To The Bone

January 29, 2015
Treating a stress fracture can test the patience of even the most experienced athletic trainer. This two-part article provides a double dose of rehab secrets.
By Summer McKeehan

Summer McKeehan, MS, ATC, LAT is Associate Athletic Trainer for women's basketball at Duke University, where she has been on staff since 2001. She has also served as the athletic trainer for the USA Basketball Women's U18 and U19 National Teams. She can be reached at: summer@duaa.duke.edu.


In more than a decade of working with the Duke University women's basketball team, I've treated stress fractures in bones ranging from the metatarsal to the navicular. Last year, I got a lesson in just how "stressful" these injuries can be while rehabbing a player with a persistent injury to her tibia.

Our starting center, junior Elizabeth Williams, was diagnosed with a tibial stress fracture in her right lower leg as she neared the end of her freshman year. Over the next 14 months, our medical and coaching staffs worked hard keep her on the court and avoid surgery. We did so--Elizabeth earned All-America honors her sophomore season--by using every resource at our disposal and implementing some creative rehab ideas.

Elizabeth came to Duke with no history of bone injury, shin splints, or any other lower-leg problem. In fact, she hardly spent any time in an athletic training room until March 2012. At our first practice in between the Atlantic Coast Conference Tournament and the NCAA Tournament, Elizabeth walked into the athletic training room complaining of pain in the middle of her right shin. She said she'd been experiencing it for three weeks but hadn't said anything, hoping it was nothing and would go away on its own. She told me the pain would come and go frequently during practice, and she often felt it just after practice ended.

Upon examination, I found a visible and palpable lump over the middle of her anterior tibia bone. The area was extremely sore to the touch, as was the medial ridge of the tibia. An X-ray showed a stress fracture in the right tibial shaft, and an MRI found periostitis along the medial ridge of the tibia.

Alison Toth, MD, the Director of the Duke Women's Sports Medicine Program and our Team Physician, determined that it would be safe for Elizabeth to play in the NCAA Tournament if she felt she could cope with the pain. Elizabeth committed to playing through the pain but her game time would have to be limited and she'd likely have to sit out most practices, so we had to ask her coaches if they were okay with this. After receiving their go-ahead, we started working on a treatment plan.

With input from our team physical therapists, physicians, an orthotist, and other sports medicine staff members, I decided to place Elizabeth in a stirrup leg brace which she was to wear whenever she put weight on her leg. I also began massaging the soft tissue around the injury and performed joint mobilizations on the ankle, knee, and hip of her injured leg, often on a daily basis.

Another point of focus for the treatment was to ensure Elizabeth was getting adequate calcium. We increased her intake to 1,200 mg daily and introduced a once-a-day dose of calcitonin (Fortical), a biphosphonate drug that slows the rate of bone thinning and provides some pain relief.

In addition to the medication, we began using the Exogen Ultrasound Bone Healing System on Elizabeth for about 20 minutes each day. The Exogen system uses low-intensity, pulsed ultrasound to stimulate bone growth and accelerate the healing process.

Her practice time was very limited and she generally only participated a day or two before a game. Even when she did take part, we only let her go for about five to 10 minutes. Her game time was cut by an average of six minutes per game, to around 32 minutes, and she was substituted in and out more frequently than during the regular season. To keep her cardio up, Elizabeth used the stationary bike or performed deep-well running in the pool, with instructions to stop if she experienced any pain.

While not an ideal training regimen when preparing for the NCAA Tournament, it enabled Elizabeth to continue playing in the competition. Though it was obvious to those who had seen her play during the season that her jumping ability and reflexes weren't as sharp, she was able to help the team reach the Elite Eight and scored in double figures in all four games.

Once the season was over at the end of March, we gave Elizabeth two weeks off from all cardio and weight-bearing exercises, with the exception of walking to class. During that time, we focused her treatment exclusively on non-weight-bearing hip- and core-strengthening exercises, reintroducing the stationary bike after she remained pain free for the entire two weeks. We also imaged her tibia once a month to ensure the treatment was producing the desired results.

When she made it through the remainder of April and into May without being bothered by the injury, we added a number of exercises, such as mini squats, hip hikes, and hip exercises utilizing an elastic band. She was also allowed to shoot with her feet planted on the floor.

At the end of May, Elizabeth was still doing well despite the additional workload, so we took her treatment to the next level and incorporated the Tibia Stress Fracture Protocol (TSFP), which would progress her from walking, to jogging, to sprinting exercises. Elizabeth spent three weeks advancing through the walking and jogging steps of the TSFP without pain in her shin during or after workouts. However, when the protocol called for sprinting, she would experience pain that prohibited her from finishing the workout. After a week of rest, we'd start the protocol over again, gradually progressing to sprints, but with the same result each time.

At this point, we made the decision to stop following the TSFP and transfer Elizabeth's rehab to our HydroWorx pool. We began with walking, squatting, and hip abduction, adduction, extension, and flexion exercises, and after several pain-free weeks, we added running. We always had Elizabeth wear shoes while walking or running in the pool to provide extra support for her feet and aid in shock absorption for her shins.

By the beginning of July, Elizabeth was again pain free. We continued rehab in the pool and added elliptical work outside the pool at the end of the month. Due to her progress, we decided to try the TSFP again in September. However, just as in May, Elizabeth experienced pain in her shin when she tried to sprint.

At this point, we began to discuss the possibility of surgery with Elizabeth and her parents, but there was still one non-surgical treatment we wanted to explore. I set up an appointment with the team's specialized orthotist, Harvey Johnson, CO, to have her evaluated for orthotics. Due to the overpronation and metatarsus varus of Elizabeth's feet, Johnson felt he could take a lot of the stress off her tibia by creating an orthotic that was supportive and added four to six degrees to the medial arch. This pitch would help decrease the stress put on the tibia by the medial musculature and tibialis anterior muscle.

With new orthotics in both shoes, we began working to get Elizabeth back to running. However, when she made another attempt to progress through the TSFP, a new problem arose--pain on the lateral side of her left foot. An MRI revealed a stress reaction in her cuboid and fifth metatarsal. Johnson shared my opinion that the orthotic, coupled with possible overcompensation for the stress fracture in her right tibia, was likely causing the pain in Elizabeth's left foot.

Johnson unloaded the area of the fifth metatarsal on Elizabeth's orthotic to relieve some of the pressure on the bone and constructed a forefoot fracture brace for her left foot. Generally, I place an athlete with a foot stress injury in a walking boot, but it worsened the pain in Elizabeth's right shin, so we eliminated the boot and had her wear her fabricated orthotics and forefoot fracture brace full time.

At this point, Elizabeth was suffering from a tibial stress fracture, periostitis, and a stress reaction--all bone-related problems. To cover all the bases, we decided to get a blood work-up done on Elizabeth and requested testing for complete blood count, calcium, phosphorus, bone alkaline phosphatase, thyroid panel, basic metabolic panel, 125 OH vitamin D total, parathormone OP panel, and serum parathyroid hormone. Thankfully, all results came back normal.

Fortunately, the fracture brace began to help ease Elizabeth's discomfort, and in early October I decided to institute a new plan to help get her back practicing again. In order to determine how much activity was required of players in her position, I timed our other post players during several practices, focusing only on the time spent in drills or other activities. I found that during a two-hour practice, our posts were participating in around 30 minutes of activity.

Elizabeth's pain was much better than at the end of the previous season, but was still an issue. I decided to start with allowing her five minutes of activity during each practice. Based on the rehab efforts earlier, we knew we could control her pain better if she practiced on two consecutive days, followed by a day off. By increasing the amount of activity by a few minutes each week, we graduated to two full practices per week by November and added a third in January. When we reached the end of February, she was practicing full time.

We continued using the ankle- and foot-joint mobilizations, orthotics, and fracture brace for the remainder of the season. It certainly wasn't an exact science, and we kept Elizabeth out of practice if she was experiencing pain in the area of the fracture, but we were able to get and keep her where she wanted to be--on the court. She finished her sophomore campaign as a John R. Wooden Award finalist, Associated Press Third-Team All-American, and ACC Defensive Player of the Year.

With the season over, we decided that Elizabeth should take two consecutive months off, with no exercises other than non-weight-bearing core work and hip strengthening. In June, we used the TSFP and continued to limit her summer practice hours. The protocol worked much better this past summer than in 2012 and she progressed to sprinting without problems.

Elizabeth has been pain free since June and is having a standout junior year. She continues to compete in practices and competitions without physical restrictions or time constraints. Everyone involved in her treatment agrees it was a challenging journey. However, we're all overjoyed to have avoided surgery and achieved such a positive outcome.


Opting for Surgery

By Dustin Williams

Dustin Williams, ATC, is an Associate Athletic Trainer at the University of Arizona, working primarily with the men's and women's cross country and track and field teams. Previously, he worked as the Head Athletic Trainer for Cross Country and Track and Field at Brigham Young University and was on the USA Track & Field Team staff at the 2012 London Olympic Games. He can be reached at: djwilliams@email.arizona.edu.


Treating stress fractures is unlike working with other injuries due to the unpredictability of the recovery process, especially when you're trying to avoid surgery. Just when you think you're making progress, another issue can pop up and derail your rehab.

While I was an athletic trainer at Brigham Young University in 2009, Rachel Fisher, a freshman pole-vaulter, reported in her pre-participation physical exam that she had been diagnosed with a navicular stress reaction in her left foot the previous spring. The injury was bad enough to keep her from competing in the high school state championships.

Her treatment had entailed crutches and a restriction to non-weight bearing movements for four weeks. She then spent another four weeks in a boot that enabled her to put minimal weight on the foot, and after progressing through walking, jogging, and light-running rehabs, she eventually went on to win the pole vault competition at the AAU Junior Olympics that August.

When she arrived on campus a few weeks later, the injury had healed, so our primary goal was to prevent a recurrence. To help achieve this, we tried to increase her ankle strength and proprioception by using resistive bands, balancing work, and single- and double-leg bounding exercises. We also had her custom-fitted for orthotics to support her foot and ankle joint.

We spoke with Rachel and then-Assistant Pole Vault Coach Erik Rasmussen about the importance of not overtraining--we wanted them to focus on quality, not quantity, especially in her pole-vaulting exercises. Coach Rasmussen substituted about 30 percent of Rachel's sprint workouts for deep-water running and bicycle sprints, and he put her through many of the pole-vaulting drills at a walking pace. We also requested that she practice on soft surfaces whenever possible, so Coach Rasmussen had her do many jump and take-off drills on the pole-vault mat.

Rachel stayed healthy and did very well during the indoor season, qualifying for the NCAA Division I Indoor Championships and finishing 16th. However, shortly after the indoor season, her left ankle began to bother her in the same area in which she had suffered the stress fracture the year before. BYU's Head Team Physician, Mitchell Pratte, MD, prescribed her an NSAID for what we thought was a soft-tissue ankle strain and not a recurrence of the stress fracture.

We began treating Rachel's ankle with various modalities, including ice, e-stim, ultrasound, Graston technique, and NormaTec compression. We also adjusted her training to include more bike and pool workouts to unload the ankle joint as much as possible.

However, after about two weeks, she started developing soreness in her left mid-foot region. An MRI revealed that she had a stress-reactive marrow edema throughout the navicular, without a focal fracture line. She had also developed a stress fracture of the fourth metatarsal. We immediately referred her to our foot and ankle orthopedist, Robert Faux, MD.

Dr. Faux noted that Rachel also had a moderate-to-severe cavus foot with first metatarsal overdrive. He felt the stress fracture in her fourth metatarsal was the result of compensation from the return of the stress reaction in her navicular. She was instructed to discontinue the NSAID and was prescribed a new orthotic with first metatarsal head release and a more rigid hindfoot and arch structural support. She was also instructed to take 1,500 mg of calcium with vitamin D daily.

Surgery was discussed at this point, but Rachel wanted to return to competition as quickly as possible, and surgery would have kept her out for six to eight months. We decided to try a conservative approach and agreed to revisit the surgical option down the road if we weren't getting results.

We kept Rachel in a walking boot and had her do some pool therapy after a week, including deep-water jogging and sprinting and bounding exercises in the shallow end. To assist the healing process, we utilized a bone stimulator, Graston technique, fascial stretching, NormaTec compression, and ice. A week later, at the end of April, we started her on jogging and running progressions on our AlterG Treadmill.

For the next four weeks, Rachel did most of her training on the AlterG. Her workouts were done at 70 percent of her bodyweight and included five minutes of jogging and 10 sprints of 20 seconds each, with 40-second rest intervals between each sprint. She was allowed to do vault drills, mainly on the pole-vault mat, but nothing that involved running.

Communication with Assistant Strength and Conditioning Coach Josh Morzelewski, MS, CSCS, was essential in making sure Rachel followed the proper progression during her lifting sessions. Utilizing the pole-vault mat to provide more cushioning for her ankle, we began with plyometric exercises, such as double-leg bounding, skips, and simulated vault take offs. We also introduced lifts such as Romanian deadlifts, glute-hamstring raises, and push presses, and slowly introduced a variety of Olympic lifts such as squats, dead lifts, and clean pulls to help strengthen her lower legs without significantly impacting her ankle.

Thanks to her strong performances during the indoor season, Rachel had qualified for the USA Junior Track and Field Championships at the end of June, and she was determined to compete in that meet. She was pain free at this point and her conditioning was nearly back to an optimum level, but her vaulting technique wasn't as sharp as it had been in the past. We had been limiting this type of activity because we felt it was too risky and might compromise her recovery.

We supported her foot and ankle joint by integrating arch and ankle taping to prevent a reccurrence of the fracture. However, her performance suffered as a result of the technique issues and she did not place well. Afterward, she went home for the remaining six weeks of the summer so we decided her recovery would be best served if she trained very lightly to allow for more healing in her foot and ankle.

For the fall training, we designed a rehab program aimed at stabilizing the ankle joint using strengthening exercises with TheraBands, balancing exercises on an Airex pad and trampoline, and plyometric and pole-vault drills on the pole-vault mat. We also included sprint workouts on the AlterG, and as a preventative measure limited her other running to what she was doing with a pole during practice.

During the 2011 indoor season, Rachel--now a sophomore--was competing well and had no pain in her left foot or ankle. We did an arch tape and ankle tape for all vaulting practices and competitions and would ice her foot regularly.

Then, after breaking BYU's indoor pole-vault record and qualifying for the NCAA Indoor Championships, she began to develop pain in her right ankle for the first time. It appeared to be a soft-tissue ankle strain so we incorporated similar treatments that we utilized for her left ankle. She was able to compete in the indoor championships, but this time the pain hindered her performance and her results suffered.

The pain persisted, so we had Rachel seen by our physician and orthopedist again. An MRI of the right ankle showed that she had diffuse bone marrow edema in her navicular bone, without a fracture line. Because this was her fourth stress fracture in a two-year period, we also did a DEXA scan and had blood work done to evaluate her bone density, but all the tests came back in the normal range. She was instructed to wear a walking boot and use a kneeling scooter for two to three weeks and we planned to slowly transition her back into full activity as the symptoms lessened.

However, at this point Rachel had grown very frustrated with the situation, especially since she was now dealing with injuries to the navicular bones in both feet. After three weeks of very little progress, and following a thorough discussion with Dr. Faux, Rachel and her parents decided it was time to pursue surgical options.

The decision was difficult for them because Rachel had experienced some success with conservative treatments and didn't want to miss an extended period of time while she recovered from surgery. However, it had become apparent that the risk of re-injury was high with the non-surgical approaches we had been taking. Ultimately, Rachel decided to have both feet operated on simultaneously.

The surgery--a bilateral navicular percutaneous ORIF procedure--was successful. Afterward, Rachel was restricted to a wheelchair for two weeks and instructed to wear bilateral walking boots and use the kneeling scooter for the next four weeks. After the initial two weeks, we began light pool workouts and ankle range-of-motion exercises. As she progressed, we introduced some work on the bike, as well as foot and ankle intrinsic rehab exercises with gradual increases in both reps and duration.

I was hired by the University of Arizona in the fall of 2011, but was later informed that Rachel continued working with the sports medicine staff to slowly progress back into full activity. Using the AlterG Treadmill and the same progression plan that we had developed for her prior to surgery, she was able to return to competition approximately eight months after her surgery. This past year, she won a number of competitions and qualified for the first round of the NCAA Division I Outdoor Championships.

I certainly don't feel that surgery is required for every athlete who suffers a navicular stress fracture, and I've had success with non-operative treatments when the injury is detected early. However, if the injury is recurrent, surgery can be a valuable tool in helping the athlete return to competition.
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