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