In patients with lower limb stress fractures is non-weight bearing better than early mobilisation in reducing complications?

Date First Published:
July 13, 2015
Last Updated:
July 13, 2015
Report by:
Alexander Bulcock, Medical Student (University of Manchester)
Search checked by:
Alexander Bulcock, University of Manchester
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
Search Details:
(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))
+
(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))
Outcome:
299 Hits
34 Relevancies
Relevant Paper(s):
Study Title Patient Group Study type (level of evidence) Outcomes Key results Study Weaknesses
Atypical stress-avulsion fracture of the Lisfranc joint complex Barry J 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
Delayed healing of a navicular stress fracture, following limited weight-bearing activity Matthew 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
Steroid-induced stress fracture of medial tibial condyle: a case report. Kamal 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
Estimation of return-to-sports-time for athletes with stress fracture–an approach combining risk level of fracture site with severity based on imaging Oliver 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
Stress fractures in 2011: practical approach Mathieu 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
Tibial shaft stress fractures resulting from placement of navigation tracker pins David 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
“March Fractures” on a Female Military Recruit Amelia M 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
Identification of a high-risk anterior tibial stress fracture Mark D 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
Management of Tarsal Navicular Stress Fractures Conservative Versus Surgical Treatment: A Meta-Analysis Joseph S 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
Stress fractures of the base of the metatarsal bones in young trainee ballet dancers Walter 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
Stress fracture of the proximal fibula in military recruits Seoung Hwan 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
Surgical Treatment of Refractory Tibial Stress Fractures in Elite Dancers A Case Series Ryan G 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
Navicular stress fractures: a prospective study on athletes Amol 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
Tarsal navicular stress injury long-term outcome and clinicoradiological correlation using both computed tomography and magnetic resonance imaging Scott G 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
Chronic anterior midtibial stress fractures in athletes treated with reamed intramedullary nailing Kevin E 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
Base of fourth metatarsal stress fracture: tendency for prolonged healing Iftach 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
Unusual cause of midfoot pain in a pole vaulter Eric Thomas 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
Insufficiency fracture of the body of the calcaneus in elderly patients with osteoporosis: a report of two cases. Kazuo 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
Fatigue fractures suggesting clinical monarthritis Carlos 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
Stress fractures of the medial great toe sesamoids in athletes Roland 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
Stress fracture of the proximal tibia after total knee arthroplasty: a case report Jiann-Long 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
Proximal fourth metatarsal injuries in athletes: similarity to proximal fifth metatarsal injury Amol 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
Delayed union stress fractures of the anterior tibia: conservative management ME 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
Results of treatment of 22 navicular stress fractures and a new proposed radiographic classification system Amol 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
Effect of rest from running on overuse injuries in army basic training Rose M 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 Methodology needs improvement/ randomised
Did not explain treatment of stress fractures that occurred.
Complications present
Bilateral midfibular stress fractures in a collegiate football player. Steven J 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
Posterior tibial stress fracture: a report of three cases Gabrielle M 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
Stress fractures in female athletes: Diagnosis, management and rehabilitation K 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
Multiple stress fractures of the tibia in a healthy adult. G 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
The effect of a pneumatic leg brace on return to play in athletes with tibial stress fractures E James 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
Common overuse running injuries: diagnosis and management. MT 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
Intramedullary Nailing for Chronic Tibial Stress Fractures A Review of Five Cases Paul S 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
Stress fracture of the body of the talus in athletes demonstrated with computer tomography. Chris 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
Outcome of conservative and surgical management of navicular stress fracture in athletes Eighty-six cases proven with computerized tomography Karim M 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
Author Commentary:
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.
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
  2. Matthew Robinson. Delayed healing of a navicular stress fracture, following limited weight-bearing activity
  3. Kamal Bali. Steroid-induced stress fracture of medial tibial condyle: a case report.
  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
  5. Mathieu Royer. Stress fractures in 2011: practical approach
  6. David Hoke. Tibial shaft stress fractures resulting from placement of navigation tracker pins
  7. Amelia M Duran-Stanton. “March Fractures” on a Female Military Recruit
  8. Mark D Thelen. Identification of a high-risk anterior tibial stress fracture
  9. Joseph S Torg. Management of Tarsal Navicular Stress Fractures Conservative Versus Surgical Treatment: A Meta-Analysis
  10. Walter Albisetti. Stress fractures of the base of the metatarsal bones in young trainee ballet dancers
  11. Seoung Hwan Hong. Stress fracture of the proximal fibula in military recruits
  12. Ryan G Miyamoto. Surgical Treatment of Refractory Tibial Stress Fractures in Elite Dancers A Case Series
  13. Amol Saxena. Navicular stress fractures: a prospective study on athletes
  14. Scott G Burne. Tarsal navicular stress injury long-term outcome and clinicoradiological correlation using both computed tomography and magnetic resonance imaging
  15. Kevin E Varner. Chronic anterior midtibial stress fractures in athletes treated with reamed intramedullary nailing
  16. Iftach Hetsroni. Base of fourth metatarsal stress fracture: tendency for prolonged healing
  17. Eric Thomas Warren. Unusual cause of midfoot pain in a pole vaulter
  18. Kazuo Ito. Insufficiency fracture of the body of the calcaneus in elderly patients with osteoporosis: a report of two cases.
  19. Carlos Garcia‐Porrua. Fatigue fractures suggesting clinical monarthritis
  20. Roland Biedert. Stress fractures of the medial great toe sesamoids in athletes
  21. Jiann-Long Jean. Stress fracture of the proximal tibia after total knee arthroplasty: a case report
  22. Amol Saxena. Proximal fourth metatarsal injuries in athletes: similarity to proximal fifth metatarsal injury
  23. ME Batt. Delayed union stress fractures of the anterior tibia: conservative management
  24. Amol Saxena. Results of treatment of 22 navicular stress fractures and a new proposed radiographic classification system
  25. Rose M Popovich. Effect of rest from running on overuse injuries in army basic training
  26. Steven J Blivin. Bilateral midfibular stress fractures in a collegiate football player.
  27. Gabrielle M van der Velde. Posterior tibial stress fracture: a report of three cases
  28. K Bennell. Stress fractures in female athletes: Diagnosis, management and rehabilitation
  29. G Lambros. Multiple stress fractures of the tibia in a healthy adult.
  30. E James Swenson. The effect of a pneumatic leg brace on return to play in athletes with tibial stress fractures
  31. MT Ballas. Common overuse running injuries: diagnosis and management.
  32. Paul S Chang. Intramedullary Nailing for Chronic Tibial Stress Fractures A Review of Five Cases
  33. Chris Bradshaw. Stress fracture of the body of the talus in athletes demonstrated with computer tomography.
  34. Karim M Khan. Outcome of conservative and surgical management of navicular stress fracture in athletes Eighty-six cases proven with computerized tomography