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CLINICAL CASE REPORT: MANAGMENT OF NAVICULAR STRESS REACTION IN ELITE ADOLESCENT SPRINTER
Musculoskeletal Physiotherapy and Sports Medicine
A 16-year-old elite national sprinter presented to a sports injury clinic with a 1 day history of left ankle and dorsomedial foot pain. He reports the onset of pain half way through sprint training less than 24 hours prior to presenting to the clinic. His main concerns were the following mornings pain and stiffness upon waking.
The sprinter describes a forced plantarflexion/ inversion action during initial contact of his left foot while sprinting the corner of the 200m track. He described his pain as initially sharp with a pinching sensation over the medial dorsal aspect of his left foot. The pain did not stop him completing the sprint and the sharp pain subsided once he stopped running. He was able to complete the full training session with a dull ache, NRS 7/10. Post training the athlete iced his foot and consumed one recommended dosage of over the counter NSAIDs. Both of which provided some pain relief overnight. The athlete describes the ankle and foot to be stiff and painful on weight-bearing, walking and had moderate discomfort with ascending stairs. The athlete is concerned about his ability to compete in an important sprint qualifying event in 10 days. The current training load on track is 4 days a week and his gym based program 3-4 days a week.
The patient has an 18-month history of left sided tarsal navicular bone stress with one reactive bone stress reoccurrences within 12 months. The athlete reports no symptomatic bone stress for the past 6 months and reports this pain in a similar location; however, is confident that this is different to what he has previously experienced.
The sport physician that has managed the athlete over the past 18-months reports on two left foot MRI’s 4 months apart. The first MRI imaging shows extensive marrow oedema in the distal central navicular with no frank fracture line, consistent with a stress reaction. The follow up MRI described improved bony oedema in comparison to the previous MRI. The management was conservative with restricted weight-bearing in a below the knee CAM boot for 6 weeks initially and 4 weeks upon flare up. This was followed by a return to sport gradual loading run program.
Functional examination revealed pain NRS 2/10 with weight-bearing, pain was increased with a double leg heel raise and single leg heel raise to NRS 5/10 and 6/10 respectively. Hopping on the left leg continuously 5 times reported pain of NRS 8/10 with push off and a decrease in jump height and poor midfoot mechanics on push off was predominantly noticeable in comparison to the unaffected side. Ankle dorsiflexion was measured with a knee to wall (KTW) test which resulted in a 7cm deficit of the left ankle (right 9cm, left 2cm).
Upon physical examination, localised oedema was noted over the talonavicular region and this was accompanied by tenderness on palpation of the talonavicular joint line. The proximal dorsal navicular (‘N spot’) was negative on palpation and subtalar stiffness was noted. Plain film findings included an unremarkable tarsal navicular and an accessory navicular bone (os tibiale externum) was documented to be an old finding due to its callus formation.
Treatment was focussed on a running diagnosis of talonavicular joint impingement. Soft tissue massage of the left deep posterior compartment, tibialis anterior, gastrocnemius and soleus muscles was performed, along with grade 4 mobilisations of talonavicular and talocrurial joints in an effort to restore ankle dorsiflexion. On re-assessment KTW was immediately improved by 4cm and single leg heel raise pain decreased to NRS 3/10. A home-based exercise program was prescribed including isometric double leg heel raises with mini band biasing lateral compartment and mini band crab walks with eversion focus. Low-die taping with a navicular lift decreased pain with weight-bearing, walking, hopping and sprint training on a 3 day follow up. The sprinter competed in 4 of his 6 possible events in the national sprint qualifiers with moderate pain during the event. After re-evaluation 18 days post initial presentation the patients acute foot pain had completely resolved; however, the runner was reporting a change in symptoms and now reports an underlying diffuse foot pain that doesn’t seem to go away. The sprinter was referred for sports physician review on the basis of navicular stress clinical suspicion in combination with the previous left foot history.
Upon review with the sport physician, the sprinter discloses a history of foot pain with training present for 4-6 weeks prior to this acute ankle pain. Palpation confirmed a positive ‘N spot’, an MRI revealed moderate navicular bone marrow oedema throughout with no frank fracture line. An extensive review of the patients 18-month history including MRI comparative images the sport physician placed the sprinter in a CAM boot NWB for 6 weeks with relative rest including NWB gym and swimming program for maintenance of strength and fitness.
The sprinter was removed from NWB CAM boot at 6 weeks. Follow up resulted in no pain on weight-bearing and some discomfort on palpation of the ‘N spot’, along with a stiff and weak ankle as to be expected. A graded return to sprint loading program commenced at 6 weeks and was planned for 8-12 weeks prior to full unrestricted return to sport. Future MRI review at 8 weeks post boot removal is requested by the sports physician for bony healing assessment. A 6 and 12-month follow up of the case to be reported when time frames met for an insight into longer term outcomes.
For information on navicular stress fractures and diagnostic imaging I searched the MEDLINE database through Ovid and SPORTDiscus through the EBSCOHost interface. Search terms “tarsal bones”, “lower limb”, “foot”, “stress fracture”, “stress reaction”, “diagnostic imaging” and “MRI” were used to define the search results.
MEDLINE focuses on a journal database targeted towards health sciences and biomedicine, only publishing journal articles that are relevant to health professionals and researchers. The literature is peer reviewed and exposes the authors, researchers and location of the research. The database itself claims that over 90 percent of their articles are published in English. The University of Technology Sydney (UTS) allows students full access to this resource.
SPORTDiscus with Full Text has a large range of peer reviewed journals dedicated to sports medicine, allied health and sports management. The search engine is simple and easy to use and UTS offers full access. The resource is relevant to this sports case and health professionals, researchers and students in the physiotherapy and biomedical profession.
Stress fractures account for a large portion of all overuse injuries in athletes, military personnel and the physically active population, with up to 95 percent of stress fractures occurring in the lower limbs (Liong & Whitehouse, 2012; Warden, Burr, & Brukner, 2006; Wright, Taylor, Ford, Siska, & Smoliga, 2015). Up to 20 percent of injuries seen in the sports medicine clinic are reported to be stress fractures, with track and field athletes the most common of all sports (Fredericson, Jennings, Beaulieu, & Matheson, 2006). In athletes, foot and ankle stress fractures contribute to approximately 10 percent of all sporting injuries (Kaiser, Guss, & DiGiovanni, 2018), with the tarsal bones comprising 10-25.3 percent (Liong & Whitehouse, 2012; Matheson et al., 1987; Wentz, Liu, Haymes, & Ilich, 2011).
Females are reported to have a higher incidence of stress fractures compared to their male counterparts; however, more research is needed around the variables contributing to females obtaining more stress fractures than males. It is now suggested that this could be less to do with gender predisposition and more heavily weighted towards overall physical conditioning and the physiological state of the individual (Wentz et al., 2011).
The tarsal navicular bone is considered a high-risk stress fracture due to a relatively avascular middle third (Boden & Osbahr, 2000). The bone is supplied from the dorsal, plantar and medial aspects by the posterior tibialis and dorsalis pedis arteries, leaving the middle third or what is commonly referred to as the ‘watershed area’ with minimal vascular supply. Various imaging studies have confirmed this area to be the most common fracture site, leaving it prone to poor healing and ultimately delayed or non-union (Khan, Fuller, Brukner, Kearney, & Burry, 1992; Mccormick et al., 2011).
Navicular bone stress is often accompanied with a lengthy delay in diagnosis of 4 to 7 months (Gross & Nunley, 2015; Torg et al., 1982). The nature of bone stress typically involves a gradual onset of symptoms with vague foot and ankle pain and no clear mechanism. The patient often presents after a period of discomfort; however, is usually high functioning. In combination with plain film radiographs having a poor diagnostic accuracy, this often builds a challenging case for diagnosis (Potter, Brukner, Makdissi, Crossley, & Kiss, 2006; Torg, Moyer, Gaughan, & Boden, 2010).
High index of suspicion is needed in athletes experiencing an insidious onset of symptoms, poorly localised midfoot pain which is aggravated by activity and eased by a period of rest (Shakked, Walters, & O’Malley, 2017). Clinically, tenderness of the ‘N-spot’ has been shown to correlate with 81 percent of confirmed navicular stress fractures (Torg et al., 1982). Pain with heel raise and single leg hop are also considered strong indicators, as well as subtalar joint stiffness and ankle dorsiflexion restriction commonly reported on in navicular stress fracture cases studies (Shakked et al., 2017).
The nature of the injury presentation leaves a key component of diagnosis to appropriate imaging. MRI is considered the best imaging modality for identifying bone oedema and stress reaction. As a bone stress reaction is often seen prior to a frank fracture line, detecting these radiographic changes early may prevent progression of a stress fracture. MRI also clearly defines the medullary extension of the fracture while minimising the amount of radiation exposure. CT scans are often used after MRI has confirmed the navicular stress fracture to remodel the fracture on imaging for precise fracture grading and intervention (Gross & Nunley, 2015; Patel, Roth, & Kapil, 2011; Shakked et al., 2017).
Prognosis of navicular stress fractures has been researched by Saxena et al using a fracture grading system to select appropriate surgical or conservative interventions. The grading system is defined as type 1 fractures: fracture extension only invades the dorsal navicular cortex, type 2: fracture extension invades into the navicular body and type 3: fracture extension into a second cortex of the navicular bone. Type 1 fractures are treated NWB for 6 weeks and type 2 and 3 fractures ORIF surgery with post op NWB for 6 weeks. The study reports an average return to play time of 4-months for both interventions. The study is to be carefully interpreted with a small sample size of only nineteen cases reported and a larger cohort may return different outcomes. When combined with an earlier study of the authors assessing the outcomes of 22 navicular stress fractures they report no statistically significant difference in recovery time between surgical and conservative management of all fracture types (Saxena & Fullem, 2006).
Recently, a meta-analysis of 251 navicular fractures concluded no statistically significant difference between 6 weeks of NWB treatment and surgical intervention ORIF, with a mean return to play time of 4.9 and 5.2 months respectively. Interestingly, the study also revealed gender, age or delay in intervention from onset of symptoms had no significant effect on outcome (Torg et al., 2010).
More recently, a systematic review contradicted Torg et al, identifying surgical intervention ORIF had a faster return to play time of 16.4 weeks compared to 21.7 weeks with conservative management. Post op complications were rarely observed compared to high rates of delayed union and refractures with conservative management. This systematic review acknowledges the limitation in the lack of RCTs; however, believe their selection criteria to eliminate rate of bias compared to Torg et al, improving their level of evidence and increasing the validity of their conclusions (Mallee et al., 2015).
Although best treatment intervention is still debated there is a clear consensus in the literature that restricted weight-bearing activity has no place in the treatment of navicular stress fractures. Confirming that both NWB for 6 weeks and ORIF had statistically superior outcomes over NWB for less than 6 weeks or restricted weight-bearing activity (Khan et al., 1992; Mallee et al., 2015; Torg et al., 2010).
Clinical and professional expertise would suggest that from the available literature to date NWB for 6 weeks is the best first line treatment to be considered for all navicular stress fractures. At this stage, conservative or surgical management is not favoured and cases should be treated at the discretion of appropriate physiotherapists, sports physicians, specialists and surgeons until further higher quality evidence is published.
The current case highlights the diagnostic challenges of navicular stress fractures. In particular, the case gives an interesting complexity of an acute foot injury concealing an underlying stress reaction pathology and the importance of a comprehensive subjective examination.
In the current case, initially the sprinter was diagnosed with talonavicular joint impingement based on the reported symptoms and physical examination. While clinically this diagnosis is a likely cause of the patients acute pain (Zwiers, Opdam, & van Dijk, 2016), more importantly a high-risk stress fracture was initially overlooked. This reiterates the concern in the literature that diagnosis of navicular stress fractures is often delayed and commonly misdiagnosed from onset of symptoms (Gross & Nunley, 2015; Torg et al., 2010). With increasing numbers of navicular stress fractures being reported on in the literature, it is imperative that clinicians use this knowledge and have a higher index of suspicion for navicular stress injuries in high-risk populations (Khan et al., 1992; Mallee et al., 2015; Shakked et al., 2017). The case underlines a gap in the current evidence for high quality RCTs on effective treatment and diagnosis. Current systematic reviews and meta-analysis are restricted to small case series and therefore an increased rate of bias.
Serial MRI imaging was employed by the treating sports physician on the patients’ case as a method to assess bone healing and assist in return to sport decision making. Further research revealed limited evidence exists for the efficacy of CT and MRI accuracy of navicular bone healing. Radiological findings in other fracture sites are known to have a lag in comparison to clinical improvement (Burne et al., 2005). The literature has also shown cases of closed navicular stress fracture sites in patients that have clinically failed with restricted weight-bearing management (Khan et al., 1992) and inversely cases of persistent fracture lines in images of asymptomatic patients of 6 years (Burne et al., 2005). Therefore, at this stage navicular stress fractures should be managed using clinical signs and symptoms as the primary indicators for return to play.
The current case ongoing for 20-months with two failed attempts of restricted weight-bearing and the use of MRI healing evaluation highlights two key aspects in the advancement of management of navicular stress reactions. Firstly, it is currently unclear whether imaging is suitable to evaluate bone healing at this stage and further inquiry into navicular stress fracture healing measurements with the use of radiography is urgently required for successful return to play outcomes. Lastly, this case reiterates that there is no place for restricted weight-bearing treatment in the management of navicular stress reactions and fractures.
PROFESSIONAL SKILLS GOALS
Professional Goal One
Role 3: Communicator
3.3 deal effectively with actual and potential conflict in a proactive and constructive manner
Clinical placement 4 highlighted a gap in my ability to communicate with senior health professionals in a proactive manner. I allowed the communication breakdown to manifest over several days before I built the courage and planned for an appropriate action. The situation was resolved but in the future my communication skills over various aspects of the profession need to continue to develop in order to achieve success as an industry leader later in my career.
S I will continue to improve my communication skills across various settings and scenarios with practitioners and patients by beginning work as a health professional in a private practice setting. This setting involves 4 business partners and many other allied health professionals and support staff. I will also take part in the UNSW Business School: Short Course on 13th May 2019, Leading through Influence – Communication Skills (1 day).
M I will seek regular informal peer reviews and quarterly business reviews with the managing partner, as well as patient feedback. I will attain a course certificate of completion for the communication course and written notes.
A Communication practiceswill be integrated into my job as a treating allied health professional. The course is short, only 1 day in which I can schedule annual leave.
R To further develop my communication skills relevant for professional relationships and combating difficult situations in the health industry. Learning and implementing new strategies to overcome personal and professional barriers.
T 5 months of professional work experience plus 1 day communication course. By May 2019 I will have improved my communication skills across a wide scope.
Steps to achieve the goal: Get approval for CPD ($1925.00) and enrol for course no later than 4 weeks before course date. If CPD approval is not met I will look into webinars or other relevant communication courses.
Professional Goal Two
Role 4: Reflective practitioner and self-directed learner
4.1 assess their practice against relevant professional benchmarks and take action to continually improve their practice
Throughout clinical placement 2 (Cronulla Sharks NRL) and clinical placement 4 (Private practice and Sports Injury Clinic) I was heavily exposed to the management of elite athletes. This confirmed my desire to work in professional sport. When evaluating my own skill set and knowledge as a graduate physiotherapist I believe exercise prescription is an area I need to improve in order to achieve my personal professional goals and also provide best care for athletes and the general population.
S Improve my exercise prescription knowledge targeted specifically at the progression and regression of exercises in a prevention and rehabilitation setting for elite athletes.
M Complete ASCA level 1 and level 2 Strength and Conditioning certificates of completion.
A ASCA level 1 competencies have been previously met with my Bachelor of Exercise Science and therefor I only need to complete a lift competency assessment. Level 2 requires a minimum of 100 hours of strength and conditioning experience with state level or above athletes. This will be met throughout my role with 2 professional sporting teams between January 2019 and November 2019.
R These certificates are often requirements for job positions in professional sport as well as a the ability to design and implement strength programs to elite level athletes. The skills are transferrable to most populations of the MSK setting.
T I will have achieved these accreditations by December 2019.
Steps to achieve the goal: Complete paper work and get lift competency signed off by January 15th 2019. Enrol in ASCA level 2 course and begin to complete required hours with 5 hours per week contributed to the contracted sporting team and 4 hours a fortnight in the performance gym for tutorials with S&C coach and one on one athlete coaching. Complete ASCA level 2 course in Sydney over 4 days (2 weekends) by the end of November 2019.
Professional Scenario CP3
|Professional Theme:||Client centred practice|
|Other: Communication and interprofessional practice|
|Situation:||Private hospital, inpatient ward and rehab gym. A new patient transferred from a major public hospital in Sydney where he underwent spinal surgery. He has been referred to this private hospital for an inpatient rehabilitation stay with indefinite approval from the rehab consultant in charge of his work cover case.|
|Task:||Complete an initial assessment including a subjective and objective examination in order to design and begin a rehabilitation program.|
|Action:||I had been assigned this patient in the mornings huddle and asked once the patient was transferred into the hospital to complete an initial assessment and begin rehab day 1. Without my knowledge, the patient was brought down to the rehab gym by the allied health assistant where they were asked to take a seat and wait for the Physiotherapist to meet with them. The patient was placed in a hospital chair at the end of the 6MWT mat (high traffic area).
I was in the middle of completing treatment and a rehab program with 2 other patients in the gym. As I look around the gym I observe a patient sitting looking uncomfortable and ask a colleague who the patient was and who was looking after him.
The AEP engaged with the patient and as I look back over I observe the AEP beginning the initial assessment.
As I finish up with my current patients the AEP calls me over to continue the initial assessment as ‘this was my patient’ handing over to me his findings so far in front of the patient.
I suggest that the patient may feel more comfortable if the AEP continues the assessment for continuity and convenience of the patient as they have already been waiting. I am told to complete the initial assessment.
I finish up the subjective assessment and begin the objective examination, it was difficult to select appropriate measures as I did not get an opportunity to educate myself on the patients’ medical notes prior to the consult; including surgical reports and surgeons’ protocols.
I assessed what I knew would be safe and suitable for the patient given the recent history of spinal surgery and continued referred left leg pain: dermatome, myotome, sensation and mobility/gait assessment. At this point the patient reported too much pain to continue.
I stopped the assessment and returned the patient back to his room, notifying the RN in charge to address the patients pain.
On the walk back to the ward I began to introduce some simple pain education and strategies.
I made sure the patient was left comfortable and safe with call bell in reach and mobility chart updated. I informed the patient of the plan for the rest of the day and for his stay in the hospital.
|Result:||Incomplete initial assessment, no treatment or rehab program completed.
The initial assessment was completed later that afternoon once the patients pain was controlled.
I had time to follow up all appropriate medical notes and was prepared for the consult. I co-ordinated the time management of patients and was able to give my full attention to the patient and design an effective treatment plan.
Efficiency of the second consult allowed for education and treatment within the time limit for the patients pain threshold.
|Evaluation:||The patient was not initially provided with client centred best practice due to a communication break down and interprofessional collaboration.
I believe to some degree this impacted on the patients recovery and initial impression of care he would receive.
I believe under my control I initiated best practice and was able to address the patients needs and expectations. I regained the patients trust through my practice skill and education.
In the future communication is critical in our role as health professionals and appropriate steps need to be taken to resolve the current breakdown.
|Strategies:||Following the initial consult a team meeting was held to allow me to address my concerns with communication and client centred care.
A procedure was put into place that the initial subjective consultation would be conducted in the patients’ private ward room which would allow the patient privacy with the practitioner when taking a detailed history. This would allow the physiotherapist to be across all medical notes prior to the initial as well.
The follow up consult could then be conducted in the gym with a written plan prior to the session.
Another procedure was put into place where by the allied health assistant would not transfer any patient to the gym without first consulting the treating physiotherapist, which was made clear on a newly designed rehab ward list.
Clinical Case Summary CP3
|Patient Information||54 yo, Female presented to a private inpatient rehabilitation hospital for rehab post stroke|
|Background / History||The patient had undergone a bilateral bunionectomy March 2018 which resulted in 6 weeks NWB wheelchair mobility. Upon recovery, the patient began feeling unwell and PE’s the size of apples were found in her lungs. She underwent emergency Pulmonary Thromboendarterectomy (removal of clots), during the surgery she had a Right CVA on the operating table due to a clot dislodging and travelling through a congenital defect in her heart which was undiagnosed until the event.|
|Outcome Measures||R CVA Stroke – Left side affected, 4 weeks post
ROM – AROM and PROM
Balance – quick screen
|Interventions||Upper and lower limb strength program: high repetitions and frequency
Dexterity and fine motor control for left hand and upper limb
Mirror therapy – sensation and mm training
|Outcomes||Left upper limb strength:
– MMT 2/5 –> MMT 3/5 Week 2 rehab –> MMT 4/5 Week 5 rehab
– Grip strength left hand initial: 0kg, week 2: 2kg, week 5: 14kg
|Plan||Continue to increase function and ADLs by improving left upper and lower limb weakness with a graded rehabilitation program.
Maintain CV fitness to decrease the chance of co-morbidities and increase prognosis and QoL.
Professional Scenario CP4
|Professional Theme:||Communication issue|
|Situation:||Private Practice, open plan clinic with gym and curtains separating plinths. Week 1.|
|Task:||Introducing myself to patients and obtaining consent.|
|Action:||During my first week I was very eager to be around patients observing, asking questions and to be involved in consults as much as possible. The physiotherapist would bring in the client and would often ask as they walked in “Is it ok if a Student Physio observes today?”. Due to the open plan of the clinic I was often waiting in sight of the patient. The principal physio would get rather annoyed at me and asked if I could not be in sight so that he’s patients don’t feel obligated to say yes. After this I began to wait in the staff room reading a text book or a research paper to fill my time. I would wait and check the clinic often to see if I was allowed in. At times I would even be alerted with a knock on the wall to tell me it was ok to come in (which I missed several times).
At the end of the Week 1 I asked for feedback and improvements I could make moving forward. After the physio had given me he’s insight I thanked him and asked if he could please be clear when he wants me involved in consults as I valued he’s business and wanted to do the right thing by him and he’s clients. He appreciated my thoughts and agreed communication needed to be better.
|Result:||I was not gaining as much experience as I would have liked in this setting and couldn’t get good communication with the treating physio.
Start of Week 2, the physio now came into the staff room and gave me a summary of the patient and alerted me to attend the consult.
|Evaluation:||I was concerned during Week 1 that this was not a good reflection of my commitment to the placement and also worried I had reflected badly on his practice.
Confronting him about the issue was a good idea and I believe I conducted myself in a professional manner to address both his and my issues with a common agreement.
|Strategies:||If I was in this situation again I would address the issue early Week 1 and also now I have an understanding of different private practice and private patients I would be pro-active and outline my roles and responsibilities on my first day.|
Clinical Case Summary CP4
|Patient Information||16 yo Male|
|Background / History||National Sprint Champion, presents with left ankle/foot pain post training 1/7 ago. Patient reports some discomfort turning the corner in a 200m sprint, completed full training session. Foot/ankle painful post training and next morning. Agg – walking, stairs. Ease – ice, NSAIDs. Competing in important qualifying events in 10/7. 18 month Hx of Left Navicular bone stress which has been pain free for 6 months.|
|Outcome Measures||P 2/10 WB
Localised fluid over the talonavicular joint region.
KTW – Left 2cm, Right 9cm
DLHR – P 5/10 and decreased left height
SLHR – P 6/10 and poor eversion/ inversion control
Hop – Left P 8/10, decreased height and poor midfoot mechanics
TOP – Talonavicular joint line, ‘N spot’ negative
Increased tone – Left tib ant, DPC, gastroc and soleus mms.
Stiff left midfoot
|Interventions||STM – Left mms a/a
Talonavicular joint and talocrurial joint mob
Re Ax: KTW Left 6cm, SLHR – P 3/10
– ISO DLHR w MB 5 x 30sec
– Low MB Crab walk 4 x 10
Low die tape w navicular lift = decreased P w walking, hop and sprint training on f/u.
|Outcomes||Post 3 treatment sessions pt. had decreased P sig with daily activities, KTW L=R and moderate P with sprinting competition w tape.
R/v with Sport Doctor = Boot NWB 6 weeks (case conference with Sport Dr the final decision concluded the risk of not treating the Navicular 6 weeks NWB are too high
MRI = increased bone mineralisation/density from previous MRI 6/12 ago.
|Plan||Relative rest NWB training.
To commence RTS physio in 6/52 (w Sport Dr approval)
APPENDIX ONE: Literature Search
Search Criteria One: Completed 28/10/18
Database: Ovid MEDLINE – Advanced Search
Boolean/ Phrase: fractures, stress/ and diagnostic Imaging/ and (lower limb.mp. or Lower Extremity/ or Tarsal Bones/) = 12 results
Specific Year Range: 2010 – 2018 = 9 results
Mapping of search results:
1 Fractures, Stress/ = 3,116 results
2 Diagnostic Imaging/ = 39,063 results
3 1 and 2 = 78 results
4 lower limb.mp. or Lower Extremity/ = 39,907 results
5 3 and 4 = 8 results
6 Tarsal Bones/ = 2,894 results
7 3 and 6 = 4 results
8 5 or 7 = 12 results
Search Criteria Two: Completed 28/10/18
Interface: EBSCOhost Research Databases
Database: SPORTDiscus with Full Text
Search Screen: Advanced Search
Boolean/Phrase: ( tarsal bones OR lower limb OR foot ) AND ( stress fracture OR stress reaction ) AND ( diagnostic imaging OR MRI ) = 20 results
Limiters: Published Date: 20080101-20181231
Source Types: Academic Journals
Mapping of search results:
S1 tarsal bones OR lower limb OR foot = 35,838 results
S2 stress fracture OR stress reaction = 2,905 results
S3 diagnostic imaging OR MRI = 6,999 results
S4 S1 AND S2 AND S3 = 40 results
S5 S1 AND S2 AND S3
Limiters -Published Date: 20080101-20181231 and Academic Journals = 20 results
APPENDIX TWO: Reference List
Boden, B. P., & Osbahr, D. C. (2000). High-risk stress fractures: evaluation and treatment. JAAOS-Journal of the American Academy of Orthopaedic Surgeons, 8(6), 344-353.
Burne, S. G., Mahoney, C. M., Forster, B. B., Koehle, M. S., Taunton, J. E., & Khan, K. M. (2005). Tarsal navicular stress injury: long-term outcome and clinicoradiological correlation using both computed tomography and magnetic resonance imaging. The American journal of sports medicine, 33(12), 1875-1881.
Fredericson, M., Jennings, F., Beaulieu, C., & Matheson, G. O. (2006). Stress fractures in athletes. Topics in Magnetic Resonance Imaging, 17(5), 309-325.
Gross, C. E., & Nunley, J. A. (2015). Navicular stress fractures. Foot & ankle international, 36(9), 1117-1122.
Kaiser, P. B., Guss, D., & DiGiovanni, C. W. (2018). Stress Fractures of the Foot and Ankle in Athletes. Foot & Ankle Orthopaedics, 3(3), 2473011418790078.
Khan, K. M., Fuller, P. J., Brukner, P. D., Kearney, C., & Burry, H. C. (1992). Outcome of conservative and surgical management of navicular stress fracture in athletes: eighty-six cases proven with computerized tomography. The American journal of sports medicine, 20(6), 657-666.
Liong, S., & Whitehouse, R. (2012). Lower extremity and pelvic stress fractures in athletes. The British journal of radiology, 85(1016), 1148-1156.
Mallee, W. H., Weel, H., van Dijk, C. N., van Tulder, M. W., Kerkhoffs, G. M., & Lin, C.-W. C. (2015). Surgical versus conservative treatment for high-risk stress fractures of the lower leg (anterior tibial cortex, navicular and fifth metatarsal base): a systematic review. Br J Sports Med, 49(6), 370-376.
Matheson, G., Clement, D., McKenzie, D., Taunton, J., Lloyd-Smith, D., & MacIntyre, J. (1987). Stress fractures in athletes: a study of 320 cases. The American journal of sports medicine, 15(1), 46-58.
Mccormick, J. J., Bray, C. C., Davis, W. H., Cohen, B. E., Jones III, C. P., & Anderson, R. B. (2011). Clinical and computed tomography evaluation of surgical outcomes in tarsal navicular stress fractures. The American journal of sports medicine, 39(8), 1741-1749.
Patel, D. S., Roth, M., & Kapil, N. (2011). Stress fractures: diagnosis, treatment, and prevention. American family physician, 83(1).
Potter, N. J., Brukner, P. D., Makdissi, M., Crossley, K., & Kiss, Z. S. (2006). Navicular stress fractures: outcomes of surgical and conservative management. British journal of sports medicine, 40(8), 692-695.
Saxena, A., & Fullem, B. (2006). Navicular stress fractures: a prospective study on athletes. Foot & ankle international, 27(11), 917-921.
Shakked, R. J., Walters, E. E., & O’Malley, M. J. (2017). Tarsal navicular stress fractures. Current reviews in musculoskeletal medicine, 10(1), 122-130.
Torg, J. S., Moyer, J., Gaughan, J. P., & Boden, B. P. (2010). Management of tarsal navicular stress fractures: conservative versus surgical treatment: a meta-analysis. The American journal of sports medicine, 38(5), 1048-1053.
Torg, J. S., Pavlov, H., Cooley, L., Bryant, M., Arnoczky, S., Bergfeld, J., & Hunter, L. (1982). Stress fractures of the tarsal navicular. A retrospective review of twenty-one cases. JBJS, 64(5), 700-712.
Warden, S. J., Burr, D. B., & Brukner, P. D. (2006). Stress Fractures: Pathophysiology, Epidemiology, and Risk Factors. Current Osteoporosis Reports, 4, 103-109.
Wentz, L., Liu, P.-Y., Haymes, E., & Ilich, J. Z. (2011). Females have a greater incidence of stress fractures than males in both military and athletic populations: a systemic review. Military medicine, 176(4), 420-430.
Wright, A. A., Taylor, J. B., Ford, K. R., Siska, L., & Smoliga, J. M. (2015). Risk factors associated with lower extremity stress fractures in runners: a systematic review with meta-analysis. Br J Sports Med, bjsports-2015-094828.
Zwiers, R., Opdam, K., & van Dijk, C. (2016). Anterior Ankle Impingement Arthroscopy (pp. 965-970): Springer.