When A Tennis Player Suffers A Talar Stress Fracture

A patient contacted me recently after suffering acute ankle pain that has hobbled him ever since June. When seeking a diagnosis, it is easy to focus on the wear and tear arthritis in the ankle, but this was a talar stress fracture due to the impact of tennis and the overpronation of the ankle. 

The patient has spent 37 years playing competitive tennis and hiking, both of which have contributed to the overuse-related injury. The patient’s first major ankle injury occurred in 1963 when he was playing basketball (stepping on top of a player’s foot) in high school. That was just the beginning. The patient has injured this ankle many times over the years, most significantly in 2009, and says he only made the stress fracture worse by playing on it for the last year or two. He has completely stopped playing tennis since the latest injury and since then has only walked on a flat surface for up to 45 minutes.

However, since June, the patient has reinjured the ankle a total of seven times due to things like gardening, using a ladder to install lights, light hiking, etc. Right now, he says the ankle feels strong and he walks every day for 45 minutes with no pain or discomfort.

The patient’s current treatment consists of:

1. Ice twice daily for 15 minutes with a reusable gel ice pack
2. Alternating heat for four minutes and ice for one minute each evening 
3. Wearing ½-inch heel inserts in shoes (The ankle has the most pressure internally, exactly where his fracture is, when his ankle is at a right angle or bent forward as in a squat. The heel lifts are to keep him slightly plantarflexed at the ankle in order to avoid crowding the joint.) 
4. Bone stimulation twice daily to increase healing
5. Continue walking on a flat surface but doing so with a wrap around brace

Another magnetic resonance image (MRI) in January, six months after the first MRI, will tell if he is healing and to what degree. For the patient’s initial MRI, one may see signs of a stress reaction, stress fracture, bone bruising, arthritic changes but the acuteness of pain on the day of injury in June is diagnostic for a talar fracture until proven otherwise. In these cases, one should treat the worst-case scenario (in this case, a stress fracture that could lead to a full fracture and major disability).  

Each month, the patient should do more activity to test how the ankle is doing. He wants to stress the area slowly and see how it responds. This patient may want to take bone density test. His vitamin D level is good (47 Ng/mL) and his calcium level is 9.2 mg/mL.

Is there a way to speed up significantly the healing process, such as wearing a boot or plaster cast for several weeks, and then proceeding to rehab? Healing will take time. In addition to avoiding irritation of the affected area’s tissue, modalities such as bone stimulation, contrast baths for a deep flush, various braces and/or orthotics may be helpful along with a gradual ankle strengthening program. Immobilization always weakens the bones so we need to create that 0–2 Visual Analogue Scale pain level and slowly increase function. The patient should stop when the pain comes on with activity or have the brace ready to put on. 

Is this patient risking injury again by playing tennis? So much depends on bone density, how hard he plays, if he plays with orthotics and a brace, etc. The patient should see how volleying leisurely feels with a tennis partner first and go from there.

Editor’s note: This blog originally appeared at https://www.drblakeshealingsole.com/2017/10/talar-injury-in-tennis-email-advice.html . It is reprinted with permission from the author.