Diagnosis of fatigue fracture
The diagnosis of a fatigue fracture is often difficult. Often athletes simply come to the doctor with complaints of the foot, lower or upper thigh, which are described as unclear pain. If the doctor suspects a fatigue fracture, he will take a specific medical history (anamnesis).
Important questions here are, for example: It is always interesting to find out whether there are other diseases (osteoporosis, foot malpositions). This interview is followed by a physical examination, during which the doctor will look at the painful area and see whether any swelling, overheating or redness has developed there. If there is still a suspicion of a fatigue fracture, an X-ray is usually taken.
However, many fatigue fractures are not visible in the X-ray image, especially at an early stage. So if the image is unremarkable, either another image can be taken after one or two weeks or a computed tomography (CT), magnetic resonance imaging (MRI) or scintigraphy can be performed. Especially the last two of these imaging methods are much more complex and expensive than X-rays, but in case of doubt they can provide a much more reliable and earlier result.
During the diagnostic process, the physician must always clarify whether the symptoms could have a different cause. Compartment syndrome and shinbone edge syndrome cause similar symptoms, as do some tumors and infections.Probably the most important differential diagnosis of a fatigue fracture is rheumatism. Many patients confuse a fatigue fracture with rheumatic complaints, which is why they consult a doctor only very late or not at all.
- How long the pain has existed
- When they occur (permanently or only under stress)
- Whether there have been recent accidents or other possible triggers for the pain and
- With women: abnormalities in the menstrual cycle or whether the menopause has already begun
Localization of a fatigue fracture
A fracture in the heel area can cause severe pain in the affected patient. In most cases, the cause of the fatigue fracture of the heel is excessive strain during walking and running. For this reason, such fatigue fractures in the heel area can be observed especially in running and hiking.
In addition to the metatarsus and the shinbone, the heel is one of the body parts where excessive strain causes fatigue fractures (synonym: stress fracture). In addition, the patients affected are at risk of developing inflammatory processes in the area of the bone fracture. For this reason, a specialist should be consulted immediately if pain symptoms exist and a fatigue fracture of the heel is suspected.
Patients who have a fatigue fracture of the heel usually complain of severe pain, which makes its occurrence almost impossible. In addition, a clear swelling and redness in the heel area can be detected during the examination. The diagnosis of heel fatigue fracture is made on the basis of the clinical symptoms and the preparation of X-rays in two different planes.
For this purpose, the foot is imaged both from the front and the side. If the findings are unclear, computer tomography (CT) and/or magnetic resonance imaging (MRI) may also be necessary. The fatigue fracture of the heel can be performed non-surgically (conservatively) or surgically, depending on its severity and exact location.
An uncomplicated fatigue fracture of the heel with well adapted fracture ends can be treated with a simple plaster cast in most cases. Painkillers such as paracetamol or ibuprofen can be taken to relieve pain. Despite the application of the plaster cast, the affected patient must protect the fractured heel for a period of ten to twelve days.
A dislocated (displaced) fatigue fracture of the heel usually requires surgical correction. During the surgical procedure, the ends of the fracture are placed together and connected with wires and/or plates. Afterwards, the foot can be plastered up to the lower leg and thus relieved.
Wires and/or plates can (but do not have to) be removed after a few months. Even if the ankle joint is involved, surgical intervention is unavoidable. Since the foot is subjected to enormous stress, especially in running, fatigue fractures are particularly common in this part of the body.
In people who regularly walk long distances, fatigue fractures occur mainly in the area of the metatarsal bones, near the second toe. Similar to the fracture of the heel, the fatigue fracture of the metatarsus also makes itself felt by the sudden appearance of severe pain. Classically, the pain symptoms intensify when walking or running.
In addition, the broken foot appears swollen and may show severe redness of the skin. The fatigue fracture of the foot cannot always be proven by X-ray in the first few days. In diagnostics, the preparation of x-rays in two planes is often only effective with a delay of three to four weeks.
The reason for this is that fatigue fractures of the foot can usually only be detected by the occurrence of typical calcifications in the area of the fracture ends. With the appropriate symptoms, the suspicion of a fatigue fracture of the foot can only be substantiated by a bone scintigraphic examination or an MRI of the foot. A skeletal scintigraphy and an MRI of the foot can reliably detect a fatigue fracture in this area.
The fatigue fracture in the area of the foot must be relieved and immobilized urgently. If the fracture ends are in the area of the metatarsus, sufficient immobilization can be achieved by wearing a so-called “forefoot relief shoe”.Decongestant measures such as lymph node drainage and kinesio tapes can be used to support the process. A fatigue fracture of the foot usually heals completely within 4 to 6 weeks.
A fatigue fracture in the metatarsus is caused by a persistent overloading of a joint or bone and is usually caused without additional external force. Theoretically, a fatigue fracture can occur in any bone, but bones that have to withstand particularly high loads are predestined. It is therefore not surprising that especially athletes often suffer a fatigue fracture in the metatarsus.
In general, the 5 metatarsal bones (Os metatarsalis) belong to the metatarsus. Particularly during various jumping exercises, the metatarsus can become overloaded. If this overload persists, it is possible that the structure of the bone and thus its resistance changes.
For example, a female figure skater may want to try out a new figure, in which she puts a lot of strain on the metatarsus, which initially causes only small softening and cracks in the bone in this area of the foot, but these then become deeper and deeper. Especially with such new exercises it can happen that one overestimates oneself and especially the strength of the bones and thus provokes an overtiredness fracture. Due to the permanent overloading of the metatarsus it is possible that a fatigue fracture develops slowly.
This means that the bone tears more and more due to the constant overloading until it finally does not have sufficient cohesion and breaks. It is important, however, that a fatigue fracture in the metatarsus, as in any other bone, does not manifest itself as a classic fracture with sudden severe pain and is the result of an event, such as an acute fall. In most cases, the patient feels the first slight symptoms already in the phase of overstrain.
For example, the metatarsus may be slightly swollen or the patient may experience increased pain in the metatarsal area after exercise. In the case of the fatigue book itself, the symptoms are then usually more severe, i.e. the midfoot is more swollen as a result of the fatigue fracture, possibly discolored slightly bluish due to bleeding, and there is more severe pain. However, in comparison to a “real” fracture, the symptoms often do not occur suddenly but only intensify the existing symptoms.
This also explains why many sportsmen and sportswomen do not notice that they have suffered a fatigue fracture of the metatarsus over a longer period of time. Here it is important to pay attention to the minor symptoms of the body. If the metatarsus is no longer able to bear weight properly and is also slightly swollen and/or reddened and/or painful, it may very well be a fatigue fracture of the metatarsus, which should definitely be treated.
In the early stages, it is usually sufficient to keep the foot still and not to put any more weight on it. However, if you ignore the symptoms and continue putting weight on the metatarsus despite the fatigue fracture, the fracture may deepen and possibly even require surgery. The most common reason to suffer a fatigue fracture of the metatarsus is excessive jogging.
Runners with a weekly volume of more than 50 km week are at risk. Runners with a weekly volume of 10 – 20 kmweek, can usually not suffer a fatigue fracture in the metatarsus. A fatigue fracture of the tibia is also most frequently caused by permanent overloading of the bone.
Fatigue fractures of the tibia are divided into two classes. A distinction is made between fractures of the healthy tibia and fractures of the pathologically altered tibia. A fatigue fracture of the tibia that is solely due to excessive load is also known as a stress fracture.
In the case of abnormally altered bone substance, however, even slight stress is sufficient to cause a fatigue fracture. In such cases one speaks synonymously of insufficiency fractures. Triggers for this form of fatigue fracture of the shin bone are osteoporotic changes, rheumatoid arthritis or rickets.
As a result of these diseases, the tibia becomes increasingly porous and less resistant to compressive forces. Typical symptoms of fatigue fracture are tibial pain, which begins gradually, increases under stress and subsides again at rest.If the fracture lasts for a long time, the pain symptoms become more pronounced, so that in the course of the fracture, symptoms are also noticeable at rest. In addition, swelling and redness in the area of the tibia can often be observed.
A restriction of mobility is not usually triggered by the fatigue fracture of the tibia. The treatment of a tibia fracture involves immobilising the affected leg for several weeks. For this purpose a plaster cast is applied in most cases.
However, if the fracture ends are poorly adapted, surgical treatment of the tibia may be necessary. During the surgical correction, the bone ends are brought together and connected with special screws and/or a metal plate. In general, the healing process of the fatigue fracture of the tibia is significantly accelerated after surgical correction.
The lower leg can be loaded again much faster. In most cases, the cause of a fatigue fracture of the tibia – as with a fatigue fracture of the metatarsus – is excessive jogging (more than 50 km week). A fatigue fracture of the knee always occurs when the knee is overloaded over a longer period of time.
However, since the knee is a joint, it is not the knee itself but one of the surrounding bones that breaks. For example, a fatigue fracture in the knee can affect the head of the fibula of the lower leg. This head is located on the outside below the knee and is particularly susceptible to fatigue fractures because it is a very narrow bone which is particularly susceptible to fatigue fractures in the knee when the knee is rotated.
As with any other fatigue fracture, it is important that the symptoms appear slowly and not, as with a “normal” fracture, caused by external force such as a fall. However, a fatigue fracture of the fibular head usually manifests itself by a significant restriction of movement of the knee and lower leg. A fatigue fracture in the area of the knee can also occur directly in the kneecap (patella).
Especially athletes who put a lot of strain on their knees, such as gymnasts or dancers, can cause the kneecap to tear further and further until a fatigue fracture occurs. Such a fracture then manifests itself especially during knee movements by pain, swelling or redness in the area of the knee. Especially climbing stairs is becoming more and more difficult for the patients concerned, as the knee is put under particular strain, but also jogging is considerably impaired.
Also here it is important to pay attention to the signs of fatigue fracture in the knee and not to underestimate it. Even if a fatigue fracture manifests itself by slowly increasing pain and not by sudden acute pain, the bone can suffer damage just as much as if it is suddenly broken by an external influence (fall, blow …). In most cases, a fatigue fracture of the knee can be treated well by simply immobilizing the knee.
However, it is important that the patient adheres to this and does not continue to overstrain the knee, as this can lead to permanent damage, which is associated with major impairments, especially in the knee. A fatigue fracture in the area of the fibula can occur either in the area of the knee, i.e. the fibular head, or in the lower area of the fibula, the area of the outer ankle. Only very rarely does the fibula break in the middle and if so, then it is more likely to be a “normal” fracture due to external violent influences than a long-lasting overload such as that which occurs in fatigue fractures.
In the area of the external ankle (malleolus lateralis), an over-fatigue fracture can occur especially in the case of sustained overload during long marches, for example in the German Armed Forces, or as a result of hard jogging training. This is manifested by recurrent swelling in the ankle area as well as redness and pain on the steps. The pain becomes worse under stress, i.e. when running, but especially when jumping or jogging, as the fracture then deepens further and further due to the continuous stress.
A fatigue fracture in the outer ankle is particularly promoted when the patient bends over and over again while jogging/walking and thus puts a lot of strain on the ligaments and muscles but also on the bone.It is also important here to take absolute care of the fatigue fracture in the outer ankle and to stop the training for a longer period of time because otherwise the fracture will continue deeper and deeper and can lead to considerable impairment. Since the first symptoms are usually only slight swelling and moderate pain, it is important to pay attention to these small signs, otherwise a fatigue fracture can usually only be diagnosed at an advanced stage. A fatigue fracture in general is caused by permanent overloading of one or more bones that together form a joint, such as the wrist.
The wrist (Articulatio manus) consists of the lower parts of the forearm as well as the front row of carpal bones, more precisely the wrist consists of the radius, a joint surface (Discus radioulnaris) and the 3 carpal bones Os scaphoideum, Os lunatum and Os triquetrum. Theoretically, a fatigue fracture can occur in any of these bones (whereby the discus is not a bone and is therefore not described further). Particularly at risk are gymnasts, who often put a lot of strain on their wrist, but also musicians can strain and irritate the bones in the wrist to such an extent that a fatigue fracture occurs due to continuous incorrect loading.
This manifests itself through swelling and slight pain in the wrist area, whereby the pain gets worse under stress and the swelling also increases depending on the degree of stress. Since a fatigue fracture initially only begins gradually, it is important that it is diagnosed in good time, as otherwise it can lead to a complete fracture of the upper part of the radius, for example. In this case a simple rest is often not enough. The wrist has to be operated and it takes much longer until the wrist can be used adequately again. Especially since the wrist is responsible for filigree work, a fatigue fracture in this area should not be underestimated and the first signs should not be ignored.
