from medial tibial stress syndrome. The patient is asked to hop on one leg. This test is positive if the runner cannot hop without pain with landing being particularly symptomatic (Kiel & Kaiser, 2023). Fulcrum test The fulcrum test is used to diagnose femoral shaft stress fractures. The patient is seated at the edge of the table. The examiner places one arm under the involved leg. This arm serves as a fulcrum and is moved from distal to proximal thigh as pressure is applied to the dorsum of the knee with the opposite hand. The test is positive if the applied pressure creates pain and apprehension (Fulcrum Test, 2021). (McClure & Oh, 2023). Physical examination
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