James Noake Profile picture
Jun 9, 2023 24 tweets 10 min read Read on X
Stress fractures - a detailed thread 🦴🦴🦴

I thought I'd put together an overview & some clinical nuggets from the 'coal-face'

First up, I prefer to call them 'bone stress injuries' - majority don't have a # line on imaging & the language can be scary / nocebic for some Image
Pathophysiology & risk factors

Stress fractures-
Occur in normal bone that is placed under abnormal / persistent load & strain ('training / sporting error')

Insufficiency fractures-
Occur in bone that is under normal strain but is structurally vulnerable eg metabolic conditions Image
In reality, can be a combination of both to varying degrees - not 'black & white'

Special mention goes to RED-S which often underpins BSI in athletes - men & women!

Ask about relationship with food (past & present) & menstrial history - periods are a barometer of athlete health Image
At a granular level, bone physiology, its hormonal control & homeostasis is complex - but the fundamentals are pretty straight forward ⬇️ Image
Grading

Fredericson classification originally created for Medial Tibial Stress Syndrome (MTSS) - now extrapolated to other BSIs

Is it helpful?🧐

I occasionally see high grade injuries with minimal pain - & low grade stress reactions with significant symptoms & functional loss Image
However, generally if cortical involvement with fracture line = significant injury & correlates with extended RTP / running timescales

A useful platform for discussion with patient around severity of injury and respecting the injury & realistic timescales
High vs Low risk BSI

Some stress #s need to be treated with extra respect & caution - see table

These are typically under sustained high strain coupled with relatively poor blood supply Image
These are more likely to go through delayed union & take longer to recover - or indeed even need early orthopaedic opinion - tension / lateral side neck of femur is a good eg

Keep them on your clinical radar & assess specifically for them - lower threshold for imaging ImageImage
Presentation

Gradual onset with persistent impact activity - but occasionally patient describes acute onset pain/ 'crack'

Pain on impact / 'first step' - tendon conditions often ‘warm up’ - unusual with BSI

Some with lower grade BSI can often run through it, but ⬇️performance Image
Rest & night pain when high grade

Ache, throb at rest - sharp, shooting under load - pelvic & proximal femur BSIs can feel 'neural' & refer into lower limb

Description of loss of power output, control, heaviness
Assessment

Lower limb & pelvic - 'Hop test' invariably positive - shut down, reduced power output

Sacral stress # - SIJ provocation tests

FADIR test positive for pubic & neck of femur BSI

Swelling & oedema (esp foot & ankle) around bony tenderness site in absence of trauma ImageImage
Imaging - X-ray

X-rays ➡️poor sensitivity eg ~ 85% of pelvic stress #s are missed on plain films

More likely to pick up a BSI in later stages (eg 4 weeks+) due to callus formation

But better than nothing, esp if suspecting high grade high risk BSI eg ant tibial ImageImage
MRI

Close to 100% sensitivity & the modality of choice

It picks up medullary bone oedema (earlier stress reaction) which X-ray & CT can't

It's more sensitive than 2 phase bone scan - plus bone scan non-specific

It also assesses periosteal & wider soft tissue involvement ImageImageImage
MRI VIBE sequences ('pseudo CT') are excellent for detailed assessment of pars stress injuries


This can be repeated to assess pars bony healing which takes longer than other BSIs (~3-6 months)
journals.assaf.org.za/index.php/sajs… Image
CT

Misconception re CT being accurate at identifying stress

Excellent at picking up & delineating high grade cortical disruption or long-standing changes eg callus formation / periosteal changes

But it's not a first line modality - MRI is gold standard Image
Lower threshold for using CT alongside MRI in high risk BSI

Useful where concern re:

Fracture configuration or cortical involvement underestimated on MRI

Healing status / delayed union

Ruing out differential diagnosis eg tumour, osteomyelitis
Ultrasound

A quick useful tool at the point of care, time efficient

Can pick up periosteal reaction, callus formation, local soft tissue swelling & inflammation

Like x-ray & CT, won't pick up medullary bone oedema

On balance probably more sensitive than x-ray Image
Management

Ideally an MDT approach best esp if RED-S part of the picture - see slide below

Communication key - ? SEM led

Pharmacological Rx 💊💊- specialist decision in difficult cases eg bisphosphonates, teriparatide, transdermal oestrogen (RED-S) Image
Nutritional & dietary modifications - eg improving macro / calorie intake in cases of low energy availability (LEA)

Vitamin D

Other adjuncts eg shockwave therapy, LIPUS - controversial
Rehab fundamentals

Return to running & load progressions guided by pain levels & function

Beware 'lag phenomenon' when assessing pain response / flare on⬆️load - delay over 2-3 days

Generally 12-16 weeks RTR

<8 weeks seems a recipe for recurrence & back to 'square 1' Image
Challenge 😤🙄 the small number of patients who have low levels of pain - or pain settles v quickly with early offload - but high grade stress radiologically

In these cases seems sensible to respect physiology & set arbitrary number of weeks before moving into RTR
Some clinicians might not agree with this & have a more pragmatic approach

@rwilly2003 paper has suggested that with MTSS, if pain free for 5 days can begin graded RTR

So clearly can't be rigidly prescriptive / recipe based - every patient different due to personal factors ++
Tips:

Time scales variable
Respect physiology
Not ‘one size fits all’
Step count?
Pragmatic approach to cross training
Parallel S&C programme
Education
Alter G – graded exposure? Image
Why aren't they getting better?

Compliance aside - misdiagnosis might be the cause -

eg rheumatological - enthesopathy with florid bone oedema

Osteoid osteoma tumour - eg proximal femur & calcaneum - here CT will help differentiate
ImageImageImage

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More from @DrJN_SportsMed

Feb 26
Consent✅

For hip & groin geeks - mini thread 🧵🧵

Elite female sprinter

Worsening medial groin pain radiating into lower abdomen & "womb" - no acute episode, pop or tear

Worst on explosive block drills; sprinting especially when fatiguing & losing form, dropping into hip & lumbar extension; core / abdominal S&C work

Can attain max 65% sprint performance

Exam - pain & weakness on isometric long leg squeeze & resisted crunches

NO pain on palpation through pubic symphysis, tubercle or adductor origin
MRI with groin protocol - marked symphysis pubis degenerative & erosive change (seen best on VIBE sequences - image) & pubic bone oedema

Common in athletes especially multi-directional sports

Do we consider injecting symphyseal cleft?🧐 Image
POCUS - clear cut enthesopathy of rectus abdominus insertion as it blends with pre-pubic aponeurotic tissues at pubic tubercle
(what would have been called rec ab- add longs aponeurosis not so long ago)

Re-visiting MRI - possibly subtle changes in deep corner (arrow) but reported as normal (MRI flipped / rotated to mimic ultrasound plain)Image
Image
Read 5 tweets
Nov 11, 2023
Documented consent for images & data ✅

Thread 🧵

'Deep gluteal syndrome' or piriformis syndrome - a patient's journey

Over-diagnosed & a diagnosis of exclusion really...
the neurogenic thoracic outlet syndrome of the pelvis? 🧐

It does exist though Image
Female ex international handball - now marathon training, HIIT, Cross Fit

Worsening inferior gluteal pain - diagnosed as proximal hamstring tendinopathy, but no improvement with physio input & load management Image
6 months later, Sx evolving - pain radiating down posterior leg, calf, foot

Intermittent parasthesiae, subjective loss power & gait coordination

Constantly stretching & massaging piriformis

Sitting😡

LSp & hip joint clear; seated stretch & active piriformis tests provocative
Read 12 tweets
Oct 30, 2022
Thread alert 🚨🚨🚨

Ankle inversion injuries don't just result in lateral ligament sprains....

...there are plenty of other injuries to bear in mind when you assess, both acutely & further down the line
1. Talar dome osteochondral injury

Intermittent catching / locking symptoms, usually deep medial joint line pain

Persistent effusion & loss of dorsiflexion

Consider MRI if not progressing with rehab - CSI & aspiration can help first line

Unstable / large fragment ➡️ortho
2. POMI (posteromedial impingement) lesion

Deep posterior fibres of deltoid ligament crushed between medial wall of the talus & the malleolus

Thick fibrotic scar tissue persists & impinges

Deep joint line pain & catching - similar to OCD

Injection, scope if recalcitrant
Read 15 tweets
Oct 12, 2022
I get asked about the utility of hip & groin tests all the time

The short answer is there's a big overlap across clinical tests & key pain drivers - no test is particularly specific; some are sensitive

This is my take based on clinical experience - opinions welcome Image
1. FADDIR test

Starting point & easy to do - should be your 'go to' test

Negative - its not coming from the hip joint

Positive - could be FAI, labral, OA, AVN ...

(disclaimer - FADDIR can also provoke irritable pubic related groin pain) Image
Hop test

If negative it's very unlikely they have a femoral or pubic stress fracture

If symptoms are produced by hopping on the side AWAY from pain, suggests driver is pubic / symphysis driven Image
Read 9 tweets
Sep 8, 2022
Thread alert - posterior ankle & heel pain 🚨🚨🚨

Most cases are ‘common garden’ achilles tendinopathy

However, here is a selection of conditions I've seen over time in clinic which can masquerade & are worth considering if the picture is atypical or patient not progressing
1. Achilles enthesitis
🧐
Insertional heel pain, not mid portion

<45?
Psoriasis or inflam bowel disease?
LSp / gluteal pain?
Early morning stiffness & ‘inflammatory’ pattern?

Think spondyloarthropathy

💊
Trial of NSAIDs may be eye-opening
Early rheumatology referral?
2. Plantaris compression tendinopathy

🧐
Refractory to achilles loading programme over 3 months
Pain on pronation
Worse on dorsiflexion eg gradients

Medial tenderness

💉
USG injection at interface can help
Surgical resection if recalcitrant
Read 13 tweets
Sep 1, 2022
Thread alert 🚨🚨🚨 - Medial knee pain!

What else should we be considering beyond OA & MCL sprains?

Here are some differentials to consider & their clinical presentation 🧐
1. Saphenous Nerve irritation

Direct impact, post surgery (eg scope / TKR)

Dislikes knee flexion, garment compression

Diffuse neuropathic Sx, P&N - medial knee, infrapatella, lower leg

🧐
+ive Tinels at Hunters canal
No motor loss, purely sensory

💉
SN block can diag & Rx
2. Meniscocapsular synovitis

Often seen in association with a meniscal tear or extrusion meniscopathy

If degenerate tear, incipient injury maybe unclear- sometimes just 🔼activity / load

"I need a pillow between my legs at night"

US- astericks = inflammation; PD hyperaemia
Read 18 tweets

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