Sports Medicine: Just the Facts

376 SECTION 4 • MUSCULOSKELETAL PROBLEMS IN THE ATHLETE

•Tension sided stress fractures(mid shaft anterior)

1.These require more aggressive treatment because

of the predisposition to nonunion. Immobilization

in a nonweightbearing cast for 3–6 months is the

standard treatment. If no evidence of healing at

3–6 months, an electrical stimulator may have

some benefit.

• Return to play
  
  
  1. Patients may return to athletic activity when they
     have no pain with unprotected daily activity,
     there is no bony tenderness, and the radiographs
     show evidence of healing (Green, Rogers, and
     Lipscomb, 1985).
  
  
  
  

2. When patients can walk without pain, they may
   jog. When they can jog without pain, they may
   run. When they can run or jump without pain,
   they may compete.

• Indications for surgery
  
  
  1. Surgery should be reserved for patients with
     anterior tibial stress fractures who fail to heal
     after 6 months of nonoperative treatment.
  
  
  2. Surgery should also be considered for the high-
     level athlete who is unwilling or unable to
     comply with a prolonged period of inactivity.
     •Surgical procedures
  
  
  3. Cortical drilling: In an attempt to stimulate the
     reparative process, multiple transverse 2–3 mm
     drill holes are made a few centimeters proximal
     and distal to the fracture. Cortical drilling is fre-
     quently combined with bone grafting.
  
  
  4. Bone grafting: Autogenous cancellous bone is
     harvested from the ipsilateral iliac crest and
     packed into the fracture gap and around the sides
     of the fracture site. Healing time may be 5 months
     from surgery (Wang et al, 1997).
  
  
  5. Intramedullary nailing: A reamed nail is recom-
     mended to provide a larger contact area and
     increased stiffness to resist tension across the
     fracture area better than an unreamed nail.
     a. A short leg splint may provide initial postop-
     erative comfort but this is exchanged for a
     hinged walking bootorthosis as soon as possi-
     ble.
     b. Knee and ankle motion exercises are begun
     immediately.
     c. Crutches are used for comfort only and dis-
     continued when weight bearing is well toler-
     ated.
     d. Conditioning with biking, swimming, or
     water walking can begin within a few weeks.
     e. Impact loading and running may begin as
     early as 6 weeks with full fracture healing
     usually taking 6 months.
  
  
  
  

POSTERIOR TIBIAL TENDON INJURY

• Injury to the posterior tibial tendon may occur
  from an acute traumatic event, which may signify
  tendon disruption, or as part of chronic overuse
  syndrome, which could signify posterior tibial ten-
  donosis.
  •Surgical evaluation
  
  
  • History: Patients report pain along the medial aspect
    of the leg posterior to the medial malleolus. The
    onset of pain is usually gradual with increases in
    such activities as walking, running, or jumping.
    •Physical examination
  
  
  • There may be loss of the longitudinal arch and a
    planovalgus deformity, as evidenced by the too
    many toes sign. When observing the patient from
    behind, the affected side will reveal more toes lat-
    eral to the heel than the unaffected side.
    •With an attempted single leg heel raise, there is loss
    of foot supination and heel inversion.
  
  
  • There is tenderness to palpation over the course of
    the tendon.
    •Pain and weakness are present with resisted inver-
    sion.
  
  
  
  


• Imaging
  
  
  • The X-ray evaluation should include standing
    anteroposterior and lateral views.
    1.Anteroposterior(AP) view: look for medial talar
    displacement in relation to the navicular bone.
    2. Lateral view: look for decreased height of the
    longitudinal arch (Trevino and Baumhauer,
    1992).
  
  
  • Magnetic resonance imaging(MRI) is the test of
    choice to evaluate the posterior tibial tendon for
    signs of tenosynovitis versus tendonosis (Trevino
    and Baumhauer, 1992).
  
  
  
  


• Nonoperative care
  
  
  • Initial management should be nonsurgical.
  
  
  • Options for resting the tendon vary from activity
    modification to immobilization with the use of a
    short leg walking boot or short leg walking cast.
  
  
  • Orthotics should be used to support the arch and
    relieve stress on the tendon.
  
  
  • Corticosteroid injections are not recommended
    because of the risk of tendon rupture.
    •Surgical management
    •Surgery should be considered in those who do not
    respond to nonsurgical management after 6–12 weeks
    or those with loss of the arch (Mann, 1993).
    •Surgical options include synovectomy for inflamed
    synovium and more extensive procedures such as
    flexor digitorum longus transfer for significant
    tendon dysfunction.