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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))
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(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 female	Case report	Immobilization recommended?	6 weeks	No control No recommendations made Unique case Rare case
			Complications present	None
Robinson 2014 New Zealand	21 year old semi-professional footballer	Case report to demonstrate importance of non-weight bearing for first 6 weeks post stress fracture	Immobilization recomended	6-8 weeks followed by limited WB If unsuccessful WB at 6-8 weeks then another 6 weeks NWB	Case study No control Based around only a handful of studies Follow up poor Makes generalisations about implications of research
			Complications present	Non-union fracture Long term pain
Bali 2013 India	47 year old man	Case report to discuss the diagnosis of steroid induced stress fracture	Immobilization recommended	Prompt immobilization	Abstract only Case study
			Complications present	Not mentioned
Dobrindt 2012 Germany	52 competitive athletes 22 male/ 30 female	Retrospective cohort study to determine the return to sports time of stress fracture based on imaging findings of severity and location	Immobilization recommended	Not mentioned	Did not mention sport of athletes No control Extrapolated conclusions Did not mention high where high risk sites were
			Complications present	Not mentioned
Royer 2012 France	Review article	To review current knowledge around stress fractures	Immobilisation recommended	Rest of 3-6 weeks for metatarsal and 6-12 weeks but does not specify NWB	Review article Does not specify NWB, just says rest which is unclear Doesn’t cover issue of complications Doesn’t justify use of US
			Complications present	Not mentioned
Hoke 2011 USA	3 patient case studies	To present stress fracture of 3 patients following TKA	Immobilisation recomended	40 days NWB	Over emphasises importance of surgery despite lack of evidence to confirm this
			Complications present	Non union
Duran-Stanton 2011 USA	19 year old female military recruit	Case report of a march fracture	Immobilisation recommended	Extended NWB	Abstract only Case study
			Complications present	Not mentioned
Thelen 2010 USA	34 year old female soldier	Case report of a 34 year old female soldier	Immobilisation recomended	Short leg cast and NWB	Case study Doesn’t expand on follow up Doesn’t have clear aims of the report Doesn’t expand on issues around non union
			Complications present	Non union
Torg 2010 USA	Systematic review of 23 reports	Meta-Analysis to compare surgical vs conservative treatment of stress fractures	Immobilisation recommended	96% 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 come	Aims 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 present	Not mentioned
Albisetti 2010 Italy	150 trainee ballet dancers 80 male and 70 female aged 10-21 years	Cohort 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 present	Not mentioned
Hong 2009 South Korea	12 male military recruits mean age 21.3 years	Retrospective cohort study to determine the pathomechanism of stress fractures of the proximal fibula	Immobilisation recommended	7 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 present	Not 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 treatment	Immobilisation recommended	3 months NWB	Did 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 present	Chronic pain
Saxena 2006 USA	19 athletes, 11 women and 8 men	Prospective cohort study to see if the more severe a stress fracture is, the longer the healing time may be.	Immobilisation recommended	6 weeks NWB in a below knee cast	Strange control, used two different studies may have different biases Did not seem to answer aim of question
			Complications present	Delayed union
Burne 2005 USA	19 patients, 13 women / 6 men	Retrospective cohort study to follow up current treatment of stress fracture in a university based sports clinic	Immobilisation Recommended	6 weeks NWB	This was more of an audit than a study Methods crude but effective No control group Small sample size
			Complications present	Not mentioned
Varner 2005 USA	7 collegiate level athletes	Case reports to report on a reamed intramedullary nailing in a series of case reports as a treatment for stress fracture.	Immobilisation recommended	Surgical treatment, weight bearing as tolerated with crutches	Only complication found so far is in surgical treatment. No control used
			Complications present	Bursitis at sight of nail insertion
Hetsroni 2005 Israel	3 female patients	Case reports to report on 3 cases of forth metatarsal stress fracture	Immobilisation recommended	NWB for 4 months	No control Extrapolated large data from small sample size Unique scenario
			Complications present	Prolonged healing time
Warren 2004 USA	1 female pole-vaulter	Case report to report on a unique stress fracture in a pole-vaulter	Immobilisation recommended	NWB for 6 weeks	Case study Unique scenario Not mentioned follow up or possible complications
			Complications present	Prolonged healing time
Ito 2004 Japan	2 elderly women	Case report to describe two cases of unique insufficiency fractures	Immobilisation recommended	NWB for 8 weeks	Case studies Question specifically avoids osteoporotic fractures.
			Complications present	None
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 recommended	NWB	Recommended NWB but did not say how long for Small population size Methods poor Did not reach criteria of inclusion
			Complications present	Osteoarthritis
Biedert 2003 Switzerland	5 females mean age 16.8 years	Cohort study to determine whether specific symptoms or findings are present in stress fractures	Immobilisation recommended	6 months for 3 however 2 required surgical repair	Small population Did not mention what conservative treatment entailed Did not explain why 2 athletes required surgical treatment
			Complications present	Not mentioned
Jean 2001 Taiwan	76 year old female	Case study to describe a patient with a stress fracture of the proximal tibia	Immobilisation Recommended	2 months immobilisation	Case study
			Complications present	Not 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 fractures	Immobilisation Recommended	16 weeks NWB	Case studies Wide variety of demographics in series, difficult to compare results for one demographic with another
			Complications present	Prolonged 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 fractures	Immobilisation recommended	Rest + pneumatic leg brace for 20 weeks	Very small population size No intervention Pneumatic leg brace Long diagnosis before treatment
			Complications present	None
Saxena 2000 USA	10 females and 9 Males all athletic	Cohort study to assess length of healing time of stress fractures based on CT findings	Immobilisation Recommended	13 Patients treated conservatively average healing time 3-13 months	Didn’t answer question Small population Good methodology but no control or intervention
			Complications present	5 patients received delayed healing time
Popovich 2000 USA	6 male training companies = 1357 male military recruits	Controlled trial to see if rest during running would prevent stress fractures in military recruits	Immobilisation Recommended	None	Methodology needs improvement/ randomised Did not explain treatment of stress fractures that occurred.
			Complications present	None
Blivin 1999 USA	20 year old male (American) football player	Case report to present an atypical presentation of a common injury	Immobilisation Recommended	Weight bearing as tolerated	Single study No repeatable data Long diagnosis time
			Complications present	Not 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 recommended	Rest for two patients between 6 weeks – 3 months	One patient lost to follow up, poor for only 3 patient series. No control No mention of potential complications
			Complications present	Not mentioned
Bennell 1998 Australia	Review article	Review article to review management of stress fractures in female athletes	Immobilisation recommended	Rest for 6-8 weeks	Review article Does not mention complications in detail Over 10 years old, potential for change in evidence
			Complications present	Potential for non union
Lambros 1997 USA	19 year old male	Case study to present the case of multiple stress fractures in a healthy adult	Immobilisation recommended	Cast immobilization for 6 weeks	Case study Little follow up Underlying pathology not explained
			Complications present	None
Swenson 1997 USA	21 runners with a mean age of 28	Randomised control trial to evaluate the effect of pneumatic leg brace on return to play time	Immobilisation recommended	Pneumatic leg brace increases return to activity by 35 days and reduces disabling pain by 30 days	Didn’t describe what traditional treatment was compared to experimental procedure.
			Complications present	Not mentioned
Ballas 1997 USA	Review article	Review article to describe common overuse injuries in runners.	Immobilisation recommended	Rest (time not specified)	Review article Abstract only Over 10 years old, conclusions may be out of date.
			Complications present	Not mentioned
Chang 1996 USA	5 male military recruits: mean age 25	Cohort study to review 5 cases of stress fracture treated surgically	Immobilisation recommended	Rest for 6 months prior to surgery	Small population size Follow up poor Did not describe sex of recruits Did not explain what criteria allowed entry into study
			Complications present	Prolonged healing time
Bradshaw 1996 Australia	4 male athletic individuals aged 30, 37, 35 +30	Case study series to describe a series of 4 stress fractures	Immobilisation recommended	2 treated with 3 weeks of NWB rest	No follow up Small population size Difficult to extrapolate results further Brief case histories in all.
			Complications present	Delayed healing Prolonged pain
Khan 1992 Australia	82 athletes 31:51 Female: Male ratio	Retrospective cohort study to evaluate if surgery or conservative management is the treatment of choice for stress fractures	Immobilisation recommended	6-8 weeks of NWB treatment	Poor selection criteria No follow up Did not explain method of immobilization
			Complications present	Continued 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