Introduction
- Timothy S. Mologne, MD
- Kari Sturtevant, DPT
Epidemiology
- •
Leg pain is a common complaint in athletes.
- •
There is no disparity between men and women, except stress fractures are more common in women.
- •
Leg pain can be seen in athletes in all sports, but is especially common in endurance sports, particularly running.
Pathophysiology
Intrinsic Factors
- •
Excessive foot pronation combined with repetitive impact activity
- •
Hormonal imbalance
- •
Female endurance athletes (anorexia, amenorrhea, osteopenia)
- •
Poor nutrition
- •
Metabolic disorders
- •
Abnormal anatomical relationship between the popliteal artery and fascia and muscles in the popliteal fossa (popliteal artery entrapment syndrome)
Extrinsic Factors
- •
Overuse
- •
Acute increase in duration and intensity of training without appropriate conditioning
- •
Repetitive loading
- •
Improper footwear
- •
Repetitive running on hard surfaces
Classic Pathological Findings
- •
Inflammatory process of the periosteum and tendinous attachments of the soleus, flexor digitorum longus, and deep crural fascia along the posteromedial aspect of the distal two thirds of the tibia: medial tibial stress syndrome
- •
Imbalance in bone turnover with more bone resorption than bone production: stress fracture
- •
Muscle ischemia related to: chronic compartment syndrome
- •
Entrapment of the popliteal artery by medial displacement of the artery by the medial head of the gastrocnemius muscle: popliteal artery entrapment syndrome
- •
Entrapment of various motor and sensory nerves in the leg and ankle: nerve entrapment syndrome
- •
Bone formation in the interosseous ligament between the tibia and fibula following an ankle or tibial fracture: tibiofibular synostosis
- •
Fascial defect in the lateral leg compartment at the site of the superficial branch of the peroneal nerve becoming superficial: muscle herniation with possible associated chronic exertional compartment syndrome
Clinical Presentation
History
- •
Activity-related aching pain along the posteromedial aspect of the distal two thirds of the tibia: posteromedial tibial stress syndrome
- •
Activity-related pain on the tibia: stress fracture
- •
Leg aching during or after exercise that usually occurs after the same duration of exercise. The pain does not resolve immediately after rest: chronic exertional compartment syndrome
- •
Possible postexercise paresthesias: chronic exertional compartment syndrome
- •
Cramping pain and paresthesias with exercise, which are relieved with rest: popliteal artery entrapment syndrome
Physical Examination
- •
Diffuse tenderness to palpation along the distal two thirds of the posteromedial aspect of the tibia: medial tibial stress syndrome
- •
Pain in the posteromedial tibia with toe raises and resisted plantar flexion: medial tibial stress syndrome
- •
More focal tenderness along the tibia with possible swelling in the same area: stress fracture
- •
Increased pain with a bending or twisting force is applied to the tibia: stress fracture
- •
Physical examination is usually normal in patient with chronic exertional compartment syndrome, but may demonstrate firm, tense leg compartments and possible paresthesias in a specific nerve distribution, depending on the compartment and pressures in the compartment that contains the nerve.
- •
The physical examination is usually normal in patients with popliteal entrapment syndrome. With the knee extended, pulses may diminish or obliterate with passive ankle dorsiflexion or active plantar flexion. Pulse may be best assessed with Doppler ultrasound.
Imaging and Other Diagnostic Studies
- •
Radiographs of the leg
- •
Bone scan (may be helpful in medial tibial stress syndrome and stress fractures) ( Figure 36-1 )
FIGURE 36-1
Bone scan showing mild increased uptake along the posteromedial aspect of the distal third of the tibia in an elite runner diagnosed with posteromedial tibial stress syndrome.
- •
Magnetic resonance imaging (MRI; helpful for stress fractures, medial tibial stress syndrome, and exertional compartment syndrome) ( Figure 36-2 )
FIGURE 36-2
Magnetic resonance image of a stress fracture of the proximal medial tibia.
- •
Arteriogram in cases of suspected popliteal artery entrapment syndrome and in patients thought to have vascular claudication
- •
Leg compartment pressure measurements at rest and 1 and 5 minutes after exercise (diagnostic for exertional compartment syndrome)
- •
Doppler ultrasound may be used to assess ankle pulses in the workup for suspected popliteal artery entrapment syndrome.
Differential Diagnosis
- •
Medial tibial stress syndrome
- •
Tibial stress fracture
- •
Chronic exertional compartment syndrome
- •
Popliteal artery entrapment syndrome
- •
Nerve entrapments
- •
Gastroc-soleus strain
- •
Plantaris tear
- •
Ruptured Baker’s cyst
- •
Tibiofibular synostosis
- •
Fascial defect with muscle herniation
- •
Lumbosacral disc herniation with radiculopathy
- •
Vascular claudication (elder athletes with possible peripheral vascular disease)
- •
Neurogenic claudication from spinal stenosis
Treatment
Nonoperative Management
- •
REST
- •
Cross-training
- •
Decrease in training intensity and duration
- •
Change in training surface
- •
Nonsteroidal antiinflammatory agents
- •
Ice
- •
Heel cord stretching
- •
Orthotics for excessive foot pronation
- •
Education on gradual progression in training and conditioning
Guidelines for Choosing Among Nonoperative Treatments
- •
Virtually all causes of leg pain in athletes, with the exception of chronic exertional compartment syndrome and popliteal artery entrapment syndrome, are treated conservatively as an initial step.
Surgical Indications
- •
At least 4 months of rest and activity modification with recurrence of symptoms once activities and sports activities are restarted (medial tibial stress syndrome)
- •
Stress fractures of the anterior tibial cortex that remain symptomatic and show signs of delayed or nonunion despite 6 months of treatment
- •
Chronic exertional compartment syndrome is not effectively managed with nonsurgical treatments except rest and activity modifications. Surgery is the best option to allow athletes to return to their respective sports.
- •
Claudication symptoms in patients found to have popliteal artery entrapment syndrome
- •
Persistent symptoms related to specific nerve compressions that do not respond to conservative treatment.
Evidence
Multiple Choice Questions
- QUESTION 1.
Intrinsic factors contributing to leg pain in the athlete include:
- A.
Poor nutrition
- B.
Being female
- C.
Abnormal hormone balance
- D.
All of the above
- A.
- QUESTION 2.
Which of the following scenarios is least likely to result in leg pain?
- A.
A 42-year-old male runner who recently increased his miles run per week from 25 to 35 and improved his pace from a 10-minute mile to an 8-minute mile
- B.
A 26-year-old woman training for an ironman who now has infrequent menstrual cycles and is concerned about her weight and body image
- C.
A 32-year-old female cyclist who recently purchased a new road bicycle, had it custom fit, and has now increased her mileage per week by 10% with similar intensity
- D.
A 21-year-old man with a history of medial tibial stress fractures who has recently returned to running with old shoes and displays moderate pronation while running
- A.
- QUESTION 3.
Which of the following is not a surgical indication?
- A.
Conservative treatment has failed to relieve specific nerve compressions.
- B.
Following 4 months of treatment, stress fractures of the anterior tibial cortex remain symptomatic.
- C.
Following 4 months of rest and activity modification, familiar symptoms are experienced once sport activities are resumed.
- D.
Claudication symptoms persist in a patient with popliteal artery entrapment.
- A.
- QUESTION 4.
Which of the following injuries is not initially treated conservatively?
- A.
Chronic exertional compartment syndrome
- B.
Tibiofibular synostosis
- C.
Medial tibial stress fracture
- D.
Decreased sensation in the area of the leg consistent with the superficial fibular nerve
- A.
- QUESTION 5.
Which of the following diagnostic images would be useful for an athlete with complaints of leg pain?
- A.
MRI
- B.
Radiograph
- C.
Doppler ultrasound
- D.
CT myelogram
- A.
Answer Key
- QUESTION 1.
Correct answer: D (see Pathophysiology : Intrinsic Factors )
- QUESTION 2.
Correct answer: C (see Pathophysiology )
- QUESTION 3.
Correct answer: B (see Treatment : Surgical Indications )
- QUESTION 4.
Correct answer: A (see Treatment : Guidelines for Choosing Among Nonoperative Treatments )
- QUESTION 5.
Correct answer: D (see Clinical Examination: Imaging and Other Diagnostic Studies )
Nonoperative Rehabilitation of Medial Tibial Stress Syndrome
- Mark F. Reinking, PT, PhD, SCS, ATC
- L. Tyler Wadsworth, MD
- •
Let the athlete’s leg pain guide the return to activity
- •
Gradual return to athletic activity
- •
Address entire kinetic chain biomechanics
Phase I (weeks 0 to 2): Acute Phase
Protection
- •
If the athlete has medial tibial pain with walking ambulation, crutches should be used until the athlete can walk without pain.
| PHASE I (weeks 0 to 2) | PHASE II (weeks 3 to 4) | PHASE III (weeks 4 to 8) |
|---|---|---|
|
|
|
Management of Pain and Swelling
- •
Icing and electrical stimulation can be used to control pain complaints.
- •
Some athletes report improvement in pain with use of a compressive sleeve worn over the leg, although there is no evidence to support or refute use of this approach.
Techniques for Progressive Increase in Range of Motion
If the athlete shows impairments of range of motion (ROM) at the ankle, the clinician needs to identify if the limitation is a result of muscle length, joint limitation, or both. The appropriate intervention would be selected based on that differential.
Manual Therapy Techniques
- •
If joint ROM limitations, joint mobilization should be applied appropriately in terms of grade and direction.
Soft Tissue Techniques
- •
The muscles that have been named as potential contributors to medial tibial stress syndromes (MTSS) include soleus, posterior tibialis, flexor digitorum longus, and flexor hallices longus.
- •
Newsham demonstrated a decrease in MTSS pain using manual techniques to reduce hypertonicity in the deep posterior compartment of the leg.
- •
Callison presented evidence that the addition of acupuncture to a standard rehabilitation program for medial tibial stress syndrome significantly decreased pain and medication use.
Stretching and Flexibility Techniques for the Musculotendinous Unit
- •
Gastrocnemius and soleus stretching as indicated by muscle length testing
Other Therapeutic Exercises
- •
Relative rest from the offending weight-bearing activities is important in Phase I. Decrease the volume of impact weight-bearing exercise by at least 50%.
- •
Add low-impact cross-training (pool running, cycling, elliptical machine) to maintain cardiorespiratory fitness.
Activation of Primary Muscles Involved
- •
Newsham recommended restoring muscle balance of the toe flexors and extensors using exercise to facilitate toe extension and short foot exercises to improve the strength of the foot intrinsics. If other muscle weakness of the crural muscles was identified in the initial examination, this should be addressed.
Sensorimotor Exercises
- •
No evidence to support this for MTSS, but if the athlete’s ground-based training is altered because of leg pain, these exercises can minimize loss of sensorimotor performance. Begin with static balance exercises such as single leg stand on floor with eyes open and progress to less stable surface and eyes closed.
Open and Closed Kinetic Chain Exercises
- •
Avoid any impact loading that is painful. If the athlete can perform closed kinetic chain exercises without leg pain, then these should not be restricted.
Techniques to Increase Muscle Strength, Power, and Endurance
- •
Niemuth identified hip abductor muscle weakness in a group of recreational runners with lower limb overuse injuries.
- •
Address any muscle imbalances in the lower kinetic chain. This should be based on careful manual muscle testing and observational gait analysis.
Milestones for Progression to the Next Phase
- •
Pain-free walking ambulation
- •
Minimal pain to palpation along posteromedial tibial crest
Phase II (weeks 3 to 4): Rehabilitation Phase
Orthotics
- •
Consideration should be given for orthotic fabrication based on lower extremity movement patterns and function.
- •
Some evidence suggests that an excessively pronated foot may increase the risk for MTSS.
- •
Other evidence suggests both over the counter and custom foot orthotics decrease pain in athletes with MTSS.
- •
Orthotic decision making is based on athlete preference, foot type, sport activity, and arch taping trial.
Management of Pain and Swelling
- •
Icing after exercise
Techniques for Progressive Increase in Range of Motion
Manual Therapy Techniques
- •
Same as described in Phase I, but progressing to more aggressive joint techniques if ROM impairment persists.
Soft Tissue Techniques
- •
Same as described in Phase I.
Stretching and Flexibility Techniques for the Musculotendinous Unit
- •
Same as described in Phase I.
Sensorimotor Exercises
- •
Progress athlete to higher demand static balance exercise including single leg stand on unstable surface with upper extremity challenges including diagonal movements, resisted upper extremity exercise, Bodyblade, and rebounder.
Open and Closed Kinetic Chain Exercises
- •
Progress resistance from Phase I and add multiplanar closed chain movements in Phase II, including multidirectional lunges, lunge with trunk rotation, squats with upper extremity diagonal patterns.
Techniques to Increase Muscle Strength, Power, and Endurance
- •
Adjust exercise dosage appropriate to functional demand of impaired muscles.
Plyometrics
- •
If athlete is pain free with all ground based exercises, begin early plyometric training with mini-trampoline double leg hops, double leg drop squats, and double leg decline squats. These exercises must be pain free and performed no more than 3 times/week on alternate days.
Functional Exercises
- •
Begin progression to return to running progression with a walk-jog-run progression. See sample progression in Box 36-1 .
Box 36-1
Walk-Jog-Run Progression
Rules of Progression:
- •
Stretching: gastroc, soleus, hamstring, quad, IT band before and after run (2 × 30 seconds each).
- •
If you have pain during run, slow to a brisk walk and complete the workout time. Do not proceed to the next step until you are able to perform that level without pain.
- •
Cross-training options: pool running, elliptical trainer, stationary cycling, swimming
- •
Minor shin soreness after running may occur but should dissipate within 1 to 2 hours. If not, do not progress to the next step!
- •
Perform weeks 1 to 2 on a treadmill, and then progress to overground exercise.
- •
Do not run through pain!
1 DAY
DISTANCE/MODE
INTENSITY
2 TIME
COMPLETED
1
Walk 3 min
Jog 2 min
Walk 3 min
Jog 3 min
Retro Walk 3 min
4.0 MPH
6.0 MPH
4.0 MPH
6.2 MPH
2.7 MPH
14 min
2
X-Train
3
Walk 2 min
Jog 3 min
Walk 4 min
Jog 3 min
Retro Walk 3 min
4.0 MPH
6.2 MPH
4.0 MPH
6.2 MPH
2.8 MPH
15 min
4
X-Train
5
Walk 2 min
Jog 3 min
Walk 3 min
Jog 4 min
Retro Walk 3 min
4.0 MPH
6.2 MPH
4.0 MPH
6.4 MPH
2.8 MPH
15 min
6
X-Train
7
Day Off
8
Walk 2 min
Jog 4 min
Walk 2 min
Jog 5 min
Retro Walk 3 min
4.0 MPH
6.2 MPH
4.0 MPH
6.4 MPH
2.8 MPH
16 min
9
X-Train
10
Walk 2 min
Jog 5 min
Walk 2 min
Jog 5 min
Retro Walk 3 min
4.0 MPH
6.4 MPH
4.0 MPH
6.7 MPH
2.8 MPH
17 min
11
X-Train
12
Walk 2 min
Jog 6 min
Walk 2 min
Jog 6 min
Retro Walk 3 min
4.0 MPH
6.4 MPH
4.0 MPH
6.7 MPH
2.8 MPH
19 min
13
X-Train
14
Day off
15
Jog 8 min
Walk 3 min
Jog 8 min
6.5 MPH
4.0 MPH
7.0 MPH
19 min
16
X-Train
17
Jog 10 min
Walk 2 min
Run 1 min
Jog 8 min
6.5 MPH
4.2 MPH
8.0 MPH
7.0 MPH
21 min
18
X-Train
19
Jog 12 min
Walk 2 min
Run 2 min
Jog 8 min
6.5 MPH
4.2 MPH
8.5 MPH
7.0 MPH
24 min
20
X-Train
21
Day Off
22
Jog 10 min
Run 5 min
Jog 10 min
6.5 MPH
8.5 MPH
7.0 MPH
25 min
23
X-Train
24
Jog 10 min
Run 7 min
Jog 10 min
6.5 MPH
8.5 MPH
7.0 MPH
27 min
25
X-Train
26
Jog 8 min
Run 5 min
Jog 8 min
Run 5 min
Jog 4 min
6.5 MPH
8.0 MPH
7.0 MPH
8.5–9.0 MPH
6.5 MPH
30 min
27
X-Train
28
Day Off
Week 5: Run on consecutive days; gradually increase mileage.
Week 6: Resume full training as long as pain free.
- •
- •
An athlete who has mild tenderness to palpation and symptoms that do not worsen with weight-bearing exercise can progress training as tolerated.
Criteria for Abandoning Nonoperative Treatment and Proceeding to Surgery or Other More Invasive Intervention
- •
Positive compartmental pressure study: Athletes who show persistence of leg pain with weight-bearing activities and inability to progress through return to running progression should be tested for chronic exertional compartment syndrome.
Milestones for Progression to the Next Phase
- •
No pain with palpation along posteromedial tibial crest
- •
Minimal to no pain with early plyometrics and walk-jog-run progression. An athlete who is doing most training in the pool may be allowed to return to competition but continue with functional progression during training time.
Phase III (weeks 4 to 8): Functional Training Phase
Management of Pain and Swelling
- •
Icing after running
Sensorimotor Exercises
- •
Progress athlete to dynamic balance activities using BOSU ball, slide board, balance beam.
Open and Closed Kinetic Chain Exercises
- •
Progress the challenge, intensity and speed of the multiplanar closed chain exercises introduced in Phase II.
Plyometrics
- •
Progress to higher level plyometric exercises including ankle hops on floor (double to single leg), depth jumps, box jumps, squat jumps, tuck jumps, and bounding.
Functional Exercises
- •
Continue with walk-jog-run progression.
Milestones for Progression to Advanced Sport-Specific Training and Conditioning
- •
Completion of functional progression
- •
Performance of all plyometric exercises without tibial pain
Criteria for Abandoning Nonoperative Treatment and Proceeding to Surgery or Other More Invasive Intervention
- •
Persistence of pain with weight-bearing activities
- •
Inability to complete functional progression to running secondary to pain
Specific Criteria for Return to Sports Participation: Tests and Measurements
- •
Pain-free running on successive days
- •
No pain with palpation along the posteromedial tibial border (MTSS)
Evidence
Multiple Choice Questions
- QUESTION 1.
Which of the following muscles has not been implicated in the etiology of medial tibial stress syndrome?
- A.
Soleus
- B.
Posterior tibialis
- C.
Flexor hallicus longus
- D.
Anterior tibialis
- A.
- QUESTION 2.
Early plyometric exercises such as ankle bounces on a mini-trampoline should be introduced in which rehabilitation Phase?
- A.
I
- B.
II
- C.
III
- D.
IV
- A.
- QUESTION 3.
When an athlete has persistent medial leg pain that is not responding to nonsurgical intervention, the most appropriate action is which of the following?
- A.
Casting of the foot and ankle
- B.
Continue with functional return to running progression
- C.
Compartmental pressure testing
- D.
Nerve conduction velocity testing
- A.
Answer Key
- QUESTION 1.
Correct answer: D (see Phase I )
- QUESTION 2.
Correct answer: B (See Phase II )
- QUESTION 3.
Correct answer: C (see Phase II )
Nonoperative Rehabilitation of Tibial Stress Fracture
- Mark F. Reinking, PT, PhD, SCS, ATC
- L. Tyler Wadsworth, MD
- •
Determine whether the stress fracture is at a high- or low-risk location.
- •
Allow adequate protection and time for clinical healing (and radiographic healing as indicated).
- •
Let the athlete’s leg pain guide the return to activity.
- •
Gradual return to athletic activity.
Phase I (weeks 0 to 2–6): Acute Phase
Protection
- •
In the leg, the tibial plateau, proximal posteromedial tibia, medial distal tibial diaphysis, and fibular stress fractures are considered low risk.
- •
Stress fractures of the anterior mid-tibia and medial malleolus have a high risk of nonunion, recurrence, and fracture completion.
- •
For high-risk stress fractures of the anterior mid-tibia and medial malleolus, immobilization and non–weight bearing are required and some athletes may require surgical treatment.
- •
Low-risk stress fractures have a low potential for nonunion or fracture completion, or other complication. Athletes with low-risk stress fractures may be allowed to continue limited participation if they are willing to accept the risk of prolonged symptoms and fracture extension or progression to complete fracture.
- •
If the athlete with a low-risk stress fracture has tibial pain with ambulation, crutches with or without fracture brace should be used until the athlete can walk without any increase in pain or discomfort. A pneumatic air brace is used for athletes who tolerate weightbearing without increase in discomfort and has been shown to reduce time to unrestricted activity in low-risk stress fractures.
- •
Underlying causes for stress fracture should be elicited, including rapid increases in training volume and/or intensity, history of menstrual irregularity in female athletes, nutritional inadequacy (especially the intake of total calories and calcium), condition and type of running shoes.
- •
Documented risk factors for recurrent stress fractures include high longitudinal arch of the foot, leg-length inequality, excessive forefoot varus, and high weekly training mileage.
- •
Consideration should be given to testing vitamin D levels, as low vitamin levels have been linked to an increased risk for stress fracture. Treatment of nutritional inadequacies is important but there is no evidence that routine treatment with calcium or vitamin D in individuals who are not deficient accelerates stress fracture healing.
| PHASE I (weeks 1 to 2) | PHASE II (weeks 3 to 4) | PHASE III (weeks 4 to 8) |
|---|---|---|
|
|
|
Management of Pain and Swelling
- •
Icing and electrical stimulation can be used to control pain complaints.
- •
Analgesics should not be used to allow weight-bearing activity, but patients who have pain can be treated with analgesics. Although there is some concern regarding potential interference of bone healing caused by nonsteroidal antiinflammatory drugs (NSAIDs), there is no evidence to date to support or disprove this theory.
- •
There are no controlled trials of electromagnetic field or ultrasonic bone stimulation in treatment of low-risk stress fractures showing improvement in healing rates when these technologies are used. However, treatment of stress fractures of the anterior mid-tibia with pulsed electromagnetic fields is widely employed despite limited evidence specific to stress fracture.
Techniques for Progressive Increase in Range of Motion
Only activities that do not cause pain progression are allowed during this stage for low-risk stress fractures, and no pain is permitted in high-risk stress fractures. If the athlete shows impairments of ROM at the ankle, the clinician needs to identify if the limitation is a result of muscle length, joint limitation, or both. The appropriate intervention would be selected based on that differential
Manual Therapy Techniques
- •
If joint ROM limitations, joint mobilization should be applied appropriately in terms of grade and direction.
Soft Tissue Techniques
- •
Address co-existing soft tissue comorbidities including medial tibial stress syndromes (MTSS) and myofascial trigger points.
Stretching and Flexibility Techniques for the Musculotendinous Unit
- •
Gastrocnemius and soleus stretching as indicated by muscle length testing.
Other Therapeutic Exercises
- •
Relative rest from any painful weight-bearing activities is important in Phase I.
- •
Pool running can be employed to maintain cardiorespiratory fitness if this can be done without exacerbating the athlete’s pain.
Activation of Primary Muscles Involved
- •
Non–weight-bearing, pain-free range of motion exercises of the hip, knee, ankle, and foot can be performed daily to preserve joint range of motion and soft-tissue length.
Sensorimotor Exercises
Begin with static balance exercises such as single leg stand on floor with eyes open and progress to eyes closed when athlete can maintain balance for 20 to 30 seconds. Athlete should then be progressed to less stable surfaces (foam, BOSU Ball, DynaDisc), first with eyes open and then with eyes closed.
Open and Closed Kinetic Chain Exercises
- •
Only pain-free closed kinetic chain exercises are allowed in Phase I. Open kinetic chain exercises targeted at muscle weakness identified in the initial examination is permitted unless painful at the fracture location. No impact loading exercises are allowed in this Phase.
Techniques to Increase Muscle Strength, Power, and Endurance
- •
Niemuth identified hip abductor muscle weakness in a group of recreational runners with lower limb overuse injuries. Address any muscle imbalances in the lower kinetic chain that can be treated without exacerbating stress fracture pain. This should be based on careful manual muscle testing and observational gait analysis.
Milestones for Progression to the Next Phase
- •
Pain-free walking ambulation
- •
No tenderness to palpation or percussion, negative provocative maneuvers (hop test, pain on tuning fork examination, pain with fulcrum testing) is allowed for high-risk stress fractures on physical examination.
Phase II (weeks 2 to 12): Rehabilitative Phase
Protection
- •
Pneumatic air brace for weight-bearing activities as needed.
- •
Only activities that do not worsen pain are allowed.
Orthotics
- •
Consideration should be given for orthotic fabrication based on lower extremity movement patterns and function.
- •
There is no evidence that over-the-counter or custom foot orthotics are useful in secondary prevention of stress fracture in athletes, although there is a high degree of acceptance and satisfaction among runners who use orthotics.
Management of Pain and Swelling
- •
Care should be taken not to allow exercise progression through pain with stress fracture.
Techniques for Progressive Increase in Range of Motion
Manual Therapy Techniques
- •
Same as described in Phase I but progressing to more aggressive joint techniques if ROM impairment persists.
Soft Tissue Techniques
- •
Same as described in Phase I.
Stretching and Flexibility Techniques for the Musculotendinous Unit
- •
Same as described in Phase I.
Sensorimotor Exercises
- •
Begin with static balance exercises such as single leg stand on floor with eyes open and progress to less stable surface and eyes closed.
- •
Progress athlete to higher demand static balance exercise, including single leg stand on unstable surface with upper extremity challenges, including diagonal upper body movements, resisted upper extremity exercise, BodyBlade, and elastic rebounder.
Open and Closed Kinetic Chain Exercises
- •
Avoid any impact loading that is painful. If the athlete can perform closed kinetic chain exercises without leg pain, then these should not be restricted.
- •
Add multiplanar closed chain movements in Phase II, including multidirectional lunges, lunge with trunk rotation, squats with upper extremity diagonal patterns.
Techniques to Increase Muscle Strength, Power, and Endurance
- •
Niemuth identified hip abductor muscle weakness in a group of recreational runners with lower limb overuse injuries.
- •
Address any muscle imbalances in the lower kinetic chain. This should be based on careful manual muscle testing and observational gait analysis.
Plyometrics
- •
May introduce if athlete is pain free with all ground based exercises. Begin early plyometric training (no evidence for plyometrics in treatment of stress fracture) with mini-trampoline double leg hops, double leg drop squats, and double leg decline squats. These exercises must be pain free and performed no more than three times/week on alternate days.
Functional Exercises
- •
Begin transition to land running with a walk-jog-run progression.
- •
Generally the athlete resumes running or weight-bearing training at no more than 50% of the volume that he or she was doing at the time of injury onset, although this recommendation is based on expert opinion rather than controlled trials.
- •
Weight-bearing activities should be limited to an exposure that does not increase symptoms.
- •
It is commonly recommended to increase weekly weight-bearing exposure by approximately 10% per week, although this rate of progression has not been tested in clinical trials.
- •
It is important that weight-bearing training be reduced or deferred if symptoms increase.
Milestones for Progression to the Next Phase
- •
Pain-free early plyometrics and walk-jog-run progression
- •
No tenderness to palpation or percussion, negative provocative maneuvers (hop test, pain on tuning fork examination, pain with fulcrum testing) on physical examination is allowed for high-risk stress fractures.
Phase III (weeks 4 to 16 or longer): Functional Training Phase
Protection
- •
Pneumatic air brace for weightbearing activities as needed until pain free with all activities for 1 to 2 weeks.
Management of Pain and Swelling
- •
Care should be taken not to allow activity progression to worsen pain with stress fracture.
Sensorimotor Exercises
- •
Progress athlete to dynamic balance activities (whole body movement) using jumping/hopping to and from BOSU ball, slide board movements, balance beam exercise.
Open and Closed Kinetic Chain Exercises
- •
Progress the challenge, intensity and speed of the multiplanar closed chain exercises introduced in Phase II.
Plyometrics
- •
Progress to higher level plyometric exercises including ankle hops on floor (double to single leg), depth jumps, box jumps, squat jumps, tuck jumps, and bounding.
Functional Exercises
- •
Continue with walk-jog-run progression
Milestones for Progression to Advanced Sport-Specific Training and Conditioning
- •
Completion of functional progression
- •
Performance of all plyometric exercises without tibial pain
Criteria for Abandoning Nonoperative Treatment and Proceeding to Surgery or More Intensive Intervention
- •
Anterior mid-tibia and medial malleolus stress fracture not responding to nonsurgical care or showing signs of non-union. In high-performance and elite athletes, early surgical treatment should be considered because this may lead to a more rapid return to competition and a lower risk for recurrence.
- •
Assess compliance in athletes who remain symptomatic from low-risk stress fractures beyond 8 to 12 weeks of treatment. Consider evaluation or re-evaluation for nutritional insufficiencies and other causes of osteopenia.
Specific Criteria for Return to Sports Participation: Tests and Measurements
- •
Pain-free running on successive days
- •
Athletes with low-risk stress fractures may be allowed to participate if they have full range of motion, full strength, and can perform the demands of their sport without gait changes.
- •
No tenderness to palpation or percussion, negative provocative maneuvers (hop test, pain on tuning fork examination, pain with fulcrum testing) on physical examination is allowed for high-risk stress fractures.
Evidence
Multiple Choice Questions
- QUESTION 1.
Which of the following features is not characteristic of a high-risk stress fracture?
- A.
High risk of fracture recurrence
- B.
High degree of pain
- C.
High risk of nonunion
- D.
High risk of fracture completion
- A.
- QUESTION 2.
Which intervention has been shown to decrease time to return to play for athletes with tibial stress fracture?
- A.
Vitamin D supplementation
- B.
Calcium supplementation
- C.
Pneumatic leg brace
- D.
High-dose nonsteroidal antiinflammatory drugs
- A.
- QUESTION 3.
Which of the following is not a risk factor for tibial stress fracture?
- A.
Leg-length inequality
- B.
Running on asphalt
- C.
Rapid training progression
- D.
Athletic menorrhea
- A.
- QUESTION 4.
Which of the following activities is not appropriate for Phase I rehabilitation?
- A.
Plyometrics
- B.
Hip abductor strengthening
- C.
Stretching exercises for the gastrocnemius and soleus
- D.
Pool running that does not exacerbate pain
- A.
Answer Key
- QUESTION 1.
Correct answer: B (see Phase I )
- QUESTION 2.
Correct answer: C (see Phase I )
- QUESTION 3.
Correct answer: C (see Phase I )
- QUESTION 4.
Correct answer: A (see Phase I )
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