Stress fractures in MARKO
PEĆINA,* MD, PhD,
From the
figure skaters IVAN
BOJANIĆ, MD,
in the Tatra Mountains and the Gold Pirouette in Zagrebtotal of 42 world class skaters were asked through a questionnaire if they had ever in their career suffered from a stress fracture. Of the 42 skaters, nine had stress fractures. A detailed interview and analysis of medical records provided data about stress fractures in six skaters (interviews and analyses carried out by one of the authors-SD), and the remaining three skaters were treated at the Department of Orthopaedic Surgery at the University of Zagreb.
relatively
common
injuries
RESULTS Four of the nine skaters with positive stress fracture history males and five were females (Table 1). The mean age at the time of injury was 22.1 years (range, 17 to 27 years). All of the subjects were competitive figure skaters with a daily training period of 3 to 8 hours, six times a week. The initial symptoms occurred from 6 to 15 years after the beginning of intensive training. The time span from the onset of symptoms to definite diagnosis ranged from 2 to 10 weeks. Four stress fractures occurred during preseason training. The history obtained from these skaters showed that there had been changes in their running routine before the fracture occurred. Increased mileage was reported by three skaters; one had done too much speed training on hills. Five stress fractures occurred during the season. In all cases, fracture was in the take-off leg. In one skater, the stress fracture of the anterior cortex in the middle third of the tibia was associated with a sudden increase in jumping exercise. Two skaters with tarsal navicular stress fracture (Figs. 1 and 2) reported that before the initial symptoms began they had practiced intensive jumping training, especially involving jumps performed on the inner edge of the skate (Salchow). Two skaters with Jones’ fractures (stress fracture of the base of the fifth metatarsal bone) complained of aching discomfort in the lateral aspect of the foot for several weeks before seeking medical attention. Although in both cases the take-off leg was affected, the connection between the jumps and Jones’ fracture was not detected. were
among ath-
letes, comprising about 5% of all sports injuries.3, 7, 12 Running causes the great majority of stress fractures, although practically any sports event can be a cause. 7, 11, 12, 17, 18 The purpose of this report is to present more information about stress fractures in
figure skaters.
MATERIALS AND METHODS In 1987,
MD
a
In 1987, during two great skating contests—the Universiade in the Tatra Mountains and the Gold Pirouette in Zagreb—a total of 42 world class skaters were asked through a questionnaire if they had ever in their career suffered from a stress fracture. Of the 42 skaters, 9 had stress fractures. Four stress fractures occurred during preseason training (two fibular, one second metatarsal, and two fourth metatarsal stress fractures). Increased mileage was reported by three skaters and the fourth had done too much speed training on hills. Five stress fractures occurred during the season (one tibial and two tarsal navicular stress fractures and two stress fractures of the base of the fifth metatarsal). In all cases, the fracture occurred in the take-off leg. All of the subjects were competitive figure skaters with a daily training period of 3 to 8 hours, six times a week. The time from the onset of symptoms to definite diagnosis ranged from 2 to 10 weeks. Of the nine injured skaters, eight were treated conservatively and one skater with Jones’ fracture was treated surgically. All of the skaters were able to resume a preinjury level of activity 3 to 7 months after treatment began. In conclusion, it may be emphasized that stress fractures in figure skaters are not rare and should, therefore, always be considered as a possibility.
are
DUBRAVČIĆ,
Department of Orthopaedic Surgery, School of Medicine, University of Zagreb, Zagreb, Yugoslavia
ABSTRACT
Stress fractures
AND SANDA
during two great skating contests-the Universiade
*
Address correspondence and repnnt requests to’ Marko Pecina, MD, PhD, Department of Orthopaedic Surgery, Salata 6, 41000 Zagreb, Yugoslama.
277
278
TABLE 1 Patient data
a
No
weightbearing.
Figure 1. Case 6. Bone scan shows markedly increased uptake in area of tarsal navicular bone and confirms diagnosis. Of the nine skaters with stress fractures, eight were treated conservatively. Rest from the activity-causing symptoms was the only mode of treatment in six cases. The patients with tarsal navicular stress fracture (Case 7) and Jones’ fracture (Case 9) were treated with immobilization in a short-leg cast with no weightbearing allowed. Because of the changes visible in the initial roentgenogram (Fig. 3A), the skater with Jones’ fracture (Case 8) was surgically treated. All of the skaters were able to resume a preinjury level of activity 3 to 7 months after the initial treatment. At followup
Figure 2. Case 7. Tomograms made 1 month after the onset of symptoms show a stress fracture of the tarsal navicular. A deeper section did not show the fracture line, which indicates that fracture was limited to the dorsal aspect of the bone.
(average followup, 23 months; range, 9 to 72 months) patients were asymptomatic, even though they were engaged in top level competing activities.
thors.~~ 5>’°
DISCUSSION
agent leading to stress fractures. The fracture site
The external and internal predisposing factors to stress fractures have been variably emphasized by different au-
12, 18
The data obtained in
our investigation indioccurring in preseason training activities significantly correlate to running and also that training errors appear to be the most important causative
cate that stress fractures
sponds to
corre-
the site distribution of stress fractures described
in runners.7,ll, 17, 18
279
variations have caused the stresses, especially the shear stress, to be concentrated on the tarsal navicular bone as a result of greater force being transmitted through the second metatarsal and the intermediate cuneiform bones. The force would be increased in an excessively pronated foot, which has actually been the case with skaters who performed intensive jumping exercises on the inner edge of the skate. Previous reports have indicated potential difficulties in the treatment of Jones’ fractures. These include prolonged immobilization, high propensity for delayed union and non-
union, and refracture.2, 3, 9, 13, 19 Only recently Torg
et
aI.l9
have noticed and reported a correlation between roentgenographic manifestations of these fractures and their response to specific methods of treatment. Torg et aI.,19 Lehman et all and Pecina et a1,l5 have all developed classifications of these fractures and treatment plans based upon roentgenographic criteria. According to their reports, patients should be surgically treated upon initial signs of intramedullary sclerosis. Surgery helps speed fracture union and returns an athlete to his or her regular athletic activities in a short period of time, as was the case in our surgically treated patient. In conclusion, it may be emphasized that stress fractures in figure skaters are not rare and should, therefore, always be considered as a possibility in skaters. REFERENCES 1
2 3
Figure 3. Case 8. A, lateral roentgenogram of the foot demonstrating stress fracture of the base of the fifth metatarsal. Note a widened fracture line with an evident sclerosing of its edges. B, 8 weeks after surgical treatment-intramedullary fixation with AO malleolar screw-there is complete healing of the fracture.
4 5. 6 7.
Blank S Transverse tibial stress fractures. A special problem. Am J Sports Med 15 597-602,1987 DeLee JC, Evans JP, Julian J: Stress fracture of the fifth metatarsal Am J Sports Med 11 349-353, 1983 Devas MB: Stress fractures in athletes Proc R Soc Med 62: 933-937, 1969 Fitch KD, Blackwell JB, Gilmour WN. Operation for non-union of stress fracture of the tarsal navicular J Bone Joint Surg 71B: 105-110, 1989 Graff KH, Krahl H, Kirschberger R. Stressfrakturen des Os Naviculare Pedis. Z Orthop 124. 228-237, 1986 Green NE, Rogers RA, Lipscomb AB: Nonunions of stress fractures of the tibia Am J Sports Med 13. 171-176, 1985 Hulkko A, Orava S: Stress fractures in athletes. Int J Sports Med 8. 221-
226, 1987
Stress fractures of the anterior cortex of the midthird of the tibia constitute only a small percentage of all tibial stress fractures. I, 7, 12, 18 Various reports show that these fractures occur most likely as a result of tensile forces associated with
jumping. I, 6, 13, 14, 16 Also,
the reports emphasize two significomplications of treatment: delayed union and complete fracture. In our study, such a fracture resulted from a sudden increase in the number of jumps and a tendency toward introducing triple jumps as part of the competition program. Treatment complications, fortunately, did not occant
cur
in this
case.
to the reports of Torg et al.,20 Graff et al.,5 Hulkko et al.,’ and Fitch et al.,4 tarsal navicular stress fractures occur in explosive athletic activities that involve sprinting, jumping, and hurdling. They have been reported in basketball players, jumpers, sprinters, hurdlers, and middle-distance runners. Previous studies have shown that relatively short first metatarsal or long second metatarsal bones were common findings in patients.2° These anatomical
According
8. Hulkko A, Orava S, Petokallio P, et al. Stress fracture of the navicular bone Acta Orthop Scand 56 503-505, 1985 9. Kavanaugh JH, Brower TD, Mann RV. The Jones fracture revisited. J Bone Joint Surg 60A 776-782, 1978 10 Lehman RC, Torg JS, Pavlov H, et al Fractures of the base of the fifth metatarsal distal to the tuberosity. A review Foot Ankle 7 245-252, 1987 11. Markey KL: Stress fractures Clin Sports Med 6. 402-425, 1987 12. Matheson GO, Clement DB, McKenzie DC, et al: Stress fractures in athletes A study of 320 cases Am J Sports Med 15: 46-58, 1987 13 Orava S, Hulkko A: Delayed unions and nonunions of stress fractures in athletes Am J Sports Med 16 : 378-382, 1988 14 Orava S, Hulkko A. Stress fracture of the mid-tibial shaft Acta Orthop Scand 55. 35-37, 1984 15. Pećina M, Bojanić I, Ribarić G: Stress fracture of the base of the fifth metatarsal—Jones’ fracture. Acta Orthop lugosl 19. 118-123, 1988 16. Rettig AC, Shelbourne KD, McCarroll JR, et al: The natural history and treatment of delayed union stress fractures of the anterior cortex of the tibia Am J Sports Med 16 250-255, 1988 17. Sullivan D, Warren RF, Pavlov H, et al: Stress fractures in 51 runners. Clin : 188-192, 1984 Orthop 187 18 Taunton JE, Clement DB, Webber D Lower extremity stress fractures in athletes Physician Sportsmed 9. 77-86, 1981 19. Torg JS, Balduini FC, Zelko RR, et al: Fractures of the base of the fifth 20.
metatarsal distal to the tuberosity J Bone Joint Surg 66A : 209-214, 1984 Torg JS, Pavlov H, Cooley LH, et al: Stress fractures of the tarsal navicular. J Bone Joint Surg 64A. 700-712, 1982
PEĆINA,* MD, PhD,
From the
figure skaters IVAN
BOJANIĆ, MD,
in the Tatra Mountains and the Gold Pirouette in Zagrebtotal of 42 world class skaters were asked through a questionnaire if they had ever in their career suffered from a stress fracture. Of the 42 skaters, nine had stress fractures. A detailed interview and analysis of medical records provided data about stress fractures in six skaters (interviews and analyses carried out by one of the authors-SD), and the remaining three skaters were treated at the Department of Orthopaedic Surgery at the University of Zagreb.
relatively
common
injuries
RESULTS Four of the nine skaters with positive stress fracture history males and five were females (Table 1). The mean age at the time of injury was 22.1 years (range, 17 to 27 years). All of the subjects were competitive figure skaters with a daily training period of 3 to 8 hours, six times a week. The initial symptoms occurred from 6 to 15 years after the beginning of intensive training. The time span from the onset of symptoms to definite diagnosis ranged from 2 to 10 weeks. Four stress fractures occurred during preseason training. The history obtained from these skaters showed that there had been changes in their running routine before the fracture occurred. Increased mileage was reported by three skaters; one had done too much speed training on hills. Five stress fractures occurred during the season. In all cases, fracture was in the take-off leg. In one skater, the stress fracture of the anterior cortex in the middle third of the tibia was associated with a sudden increase in jumping exercise. Two skaters with tarsal navicular stress fracture (Figs. 1 and 2) reported that before the initial symptoms began they had practiced intensive jumping training, especially involving jumps performed on the inner edge of the skate (Salchow). Two skaters with Jones’ fractures (stress fracture of the base of the fifth metatarsal bone) complained of aching discomfort in the lateral aspect of the foot for several weeks before seeking medical attention. Although in both cases the take-off leg was affected, the connection between the jumps and Jones’ fracture was not detected. were
among ath-
letes, comprising about 5% of all sports injuries.3, 7, 12 Running causes the great majority of stress fractures, although practically any sports event can be a cause. 7, 11, 12, 17, 18 The purpose of this report is to present more information about stress fractures in
figure skaters.
MATERIALS AND METHODS In 1987,
MD
a
In 1987, during two great skating contests—the Universiade in the Tatra Mountains and the Gold Pirouette in Zagreb—a total of 42 world class skaters were asked through a questionnaire if they had ever in their career suffered from a stress fracture. Of the 42 skaters, 9 had stress fractures. Four stress fractures occurred during preseason training (two fibular, one second metatarsal, and two fourth metatarsal stress fractures). Increased mileage was reported by three skaters and the fourth had done too much speed training on hills. Five stress fractures occurred during the season (one tibial and two tarsal navicular stress fractures and two stress fractures of the base of the fifth metatarsal). In all cases, the fracture occurred in the take-off leg. All of the subjects were competitive figure skaters with a daily training period of 3 to 8 hours, six times a week. The time from the onset of symptoms to definite diagnosis ranged from 2 to 10 weeks. Of the nine injured skaters, eight were treated conservatively and one skater with Jones’ fracture was treated surgically. All of the skaters were able to resume a preinjury level of activity 3 to 7 months after treatment began. In conclusion, it may be emphasized that stress fractures in figure skaters are not rare and should, therefore, always be considered as a possibility.
are
DUBRAVČIĆ,
Department of Orthopaedic Surgery, School of Medicine, University of Zagreb, Zagreb, Yugoslavia
ABSTRACT
Stress fractures
AND SANDA
during two great skating contests-the Universiade
*
Address correspondence and repnnt requests to’ Marko Pecina, MD, PhD, Department of Orthopaedic Surgery, Salata 6, 41000 Zagreb, Yugoslama.
277
278
TABLE 1 Patient data
a
No
weightbearing.
Figure 1. Case 6. Bone scan shows markedly increased uptake in area of tarsal navicular bone and confirms diagnosis. Of the nine skaters with stress fractures, eight were treated conservatively. Rest from the activity-causing symptoms was the only mode of treatment in six cases. The patients with tarsal navicular stress fracture (Case 7) and Jones’ fracture (Case 9) were treated with immobilization in a short-leg cast with no weightbearing allowed. Because of the changes visible in the initial roentgenogram (Fig. 3A), the skater with Jones’ fracture (Case 8) was surgically treated. All of the skaters were able to resume a preinjury level of activity 3 to 7 months after the initial treatment. At followup
Figure 2. Case 7. Tomograms made 1 month after the onset of symptoms show a stress fracture of the tarsal navicular. A deeper section did not show the fracture line, which indicates that fracture was limited to the dorsal aspect of the bone.
(average followup, 23 months; range, 9 to 72 months) patients were asymptomatic, even though they were engaged in top level competing activities.
thors.~~ 5>’°
DISCUSSION
agent leading to stress fractures. The fracture site
The external and internal predisposing factors to stress fractures have been variably emphasized by different au-
12, 18
The data obtained in
our investigation indioccurring in preseason training activities significantly correlate to running and also that training errors appear to be the most important causative
cate that stress fractures
sponds to
corre-
the site distribution of stress fractures described
in runners.7,ll, 17, 18
279
variations have caused the stresses, especially the shear stress, to be concentrated on the tarsal navicular bone as a result of greater force being transmitted through the second metatarsal and the intermediate cuneiform bones. The force would be increased in an excessively pronated foot, which has actually been the case with skaters who performed intensive jumping exercises on the inner edge of the skate. Previous reports have indicated potential difficulties in the treatment of Jones’ fractures. These include prolonged immobilization, high propensity for delayed union and non-
union, and refracture.2, 3, 9, 13, 19 Only recently Torg
et
aI.l9
have noticed and reported a correlation between roentgenographic manifestations of these fractures and their response to specific methods of treatment. Torg et aI.,19 Lehman et all and Pecina et a1,l5 have all developed classifications of these fractures and treatment plans based upon roentgenographic criteria. According to their reports, patients should be surgically treated upon initial signs of intramedullary sclerosis. Surgery helps speed fracture union and returns an athlete to his or her regular athletic activities in a short period of time, as was the case in our surgically treated patient. In conclusion, it may be emphasized that stress fractures in figure skaters are not rare and should, therefore, always be considered as a possibility in skaters. REFERENCES 1
2 3
Figure 3. Case 8. A, lateral roentgenogram of the foot demonstrating stress fracture of the base of the fifth metatarsal. Note a widened fracture line with an evident sclerosing of its edges. B, 8 weeks after surgical treatment-intramedullary fixation with AO malleolar screw-there is complete healing of the fracture.
4 5. 6 7.
Blank S Transverse tibial stress fractures. A special problem. Am J Sports Med 15 597-602,1987 DeLee JC, Evans JP, Julian J: Stress fracture of the fifth metatarsal Am J Sports Med 11 349-353, 1983 Devas MB: Stress fractures in athletes Proc R Soc Med 62: 933-937, 1969 Fitch KD, Blackwell JB, Gilmour WN. Operation for non-union of stress fracture of the tarsal navicular J Bone Joint Surg 71B: 105-110, 1989 Graff KH, Krahl H, Kirschberger R. Stressfrakturen des Os Naviculare Pedis. Z Orthop 124. 228-237, 1986 Green NE, Rogers RA, Lipscomb AB: Nonunions of stress fractures of the tibia Am J Sports Med 13. 171-176, 1985 Hulkko A, Orava S: Stress fractures in athletes. Int J Sports Med 8. 221-
226, 1987
Stress fractures of the anterior cortex of the midthird of the tibia constitute only a small percentage of all tibial stress fractures. I, 7, 12, 18 Various reports show that these fractures occur most likely as a result of tensile forces associated with
jumping. I, 6, 13, 14, 16 Also,
the reports emphasize two significomplications of treatment: delayed union and complete fracture. In our study, such a fracture resulted from a sudden increase in the number of jumps and a tendency toward introducing triple jumps as part of the competition program. Treatment complications, fortunately, did not occant
cur
in this
case.
to the reports of Torg et al.,20 Graff et al.,5 Hulkko et al.,’ and Fitch et al.,4 tarsal navicular stress fractures occur in explosive athletic activities that involve sprinting, jumping, and hurdling. They have been reported in basketball players, jumpers, sprinters, hurdlers, and middle-distance runners. Previous studies have shown that relatively short first metatarsal or long second metatarsal bones were common findings in patients.2° These anatomical
According
8. Hulkko A, Orava S, Petokallio P, et al. Stress fracture of the navicular bone Acta Orthop Scand 56 503-505, 1985 9. Kavanaugh JH, Brower TD, Mann RV. The Jones fracture revisited. J Bone Joint Surg 60A 776-782, 1978 10 Lehman RC, Torg JS, Pavlov H, et al Fractures of the base of the fifth metatarsal distal to the tuberosity. A review Foot Ankle 7 245-252, 1987 11. Markey KL: Stress fractures Clin Sports Med 6. 402-425, 1987 12. Matheson GO, Clement DB, McKenzie DC, et al: Stress fractures in athletes A study of 320 cases Am J Sports Med 15: 46-58, 1987 13 Orava S, Hulkko A: Delayed unions and nonunions of stress fractures in athletes Am J Sports Med 16 : 378-382, 1988 14 Orava S, Hulkko A. Stress fracture of the mid-tibial shaft Acta Orthop Scand 55. 35-37, 1984 15. Pećina M, Bojanić I, Ribarić G: Stress fracture of the base of the fifth metatarsal—Jones’ fracture. Acta Orthop lugosl 19. 118-123, 1988 16. Rettig AC, Shelbourne KD, McCarroll JR, et al: The natural history and treatment of delayed union stress fractures of the anterior cortex of the tibia Am J Sports Med 16 250-255, 1988 17. Sullivan D, Warren RF, Pavlov H, et al: Stress fractures in 51 runners. Clin : 188-192, 1984 Orthop 187 18 Taunton JE, Clement DB, Webber D Lower extremity stress fractures in athletes Physician Sportsmed 9. 77-86, 1981 19. Torg JS, Balduini FC, Zelko RR, et al: Fractures of the base of the fifth 20.
metatarsal distal to the tuberosity J Bone Joint Surg 66A : 209-214, 1984 Torg JS, Pavlov H, Cooley LH, et al: Stress fractures of the tarsal navicular. J Bone Joint Surg 64A. 700-712, 1982
