Femoral Stress Fracture

I have had several patients over the past couple of years that have sustained femoral stress fractures while running. The presentation is not always the same because the fractures happen in different places along the femur. In each case, the patient was referred to me by another medical practitioner for physical therapy to treat their non-specific leg pain. In each case, the pain mimicked muscle pain and only a careful history teased out the possibility that a stress fracture was hiding under the radar.

• First of all, I can say that almost without fail, the fracture occurred as the running intensity was elevated. The patient did not notice the pain immediately, but noticed it soon after, in each case by the next day.

• Second, the pain was exacerbated with running, and specifically elevated with impact (landing on the injured leg).

• Third, no matter what stretches the patient employed, if they used ice or not, the pain did not diminish.

• Fourth, taking meds, like NSAIDs, did not resolve the pain.

• Fifth, a complete orthopedic evaluation ruled out all the muscles as a source of the pain.

A suspicion of a stress fracture needs to be further investigated by a bone scan which shows a 2% change in bone density rather than an x-ray which illustrates a fracture when there is a 50% change in bone density. Some physicians prefer an MRI to rule it out, but most opt for a bone scan.

The treatment for a stress fracture is the same as for any fracture. Non-weight bearing for 6 weeks, followed by 6 weeks of rehab before returning to previous mileages.

What is a Forefoot Varus?

This topic is the source of a great deal of misunderstanding. First, lets define some terms:
- "Supinated" and "pronated" are POSITIONS
- "Supination" and "Pronation" are MOTIONS

The whole body supinates and pronates during normal everyday activity. Gravity is trying to squish us into the ground (pronate us) and we resist that force (by supinating). Every step we take causes us to go through pronation and supination at every joint in the body.

The foot is said to be pronated or supinated. This is in reference to the subtalar joint, and specifically to a position called subtalar neutral (where the rear foot is neither pronated nor supinated).

When the forefoot is supinated relative to the rear foot, the condition is referred to as a forefoot varus.




So in other words, when a forefoot is supinated it can appear to be pronated because the body will get the forefoot onto the ground by pronating somewhere. The thing of it is that the pronation that gets the foot on the ground actually occurs higher up the chain as in at the rear foot, the ankle, the knee,the hip or the pelvis and lower back. When this occurs at the subtalar joint, for example,it is not uncommon to see the knees achieve a valgus position (knock kneed).




When a foot APPEARS pronated, one first has to determine if the foot ITSELF is pronated or if it just APPEARS to be pronated. It is easy to confuse the appearance of pronation in the case of a forefoot varus where the forefoot is effectively supinated. The nature of the condition causes failure in teh foot, at the ankle, at the knee and at the hip.

The incidence of this condition is 8% of 116 female subjects (McPoil et al, 1988) and 86% of 120 male and female subjects (Garbalosa et al, 1994).

There are three patterns of compensation:
- uncompensated
- fully compensated
- partially compensated

Forefoot Varus deformities produce numerous associated pathologies, including:

- shin splints
- plantar fasciitis
- tibialis posterior tendonitis
- patello-femoral syndrome
- lesser digital deformity
- hallux abducto valgus
- lower back pain
- sciatica
- metatarsal stress fracture (see Hughes, 1983)

Varus problems are easily treated through the application of Custom Orthotic Therapy.