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Copyright ©The Author(s) 2017. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Orthop. Mar 18, 2017; 8(3): 242-255
Published online Mar 18, 2017. doi: 10.5312/wjo.v8.i3.242
Lower limb stress fractures in sport: Optimising their management and outcome
Greg A J Robertson, Alexander M Wood
Greg A J Robertson, Edinburgh Orthopaedic Trauma Unit, Royal Infirmary of Edinburgh, Edinburgh, Scotland EH16 4SA, United Kingdom
Alexander M Wood, Department of Orthopaedic, Leeds General Infirmary, Leeds LS1 3EX, United Kingdom
Author contributions: Robertson GAJ and Wood AM conceived the issues which formed the content of the manuscript and wrote the manuscript.
Conflict-of-interest statement: The authors declare no conflicts of interest regarding this manuscript.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Correspondence to: Greg A J Robertson, MBChB, BMedSci (Hons), MSc, MRCSEd, Edinburgh Orthopaedic Trauma Unit, Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh, Scotland EH16 4SA, United Kingdom. greg_robertson@live.co.uk
Telephone: +44-131-2423545 Fax: +44-131-2423541
Received: August 29, 2016
Peer-review started: September 1, 2016
First decision: September 29, 2016
Revised: November 24, 2016
Accepted: December 16, 2016
Article in press: December 18, 2016
Published online: March 18, 2017
Processing time: 200 Days and 2.9 Hours
Abstract

Stress fractures in sport are becoming increasing more common, comprising up to 10% of all of sporting injuries. Around 90% of such injuries are located in the lower limb. This articles aims to define the optimal management of lower limb stress fractures in the athlete, with a view to maximise return rates and minimise return times to sport. Treatment planning of this condition is specific to the location of the injury. However, there remains a clear division of stress fractures by “high” and “low” risk. “Low risk” stress fractures are those with a low probability of fracture propagation, delayed union, or non-union, and so can be managed reliably with rest and exercise limitation. These include stress fractures of the Postero-Medial Tibial Diaphysis, Metatarsal Shafts, Distal Fibula, Medial Femoral Neck, Femoral Shaft and Calcaneus. “High risk” stress fractures, in contrast, have increased rates of fracture propagation, displacement, delayed and non-union, and so require immediate cessation of activity, with orthopaedic referral, to assess the need for surgical intervention. These include stress fractures of the Anterior Tibial Diaphysis, Fifth Metatarsal Base, Medial Malleolus, Lateral Femoral Neck, Tarsal Navicular and Great Toe Sesamoids. In order to establish the optimal methods for managing these injuries, we present and review the current evidence which guides the treatment of stress fractures in athletes. From this, we note an increased role for surgical management of certain high risk stress fractures to improve return times and rates to sport. Following this, key recommendations are provided for the management of the common stress fracture types seen in the athlete. Five case reports are also presented to illustrate the application of sport-focussed lower limb stress fracture treatment in the clinical setting.

Keywords: Fractures; Lower; Limb; Sport; Management; Stress

Core tip: This editorial article offers a current perspective on the treatment of lower limb stress fractures in the athlete. The authors focus on the most common “high risk” (Anterior Tibial Diaphysis, Fifth Metatarsal Base, Medial Malleolus, Lateral Femoral Neck, Tarsal Navicular, Great Toe Sesamoid) and “low risk” stress fractures (Postero-Medial Tibial Diaphysis, Metatarsal Shafts, Distal Fibula, Medial Femoral Neck, Femoral Shaft, Calcaneus), highlighting the optimal treatment methods for each, and assessing the most recent evidence which directs this. The value of preventative interventions is also discussed. Finally, five case reports are presented to demonstrate the evidence-based treatment process in clinical practice.