Miller et al. (2018) DOI: 10.5435/JAAOS-D-19-00112
Emerging Options for Biologic Enhancement of Stress Fracture Healing in Athletes
Emerging Options for Enhancing Stress Fracture Healing in Athletes
Topical
Pulsed PTH1. Electrical osseous stimulation2. ESWT
Immobilization and extended rest are often impractical for elite athletes
High-risk fractures
Modern strategies can ensure the
quickest return to full activity
The Kaeding-Miller Classification System
Grade Pain Radiographic findings
Stress fracture diagnosed and risk-stratified based on history, physical examination, and imaging
Optimize biomechanics, mental health, and loading exposures Assess nutritional and
hormonal status
Nutrition/hormonal status optimized?
Direct injectable modalities
1. Concentrated bone marrow aspirate2. Autologous platelet solutions3. Injectable bone graft substitutes
Imaging evidence of stress injuryNo fracture line
I
II
III Nondisplaced fracture line
IV Displaced fracture (≥2 mm)
V NonunionFifth metatarsal proximal metadiaphysis
Great toe sesamoids
Emerging techniques augmenting biologic environment offer minimally invasive methods to stimulate and support bone healing and expedite recovery
Incomplete healing or recurrence?
Vitamin D supplementation
Nutrition consultation
Sex hormone supplemention
No Yes
Yes
Consider external simulation
Low-risk sites !Consider internal �xation with biologicaugmentation
High-risk sites !
Indirect stimulating treatments
Multiple Sites?
Systemic
No
Tarsal navicular
Tibial diaphysis anterior cortex
Talus
Medial malleolus
Femoral neck superior cortex
Patella