Stress fracture treatment interventions

Abstract

Introduction: The occurrence of a stress fracture during military or athletic training can have catastrophic consequences on an individual's ability to fulfill a career or performance objective. Further, costs to defense forces for prolonged rehabilitation from stress fracture can be considerable. Identification of an effective means by which the rate of healing of stress fractures can be accelerated will diminish the negative consequences of the injury. Purpose: There is no universally-accepted treatment for stress fracture that is consistently efficacious. Relative rest remains the primary evidence-based strategy to facilitate healing. Differences in stress fracture location and severity are complex confounders of trials examining the efficacy of novel treatments. The purpose of the current presentation is to summarize and evaluate treatment strategies that have been tested for their ability to accelerate the healing of stress fracture. Implementation: Complete or relative rest followed by gradual reintroduction of training has historically been considered the most consistently successful treatment for most forms of stress fracture. The prolonged nature of healing in some cases, however, has prompted the examination of a number of strategies to accelerate the process. Considered here are only those methods that have been tested by well-designed, randomized controlled trials, including: pneumatic tibial bracing, low energy laser therapy, electric field stimulation (EFS) and low intensity pulsed ultrasound (LIPUS). Outcomes: Trials of pneumatic tibial braces have produced equivocal results; effective in a small sample of athletes (n=18), but ineffective in a larger study of military recruits (n=31). Low energy laser therapy did not improve healing outcomes for recruits with MTSS (n=49). Although EFS and LIPUS convincingly enhance the rate of healing of frank, delayed and non-union fracture, their effects on stress fracture in human trials have been somewhat disappointing. Close scrutiny of the data suggests, however, that more severe stress fractures may benefit from EFS, particularly in more compliant subjects. It is important to note that subtle differences exist between injuries routinely classified as stress fractures. Examination of the effects of a treatment method on different injury severities can confound even the strongest research design if not recognized and accommodated by subgroup analysis. Such severity differences do not arise for frank fractures, an observation that likely explains the more apparent stimulation efficacy than for stress fractures. There is evidence to suggest that NSAIDs may disturb fracture healing. Conclusions: It is not possible to conclude unequivocally that any treatment other than rest will assist healing of all forms of stress fracture in all populations. Preliminary evidence suggests, however, that treatment with EFS, LIPUS and/or pneumatic brace is safe and may be effective in certain cases (e.g. more severe injury, highly compliant patients). There is currently no evidence or insufficient data to support the use of other novel treatments such as bisphosphonates or laser. NSAIDs are contraindicated during stress fracture healing. Recommendations: It is clear from the limited literature that more research of treatment strategies for stress fracture is necessary. Study design will be critical, taking into account the need for stratification of injury severity within subject samples. In the meantime, given an absence of harmful side effects, it is reasonable to continue efforts to observe the ability of pneumatic braces, EFS and LIPUS to accelerate stress fracture healing in the field in comparison with historical rates of healing.