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In patients with lower limb stress fractures is non-weight bearing better than early mobilisation in reducing complications?

Three Part Question

In [active adults over the age of 16] is [early mobilisation better than immobilisation] in [reducing complications in below knee stress fractures].

Clinical Scenario

A patient has bee diagnosed with a lower limb stress fracture following an MRI scan. You wonder if early mobilisation is better than non-weight bearing in managing this patient and reducing complications.

Search Strategy

Ovid MEDLINE(R) 1946 to July Week 1 2015
Embase 1980 to 2015 Week 28

(exp Fractures, stress/ OR insufficiency fracture.mp./OR fatigue fracture.mp./ OR stress injury.mp.) AND (exp Immobilization/ OR exp weight bearing/ OR non weight bearing.mp./ OR rest.mp.) Limit (English language AND humans AND all adults (19 plus))
+
(exp Fractures, stress/ OR insufficiency fracture.mp./OR fatigue fracture.mp./ OR stress injury.mp.) AND (exp Immobilization/ OR exp weight bearing/ OR non weight bearing.mp./ OR rest.mp.) Limit (English language AND humans AND all adults (<18-64 years))

Search Outcome

299 Hits
34 Relevancies

Relevant Paper(s)

Author, date and country Patient group Study type (level of evidence) Outcomes Key results Study Weaknesses
O'Neill
2014
Ireland
46 year old femaleCase reportImmobilization recommended?6 weeksNo control No recommendations made Unique case Rare case
Complications presentNone
Robinson
2014
New Zealand
21 year old semi-professional footballerCase report to demonstrate importance of non-weight bearing for first 6 weeks post stress fractureImmobilization recomended6-8 weeks followed by limited WB If unsuccessful WB at 6-8 weeks then another 6 weeks NWBCase study No control Based around only a handful of studies Follow up poor Makes generalisations about implications of research
Complications presentNon-union fracture Long term pain
Bali
2013
India
47 year old manCase report to discuss the diagnosis of steroid induced stress fractureImmobilization recommendedPrompt immobilizationAbstract only Case study
Complications presentNot mentioned
Dobrindt
2012
Germany
52 competitive athletes 22 male/ 30 femaleRetrospective cohort study to determine the return to sports time of stress fracture based on imaging findings of severity and locationImmobilization recommendedNot mentionedDid not mention sport of athletes No control Extrapolated conclusions Did not mention high where high risk sites were
Complications presentNot mentioned
Royer
2012
France
Review articleTo review current knowledge around stress fracturesImmobilisation recommendedRest of 3-6 weeks for metatarsal and 6-12 weeks but does not specify NWBReview article Does not specify NWB, just says rest which is unclear Doesn’t cover issue of complications Doesn’t justify use of US
Complications presentNot mentioned
Hoke
2011
USA
3 patient case studiesTo present stress fracture of 3 patients following TKAImmobilisation recomended40 days NWBOver emphasises importance of surgery despite lack of evidence to confirm this
Complications present Non union
Duran-Stanton
2011
USA
19 year old female military recruitCase report of a march fractureImmobilisation recommendedExtended NWBAbstract only Case study
Complications presentNot mentioned
Thelen
2010
USA
34 year old female soldierCase report of a 34 year old female soldierImmobilisation recomendedShort leg cast and NWBCase study Doesn’t expand on follow up Doesn’t have clear aims of the report Doesn’t expand on issues around non union
Complications presentNon union
Torg
2010
USA
Systematic review of 23 reportsMeta-Analysis to compare surgical vs conservative treatment of stress fracturesImmobilisation recommended96% of 73 fractures treated with NWB for 6 weeks had a successful outcome 43% of 92 fractures treated with weight bearing had a successful out comeAims not clear Doesn’t quantify what kind of casts used Doesn’t explain what a successful outcome is Not enough mention of complications that may arise
Complications presentNot mentioned
Albisetti
2010
Italy
150 trainee ballet dancers 80 male and 70 female aged 10-21 yearsCohort study to describe diagnosis and treatment of stress fractures in young ballet dancers.Immobilisation recommended 3-5 weeks of rest, casting not recommended Poor results and not explanation of method. Stated large sample size but in reality was much smaller than this Poor extrapolation of results from data
Complications presentNot mentioned
Hong
2009
South Korea
12 male military recruits mean age 21.3 yearsRetrospective cohort study to determine the pathomechanism of stress fractures of the proximal fibulaImmobilisation recommended7 days bed rest followed by FWB at 14 days. Does not mention casting.Does not meet aims of study Doesn’t seem to have drawn any clear conclusions Results unclear Does not explain consequences of management.
Complications presentNot mentioned
Miyamoto
2009
USA
7 professional dancers 4 male, 3 female.Retrospective cohort study to report on a series of 7 cases that were treated surgically following unsuccessful conservative treatmentImmobilisation recommended3 months NWBDid not expand on complications, did not expand on surgery Did not explain why people had been excluded from study Put too much emphasis on surgery
Complications presentChronic pain
Saxena
2006
USA
19 athletes, 11 women and 8 menProspective cohort study to see if the more severe a stress fracture is, the longer the healing time may be.Immobilisation recommended6 weeks NWB in a below knee castStrange control, used two different studies may have different biases Did not seem to answer aim of question
Complications presentDelayed union
Burne
2005
USA
19 patients, 13 women / 6 menRetrospective cohort study to follow up current treatment of stress fracture in a university based sports clinicImmobilisation Recommended6 weeks NWBThis was more of an audit than a study Methods crude but effective No control group Small sample size
Complications presentNot mentioned
Varner
2005
USA
7 collegiate level athletesCase reports to report on a reamed intramedullary nailing in a series of case reports as a treatment for stress fracture.Immobilisation recommendedSurgical treatment, weight bearing as tolerated with crutchesOnly complication found so far is in surgical treatment. No control used
Complications presentBursitis at sight of nail insertion
Hetsroni
2005
Israel
3 female patientsCase reports to report on 3 cases of forth metatarsal stress fractureImmobilisation recommended NWB for 4 monthsNo control Extrapolated large data from small sample size Unique scenario
Complications presentProlonged healing time
Warren
2004
USA
1 female pole-vaulterCase report to report on a unique stress fracture in a pole-vaulterImmobilisation recommended NWB for 6 weeksCase study Unique scenario Not mentioned follow up or possible complications
Complications presentProlonged healing time
Ito
2004
Japan
2 elderly womenCase report to describe two cases of unique insufficiency fracturesImmobilisation recommendedNWB for 8 weeksCase studies Question specifically avoids osteoporotic fractures.
Complications presentNone
Garcia-Porrua
2003
Spain
6 female patients Prospective cohort study to investigate the etiological/clinical and diagnostic approach in patients presenting with fatigue fractures.Immobilisation recommendedNWBRecommended NWB but did not say how long for Small population size Methods poor Did not reach criteria of inclusion
Complications presentOsteoarthritis
Biedert
2003
Switzerland
5 females mean age 16.8 yearsCohort study to determine whether specific symptoms or findings are present in stress fracturesImmobilisation recommended6 months for 3 however 2 required surgical repairSmall population Did not mention what conservative treatment entailed Did not explain why 2 athletes required surgical treatment
Complications presentNot mentioned
Jean
2001
Taiwan
76 year old femaleCase study to describe a patient with a stress fracture of the proximal tibiaImmobilisation Recommended2 months immobilisation Case study
Complications presentNot mentioned
Saxena
2001
USA
5 cases 4 males: 13, 50, 16 + 16 years 1 Female: 16 years Case study series to describe the difference between 4th and 5th metatarsal stress fracturesImmobilisation Recommended16 weeks NWBCase studies Wide variety of demographics in series, difficult to compare results for one demographic with another
Complications presentProlonged healing time
Batt
2001
UK
1 male, 2 females: Mean age = 28 years All athletic Cohort study to describe a series of cases of treating stress fracturesImmobilisation recommendedRest + pneumatic leg brace for 20 weeksVery small population size No intervention Pneumatic leg brace Long diagnosis before treatment
Complications presentNone
Saxena
2000
USA
10 females and 9 Males all athleticCohort study to assess length of healing time of stress fractures based on CT findingsImmobilisation Recommended13 Patients treated conservatively average healing time 3-13 monthsDidn’t answer question Small population Good methodology but no control or intervention
Complications present5 patients received delayed healing time
Popovich
2000
USA
6 male training companies = 1357 male military recruitsControlled trial to see if rest during running would prevent stress fractures in military recruitsImmobilisation RecommendedNoneMethodology needs improvement/ randomised Did not explain treatment of stress fractures that occurred.
Complications presentNone
Blivin
1999
USA
20 year old male (American) football playerCase report to present an atypical presentation of a common injuryImmobilisation RecommendedWeight bearing as toleratedSingle study No repeatable data Long diagnosis time
Complications presentNot mentioned
Van der Velde
1999
Canada
15 year old male, 25 year old female, 30 year old marathon runner (gender unspecified)Case series to describe three cases of tibial stress fracture.Immobilisation recommendedRest for two patients between 6 weeks – 3 monthsOne patient lost to follow up, poor for only 3 patient series. No control No mention of potential complications
Complications presentNot mentioned
Bennell
1998
Australia
Review articleReview article to review management of stress fractures in female athletesImmobilisation recommendedRest for 6-8 weeksReview article Does not mention complications in detail Over 10 years old, potential for change in evidence
Complications presentPotential for non union
Lambros
1997
USA
19 year old maleCase study to present the case of multiple stress fractures in a healthy adultImmobilisation recommendedCast immobilization for 6 weeksCase study Little follow up Underlying pathology not explained
Complications presentNone
Swenson
1997
USA
21 runners with a mean age of 28Randomised control trial to evaluate the effect of pneumatic leg brace on return to play timeImmobilisation recommendedPneumatic leg brace increases return to activity by 35 days and reduces disabling pain by 30 daysDidn’t describe what traditional treatment was compared to experimental procedure.
Complications presentNot mentioned
Ballas
1997
USA
Review articleReview article to describe common overuse injuries in runners.Immobilisation recommendedRest (time not specified)Review article Abstract only Over 10 years old, conclusions may be out of date.
Complications presentNot mentioned
Chang
1996
USA
5 male military recruits: mean age 25Cohort study to review 5 cases of stress fracture treated surgicallyImmobilisation recommendedRest for 6 months prior to surgerySmall population size Follow up poor Did not describe sex of recruits Did not explain what criteria allowed entry into study
Complications presentProlonged healing time
Bradshaw
1996
Australia
4 male athletic individuals aged 30, 37, 35 +30Case study series to describe a series of 4 stress fracturesImmobilisation recommended2 treated with 3 weeks of NWB restNo follow up Small population size Difficult to extrapolate results further Brief case histories in all.
Complications presentDelayed healing Prolonged pain
Khan
1992
Australia
82 athletes 31:51 Female: Male ratioRetrospective cohort study to evaluate if surgery or conservative management is the treatment of choice for stress fracturesImmobilisation recommended6-8 weeks of NWB treatmentPoor selection criteria No follow up Did not explain method of immobilization
Complications presentContinued pain Delayed healing

Comment(s)

22 Studies advised NWB Modal time for NWB 6-8 weeks 16 Studies were case reports of which 15 recommended NWB 3 Studies recommended surgery however only 1 recommended as first line treatment. 6 Studies recommended rest but most did not mention immobilization Only 1 study advised against immobilization 1 meta-analysis advised NWB with a 96% successful treatment rate compared to 46% for continued activity.

Clinical Bottom Line

Patients with confirmed lower limb stress fracture should be managed with non-weight bearing for a mean time period of 6 weeks.

References

  1. Barry J O’Neill Atypical stress-avulsion fracture of the Lisfranc joint complex Foot & ankle specialist April 14; 155-158:
  2. Matthew Robinson Delayed healing of a navicular stress fracture, following limited weight-bearing activity BMJ case reports March 14; bcr2013203216
  3. Kamal Bali Steroid-induced stress fracture of medial tibial condyle: a case report. The journal of knee surgery Dec 2013; S25-9:
  4. Oliver Dobrindt Estimation of return-to-sports-time for athletes with stress fracture–an approach combining risk level of fracture site with severity based on imaging BMC musculoskeletal disorders August 2012; 139
  5. Mathieu Royer Stress fractures in 2011: practical approach Joint Bone Spine Oct 2012; S86-S90:
  6. David Hoke Tibial shaft stress fractures resulting from placement of navigation tracker pins The Journal of arthroplasty 2011 Apr; e5-8:
  7. Amelia M Duran-Stanton “March Fractures” on a Female Military Recruit Military medicine 2011 Jan; 53-5:
  8. Mark D Thelen Identification of a high-risk anterior tibial stress fracture Journal of Orthopaedic & Sports Physical Therapy Dec 2012; 833
  9. Joseph S Torg Management of Tarsal Navicular Stress Fractures Conservative Versus Surgical Treatment: A Meta-Analysis The American journal of sports medicine May 10; 1048-1053
  10. Walter Albisetti Stress fractures of the base of the metatarsal bones in young trainee ballet dancers International orthopaedics Jan 2010; 51-55:
  11. Seoung Hwan Hong Stress fracture of the proximal fibula in military recruits Clinics in orthopedic surgery 2009 Sep; 161-4:
  12. Ryan G Miyamoto Surgical Treatment of Refractory Tibial Stress Fractures in Elite Dancers A Case Series The American journal of sports medicine 2009 Jun; 1150-4:
  13. Amol Saxena Navicular stress fractures: a prospective study on athletes Foot & ankle international Nov 2011; 917-921
  14. Scott G Burne Tarsal navicular stress injury long-term outcome and clinicoradiological correlation using both computed tomography and magnetic resonance imaging The American journal of sports medicine Dec 2005; 1875-1881:
  15. Kevin E Varner Chronic anterior midtibial stress fractures in athletes treated with reamed intramedullary nailing The American journal of sports medicine 2005 Jul; 1071-6:
  16. Iftach Hetsroni Base of fourth metatarsal stress fracture: tendency for prolonged healing Clinical Journal of Sport Medicine 2005 May; 186-8:
  17. Eric Thomas Warren Unusual cause of midfoot pain in a pole vaulter Clinical Journal of Sport Medicine 2004 Nov; 360-1:
  18. Kazuo Ito Insufficiency fracture of the body of the calcaneus in elderly patients with osteoporosis: a report of two cases. Clinical orthopaedics and related research 2004 May; 190-4:
  19. Carlos Garcia‐Porrua Fatigue fractures suggesting clinical monarthritis Arthritis Care & Research 2003 Dec; 741-4:
  20. Roland Biedert Stress fractures of the medial great toe sesamoids in athletes Foot & ankle international 2003 Feb; 137-141:
  21. Jiann-Long Jean Stress fracture of the proximal tibia after total knee arthroplasty: a case report JOURNAL-FORMOSAN MEDICAL ASSOCIATION 2001 Aug; 561-564:
  22. Amol Saxena Proximal fourth metatarsal injuries in athletes: similarity to proximal fifth metatarsal injury Foot & Ankle International 2001 Jul; 603-608
  23. ME Batt Delayed union stress fractures of the anterior tibia: conservative management British journal of sports medicine 2001 Feb; 74-77:
  24. Amol Saxena Results of treatment of 22 navicular stress fractures and a new proposed radiographic classification system The Journal of foot and ankle surgery 2000 April; 96-103:
  25. Rose M Popovich Effect of rest from running on overuse injuries in army basic training American journal of preventive medicine 2000 April; 147-155
  26. Steven J Blivin Bilateral midfibular stress fractures in a collegiate football player. Clinical Journal of Sport Medicine 1999 April; 95-96:
  27. Gabrielle M van der Velde Posterior tibial stress fracture: a report of three cases Journal of manipulative and physiological therapeutics 1999 June; 341-346
  28. K Bennell Stress fractures in female athletes: Diagnosis, management and rehabilitation Current therapeutics 1998 Dec; 13
  29. G Lambros Multiple stress fractures of the tibia in a healthy adult. American journal of orthopedics 1997 Oct; 687:
  30. E James Swenson The effect of a pneumatic leg brace on return to play in athletes with tibial stress fractures The American journal of sports medicine 1997 Jun; 322-328
  31. MT Ballas Common overuse running injuries: diagnosis and management. American family physician 1997 May; 2473-2484
  32. Paul S Chang Intramedullary Nailing for Chronic Tibial Stress Fractures A Review of Five Cases The American journal of sports medicine 1996 Sept; 688-692:
  33. Chris Bradshaw Stress fracture of the body of the talus in athletes demonstrated with computer tomography. Clinical Journal of Sport Medicine 1996 Jan; 48-51
  34. Karim M Khan Outcome of conservative and surgical management of navicular stress fracture in athletes Eighty-six cases proven with computerized tomography The American journal of sports medicine 1992 Dec; 657-666