Improving the Management of Tibia Stress Fractures

Roberts, Cindy L.; Meyering, Christopher; Zychowicz, Michael E.

doi:10.1097/nor.0000000000000032

Cited by 4 publications

(2 citation statements)

References 17 publications

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“…The epidemiology and clinical challenges associated with bone stress injuries in military training indicated the need for an updated algorithm to improve the timeliness and accuracy of diagnosis and treatment. Many existing algorithms for evaluation 23 , 24 , 32 and treatment 13 of stress fractures do not contain clinical prediction rules and/or rely primarily on bone scan. Of note, a recently published algorithm by Wright et al 32 is useful for the selection of proper imaging modalities but neither does it offer guidance on a threshold for beginning a diagnostic workup nor does it guide initial treatment steps.…”

Section: New Diagnostic Algorithmmentioning

confidence: 99%

Improving Diagnostic Accuracy and Efficiency of Suspected Bone Stress Injuries

et al. 2016

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Context:Lower extremity stress fractures among athletes and military recruits cause significant morbidity, fiscal costs, and time lost from sport or training. During fiscal years (FY) 2012 to 2014, 1218 US Air Force trainees at Joint Base San Antonio–Lackland, Texas, were diagnosed with stress fracture(s). Diagnosis relied heavily on bone scans, often very early in clinical course and often in preference to magnetic resonance imaging (MRI), highlighting the need for an evidence-based algorithm for stress injury diagnosis and initial management.Evidence Acquisition:To guide creation of an evidence-based algorithm, a literature review was conducted followed by analysis of local data. Relevant articles published between 1995 and 2015 were identified and reviewed on PubMed using search terms stress fracture, stress injury, stress fracture imaging, and stress fracture treatment. Subsequently, charts were reviewed for all Air Force trainees diagnosed with 1 or more stress injury in their outpatient medical record in FY 2014.Study Design:Clinical review.Level of Evidence:Level 4.Results:In FY 2014, 414 trainees received a bone scan and an eventual diagnosis of stress fracture. Of these scans, 66.4% demonstrated a stress fracture in the symptomatic location only, 21.0% revealed stress fractures in both symptomatic and asymptomatic locations, and 5.8% were negative in the symptomatic location but did reveal stress fracture(s) in asymptomatic locations. Twenty-one percent (18/85) of MRIs performed a mean 6 days (range, 0- 21 days) after a positive bone scan did not demonstrate any stress fracture.Conclusion:Bone stress injuries in military training environments are common, costly, and challenging to diagnose. MRI should be the imaging study of choice, after plain radiography, in those individuals meeting criteria for further workup.

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Section: New Diagnostic Algorithmmentioning

confidence: 99%

Improving Diagnostic Accuracy and Efficiency of Suspected Bone Stress Injuries

et al. 2016

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“…Most studies on TBSIs have focused on clinical outcomes (13,19,20) and do not examine the mechanical loading environment of bone when wearing a walking boot. Findings from studies focused on the biomechanics of walking boots found that they provide a reduction in forefoot pressure, but conflicting evidence suggest they moderately reduce or increase heel pressure (21)(22)(23)(24).…”

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confidence: 99%

A Dynamic Ankle Orthosis Reduces Tibial Compressive Force and Increases Ankle Motion Compared With a Walking Boot

Johnson

Paquette

DiAngelo

2023

Medicine &Amp; Science in Sports &Amp; Exercise

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Purpose: Tibial bone stress injuries are a common overuse injury among runners and military cadets. Current treatment involves wearing an orthopedic walking boot for 3 to 12 wk, which limits ankle motion and leads to lower limb muscle atrophy. A dynamic ankle orthosis (DAO) was designed to provide a distractive force that offloads in-shoe vertical force and retains sagittal ankle motion during walking. It remains unclear how tibial compressive force is altered by the DAO. This study compared tibial compressive force and ankle motion during walking between the DAO and an orthopedic walking boot. Methods: Twenty young adults walked on an instrumented treadmill at 1.0 m•s −1 in two brace conditions: DAO and walking boot. Three-dimensional kinematic, ground reaction forces, and in-shoe vertical force data were collected to calculate peak tibial compressive force. Paired t-tests and Cohen's d effect sizes were used to assess mean differences between conditions. Results: Peak tibial compressive force (P = 0.023; d = 0.5) and Achilles tendon force (P = 0.017; d = 0.5) were moderately lower in the DAO compared with the walking boot. Sagittal ankle excursion was 54.9% greater in the DAO compared with the walking boot (P = 0.05; d = 3.1). Conclusions: The findings from this study indicated that the DAO moderately reduced tibial compressive force and Achilles tendon force and allowed more sagittal ankle excursion during treadmill walking compared with an orthopedic walking boot.

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Evaluating an Algorithm and Clinical Prediction Rule for Diagnosis of Bone Stress Injuries

Nye

Covey

Pawlak³

et al. 2020

Sports Health

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Background: A novel algorithm and clinical prediction rule (CPR), with 18 variables, was created in 2014. The CPR generated a bone stress injury (BSI) score, which was used to determine the necessity of imaging in suspected BSI. To date, there are no validated algorithms for imaging selection in patients with suspected BSI. Hypothesis: A simplified CPR will assist clinicians with diagnosis and decision making in patients with suspected BSI. Study Design: Prospective cohort study. Level of Evidence: Level 3. Methods: A total of 778 military trainees with lower extremity pain were enrolled. All trainees were evaluated for 18 clinical variables suggesting BSI. Participants were monitored via electronic medical record review. Then, a prediction model was developed using logistic regression to identify clinical variables with the greatest predictive value and assigned appropriate weight. Test characteristics for various BSI score thresholds were calculated. Results: Of the enrolled trainees, 204 had imaging-confirmed BSI in or distal to the femoral condyles. The optimized CPR selected 4 clinical variables (weighted score): bony tenderness (3), prior history of BSI (2), pes cavus (2), and increased walking/running volume (1). The optimized CPR with a score ≥3 yielded 97.5% sensitivity, 54.2% specificity, and 98.2% negative predictive value. An isolated measure, bony tenderness, demonstrated similar statistical performance. Conclusion: The optimized CPR, which uses bony tenderness, prior history of BSI, pes cavus, and increased walking/running volume, is valid for detecting BSI in or distal to the femoral condyles. However, bony tenderness alone provides a simpler criterion with an equally strong negative predictive value for BSI decision making. Clinical Relevance: For suspected BSI in or distal to the femoral condyles, imaging can be deferred when there is no bony tenderness. When bony tenderness is present in the setting of 1 or more proven risk factors and no clinical evidence of high-risk bone involvement, presumptive treatment for BSI and serial radiographs may be appropriate.

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Improving the Management of Tibia Stress Fractures

Abstract: The LPS&RT was an effective, uniform measure to standardize the plan of care for tibia stress fractures in one outpatient clinic.

Cited by 4 publications

References 17 publications

Improving Diagnostic Accuracy and Efficiency of Suspected Bone Stress Injuries

Improving Diagnostic Accuracy and Efficiency of Suspected Bone Stress Injuries

A Dynamic Ankle Orthosis Reduces Tibial Compressive Force and Increases Ankle Motion Compared With a Walking Boot

Evaluating an Algorithm and Clinical Prediction Rule for Diagnosis of Bone Stress Injuries

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