Stress Fractures and Stress Reactions: Applications to Orthotics Programs

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Welcome back everyone to Podiatry Today Podcasts, where we bring you the latest in foot and ankle medicine and surgery from leaders in the field. Today's episode is one of our orthotics Q & A columns, created in partnership with the American Association for Women Podiatrists. We have two experts with us today discussing key orthotic considerations for stress fractures, Dr. Alicia Canzanese and Dr. Karen Langone. Dr. Canzanese is a Fellow of, and secretary treasurer for the American Academy of Podiatric Sports Medicine. She is a Diplomate of the American Board of Podiatric Medicine, a member of the American Association for Women Podiatrists, a certified athletic trainer, and practices in Glenside, Pennsylvania.

Dr. Langone is a Diplomate of the American Board of Podiatric Medicine, a Fellow of the American College of Podiatric Medicine, a Fellow and Past President of the American Academy of Podiatric Sports Medicine, and a trustee of the New York State Podiatric Medical Association. She serves as co-chair of the NYSPMA Public and Population Health committee, and the legislative committee. Dr. Langone has most recently served, also, as President of AAWP. She's in private practice in Southhampton, New York. This is such an important topic that I don't think immediately comes to mind for practitioners when treating stress, bone injuries. Thank you so much for being with us today. So I think the first question that we wanted to pose to both of you today, is at what point during treatment for a stress fracture or stress reaction, do you consider incorporating orthotics? And I'd love to hear a little bit more about your reasoning behind it as well.

Alicia Canzanese, DPM:
Thinking about orthotics and stress fractures, I feel like if you're looking at the initial treatment and management of the stress fracture, or let's say a stress reaction, or a mild bone stress injury, oftentimes the question isn't for me of am I incorporating a [inaudible 00:02:04] orthotic, but more so in the initial stages of do I need to modify the insole such as the balance padding, modify their current insert, or orthotic with balance padding to take pressure off the specific area, such as a metatarsal. But thinking of the treatment and management of stress fractures moving forward, if someone has recovered from their bone stress injury, and now we're thinking of more prevention, let's make sure this doesn't happen again. Then we're definitely going to address whether or not that person has a biomechanical abnormality that led to the stress fracture in which an orthotic would address that.

Jennifer Spector, DPM:
Dr. Langone, what about yourself?

Karen Langone, DPM:
I agree with that. I think that any time, really with any entity, and even more so with a stress fracture, that you suspect there's a mechanical reason for this, and it's going to be rare that you're not going to see some mechanical inconsistency that's leading to the stress fracture, then it's the time to do it. You tend to find, and back me up or disagree on this, but most times these people will do relatively well. You immobilize them for a short amount of time and then as you start pulling them out of that immobilization, without the introduction of some kind of orthotics, they just stall. They remain at that low level. I've got 20 to 30% pain. I can't really return to my full activities. The more I do, the more I still feel a little bit of pain through there. So I think that really looking at it and addressing it pretty early on, so that you're able as rapidly as possible, to get them out of their immobilization, to get them back to full activities. It's a good thing to introduce the orthotics.

Alicia Canzanese, DPM:
Yes. I definitely agree with that. Looking at, as someone's moving forward, if they had a stress that led to the bone injury to begin with, if you don't address that stress, it's just going to come right back. So looking at what we need to do to correct the imbalance that led to the injury to begin with is definitely important.

Karen Langone, DPM:
And I would say the only time, and again, weigh in on this one, is the times that you see just a gross and rapid change to an improper type of athletic shoe. Where someone who's been wearing an Asics Kayano for 40 years suddenly decides they're going to go into an Innovate or a Five Fingers and run a marathon. So aside from those times where you really see that incredible change that may have led to it, and it may not necessarily be the mechanics as the primary cause.

Alicia Canzanese, DPM:
Exactly. Oftentimes there's a 10 mile race in Philadelphia where people will just not train and run this 10 mile race, and they might have relatively rectus biomechanics and they just purely did over-training and overexerted themselves. They happen to have a low vitamin D level, and they've had this just pure doing way too much too soon and maybe not the correct footwear. Where once they're healed, like you said, they might not need orthotic intervention. They just need to train properly.

Jennifer Spector, DPM:
You just mentioned the biomechanics and that's a really great point. Are there any particular features of the biomechanical exam that you feel are especially important?

Alicia Canzanese, DPM:
Specifically with a biomechanical exam, I feel like often it's important to do a relatively more comprehensive biomechanical exam to figure out what's leading to this increased pathomechanical stress. Could it be something at the foot level? Does it have to do with first ray hypermobility? Has it to do with over-pronation? Or is there some proximal weakness or proximal abnormality that could be leading to increased distal stress? So for me, it's doing a comprehensive exam, getting them weight bearing, watching them walk and looking for what could be leading to this inappropriate stress. Obviously, I'm not having them stand, and walk, and jump, and things like that, when they acutely are coming in with a stress reaction. But once they've started to recover, once they're trying to get back into activity, once we start thinking about how do we prevent this, doing a more thorough biomechanical exam, I think is key.

Karen Langone, DPM:
Yeah, I'd have to agree. I think as you're starting to get them after that, let's say like two week period, you're starting to look at the mechanics and see what's going on. I think for me, because I have so much focus on sagittal plane mechanics, and first ray function. And inevitably, I think we tend to see those stress fractures greatest in the second, then a little bit less in the third, and then even less than the fourth and fifth metatarsal. I put a lot of focus on that. The one thing that's always difficult is, as Alicia said, you really can't take that person and watch them run because they're really not up for it at that point. You can take them, you can have them do some short walking for you, you can do some stressors to see how they might function under stressful load. But it's hard to take an athlete at the three week point after a stress fracture and get them out and see them run in such a way that you get an idea of their pre-injury mechanics.

Karen Langone, DPM:
But I think we have to try to do the best we can on that one, with the thought that perhaps then you're going to modify that orthotic as the athlete continues to progress.

Alicia Canzanese, DPM:
And then just, you're thinking about second metatarsal stress fractures. I always have a look at their first metatarsal and first ray range of motion, both with their foot unloaded and loaded. It's really trying to rule out that functional hallux limitus to see if they're having some issues with their first ray and first [inaudible 00:07:44] really increasing the stress of the second metatarsal. And I think that's one scenario where there's that one thing that I really definitely want to make sure I'm looking at, but eventually then doing a more thorough biomechanical exam.

Karen Langone, DPM:
And I think too, another important thing can be limb length in that when you see those stress fractures. Because inevitably we're seeing them unilaterally and very, very rarely are we seeing bilateral stress fractures.

Jennifer Spector, DPM:
That's a great point. So that being said, what specific features do you like to incorporate for patients in an orthotic post stress fracture or is it more the materials that you're incorporating that are more targeted? Love to hear a little more about that?

Alicia Canzanese, DPM:
I feel like oftentimes it's going to be very individualized. So it's hard to give a blanket answer as to I'm going to do this with most of my stress fractures. That being said, especially with metatarsal stress fractures, I know I keep bringing back to those, but with those patients in the early stages, oftentimes in their insole of their shoe and as we're progressing them back into their sneakers, I usually use balance padding. It's usually something temporarily I'll add to their insert. So, I usually use an adhesive felt, depending on their footwear maybe an eighth to a quarter inch, and I'll load the metatarsals, basically the medial and lateral ones to that metatarsal. So we won't put any padding underneath the metatarsal in question, and that's purely just to help offload that metatarsal. So I'm often doing balance padding, at least temporary in the beginning stages and sometimes in their shoes, as they progress out of whatever type of a mobilization they needed.

Alicia Canzanese, DPM:
And like I said, sometimes that's temporary. Other times, if we do move to a customer orthotic and they're having persistent or they've had chronic issues with this same metatarsal, I might build some thin or mild balance padding into the extension on their orthotic. Also, with these patients, especially when it's a metatarsal stress fracture, I usually do try to encourage a full length orthotic, especially if they're putting it in a running sneaker. That way we can add an element of additional padding and cushioning to the four foot of their orthotic.

Karen Langone, DPM:
So I like to always say that I almost put a blindfold on as to what the patients chief complaint or presentation is, when I make them an orthotic. And I'm really going to look through the components of my biomechanical exam and the weight bearing exam to see what's going on, look and see where any imperfections lie or where I feel that things are not optimum. And then look at that and see if that brings me back, if I put the pieces of the puzzle together, to the complaint that the patient shows up with. So that there's nothing that I could say, this is what I do every time I see a stress fracture, it really is going to be dependent upon that individual patient. For patients that I have who have osteopenia, osteoporosis, and for whom this might not be an athletic injury, but more a day to day type of an injury.

Karen Langone, DPM:
One of the things that I'll tend to do is probably put a bit more padding on their orthotic initially, to get them acclimated to the device. And then over time, try to decrease the amount of that padding. So let's say we started off with a quarter inch or something like that, we're going to bring it down slowly over time so that I'm gradually, theoretically, allowing that bone to bear more load. Only because I don't want to take somebody whose bone is not that strong to begin with, I don't want to overload it initially, but I don't want to prevent them from being able to get the benefit of them exercising and building better bone health as they go along.

Jennifer Spector, DPM:
So that being said about bone health, playing a role. Are there any other relevant tests that you might order as part of a post fracture, long term plan? I know you mentioned that there could be orthotic modifications, but what else is part of your algorithm for that?

Alicia Canzanese, DPM:
Oftentimes I will order, especially if it's somebody who is otherwise seemingly healthy, we can't really pick a distinct training error that might have led to why they might be developing this stress fracture, it kind of came out of left field, in that patient I'm definitely going to order blood work. Typically, on that blood work, I'm going to be looking for bone health. So usually I'm going to be ordering a vitamin D level, oftentimes that's thyroid and parathyroid levels and calcium levels, to see if there's anything systemically which could be leading to poor bone health, even in some of the younger athletes.

Alicia Canzanese, DPM:
For almost all of my stress fracture patients, we often talk about vitamin D levels. And oftentimes I'm seeing there is some significant deficiencies in vitamin D in the patients who are developing these stress reactions, whether it be metatarsal or tibial. So I definitely almost always order a vitamin D level, but if it's somewhere where there's increased clinical concern, it's hard to pinpoint a training error that might have led to this, I'll probably order a more in depth bone health panel.

Karen Langone, DPM:
So for me, I will do blood work, the same components, basically. We'll do some calcium levels too. I've started, because of my work on the falls prevention pilot program with NYSPMA, I've taken it back a step further so I'm really starting to screen anybody who's got a stress fracture or stress reaction, all women over 55, and anybody that I notice changes on x-rays for signs of osteopenia, osteoporosis. So we order a lot of DEXA scans if people aren't up to date on theirs. If they've been up to date, we ask to see the last several that they've had to track how they're going. We do the DEXA, we do the blood work, and then we have a pretty good program where we really start to assess how they do in multidirectional activity, what their balance is like, to really assess for anything that might make them a fall risk.

Karen Langone, DPM:
I look at their aerobic training program. We look to see if they're doing strength training. We'll do a postural evaluation to see if there's anything there that needs to be addressed. For people that are very deficient, I'll get them into physical therapy. For others that are not that deficient, we try to just tweak what they're doing. So many women are told they have osteopenia, they should go out and walk. But it's crucial that they have multi-directional activity. So we try to encourage everybody to add that to their regimen. We try to get them to avoid any activities that are particularly stressful or problematic, like leaning forward and then attempting to lift a load. So we try to work with them on proper body mechanics as well.

Karen Langone, DPM:
We do a dietary screening where we give them a handout on calcium content in the most common foods, have them work up what they generally take in in a day and then look to see if we need to supplement that, to get them to about 1200mg a day. Same thing with the vitamin D, really looking at that as well. And of course all the things that we all do, looking at their shoe gear, making sure that that's appropriate for them. So we do a pretty thorough workup on that. My concern is always that we start to see these stress fractures in middle-aged people, and we're not really intervening until people become osteoporotic. And my thought is, is there a way that we can take people earlier on and prevent that outcome from happening down the road in, perhaps, these stress fractures or an early indication that something is not right.

Alicia Canzanese, DPM:
And I would say the biggest thing is number one, treating the initial stress fracture, treating the injury, but then it's really working with these patients to figure out why they got it to begin with. And then the biggest thing is preventing it from happening again. Because I know, especially with working with runners, they're going to be frustrated if every couple months they're developing these bone stress injuries. So I always feel like an important component of sports medicine and working with athletes and runners, where anybody who develops a bone stress injury is preventing it from happening again. And I think that's a big part that sometimes can be overlooked, but I feel it's important to make sure that we counsel and speak with our athletes and patients about this.

Jennifer Spector, DPM:
Thank you so much to both doctors for sharing their insights with us and to the listeners for tuning in and learning more. Thanks also to the American Association for Women Podiatrists, with whom we partnered on this podcast. Check out the work they are doing at www.Americanwomenpodiatrists.com and past and future episodes of Podiatry Today podcast at podiatrytoday.com, Spreaker, Spotify, Apple Podcasts, and your favorite podcast platforms.