Stress fractures in
MARKO PEĆINA,* MD, PhD, IVAN
From the Department of Orthopaedic Surgery, School of Medicine, University of Zagreb,
ABSTRACT
In 1987, during two great skating contests—the Univ-
ersiade in the Tatra Mountains and the Gold Pirouette
in Zagreb—a total of 42 world class skaters were asked
through a questionnaire if they had ever in their career
suffered from a stress fracture. Of the 42 skaters, 9
had stress fractures. Four stress fractures occurred
during preseason training (two fibular, one second
metatarsal, and two fourth metatarsal stress fractures).
Increased mileage was reported by three skaters and
the fourth had done too much speed training on hills.
Five stress fractures occurred during the season (one
tibial and two tarsal navicular stress fractures and two
stress fractures of the base of the fifth metatarsal). In
all cases, the fracture occurred in the take-off leg. All
of the subjects were competitive figure skaters with a
daily training period of 3 to 8 hours, six times a week.
The time from the onset of symptoms to definite diag-
nosis ranged from 2 to 10 weeks. Of the nine injured
skaters, eight were treated conservatively and one
skater with Jones’ fracture was treated surgically. All
of the skaters were able to resume a preinjury level of
activity 3 to 7 months after treatment began. In conclu-
sion, it may be emphasized that stress fractures in
figure skaters are not rare and should, therefore, always
be considered as a possibility.
Stress fractures are relatively common injuries among ath-
letes, comprising about 5% of all sports injuries.3, 7, 12 Run-
ning causes the great majority of stress fractures, although
practically any sports event can be a cause. 7, 11, 12, 17, 18
The purpose of this report is to present more information
about stress fractures in figure skaters.
MATERIALS AND METHODS
In 1987, during two great skating contests-the Universiade
*
Address correspondence and repnnt requests to’ Marko Pecina, MD, PhD,
Department of Orthopaedic Surgery, Salata 6, 41000 Zagreb, Yugoslama.
figure skaters
BOJANIĆ, MD, AND SANDA DUBRAVČIĆ, MD
Zagreb, Yugoslavia
in the Tatra Mountains and the Gold Pirouette in Zagreb-
a total of 42 world class skaters were asked through a
questionnaire if they had ever in their career suffered from
a stress fracture.
Of the 42 skaters, nine had stress fractures. A detailed
interview and analysis of medical records provided data
about stress fractures in six skaters (interviews and analyses
carried out by one of the authors-SD), and the remaining
three skaters were treated at the Department of Orthopaedic
Surgery at the University of Zagreb.
RESULTS
Four of the nine skaters with positive stress fracture history
were males and five were females (Table 1). The mean age
at the time of injury was 22.1 years (range, 17 to 27 years).
All of the subjects were competitive figure skaters with a
daily training period of 3 to 8 hours, six times a week. The
initial symptoms occurred from 6 to 15 years after the
beginning of intensive training. The time span from the
onset of symptoms to definite diagnosis ranged from 2 to 10
weeks.
Four stress fractures occurred during preseason training.
The history obtained from these skaters showed that there
had been changes in their running routine before the fracture
occurred. Increased mileage was reported by three skaters;
one had done too much speed training on hills.
Five stress fractures occurred during the season. In all
cases, fracture was in the take-off leg. In one skater, the
stress fracture of the anterior cortex in the middle third of
the tibia was associated with a sudden increase in jumping
exercise. Two skaters with tarsal navicular stress fracture
(Figs. 1 and 2) reported that before the initial symptoms
began they had practiced intensive jumping training, espe-
cially involving jumps performed on the inner edge of the
skate (Salchow). Two skaters with Jones’ fractures (stress
fracture of the base of the fifth metatarsal bone) complained
of aching discomfort in the lateral aspect of the foot for
several weeks before seeking medical attention. Although in
both cases the take-off leg was affected, the connection
between the jumps and Jones’ fracture was not detected.
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TABLE 1
Patient data

a
No weightbearing.

Figure 1. Case 6. Bone scan shows markedly increased

uptake in area of tarsal navicular bone and confirms diagnosis.
Of the nine skaters with stress fractures, eight were
treated conservatively. Rest from the activity-causing symp-
toms was the only mode of treatment in six cases. The
patients with tarsal navicular stress fracture (Case 7) and
Jones’ fracture (Case 9) were treated with immobilization in
a short-leg cast with no weightbearing allowed. Because of
the changes visible in the initial roentgenogram (Fig. 3A), Figure 2. Case 7. Tomograms made 1 month after the onset
the skater with Jones’ fracture (Case 8) was surgically of symptoms show a stress fracture of the tarsal navicular. A
treated. deeper section did not show the fracture line, which indicates
All of the skaters were able to resume a preinjury level of that fracture was limited to the dorsal aspect of the bone.
activity 3 to 7 months after the initial treatment. At followup
(average followup, 23 months; range, 9 to 72 months) pa- thors.~~ 5>’° 12, 18 The data obtained in
our investigation indi-
tients were asymptomatic, even though they were engaged cate that stress fractures occurring in preseason training
in top level competing activities. activities significantly correlate to running and also that

DISCUSSION
The external and internal predisposing factors to stress
fractures have been variably emphasized by different au-
training errors appear to be the most important causative
agent leading to stress fractures. The fracture site corre-
sponds to the site distribution of stress fractures described
in runners.7,ll, 17, 18

Figure 3. Case 8. A, lateral roentgenogram of the foot dem-
onstrating stress fracture of the base of the fifth metatarsal.
Note a widened fracture line with an evident sclerosing of its
edges. B, 8 weeks after surgical treatment-intramedullary
fixation with AO malleolar screw-there is complete healing
of the fracture.
Stress fractures of the anterior cortex of the midthird of
the tibia constitute only a small percentage of all tibial stress
fractures. I, 7, 12, 18 Various reports show that these fractures
occur most likely as a result of tensile forces associated with
jumping. I, 6, 13, 14, 16 Also,
the reports emphasize two signifi-
cant complications of treatment: delayed union and com-
plete fracture. In our study, such a fracture resulted from a
sudden increase in the number of jumps and a tendency
toward introducing triple jumps as part of the competition
program. Treatment complications, fortunately, did not oc-
cur in this case.
to the reports of Torg et al.,20 Graff et al.,5
According
Hulkko et al.,’ and Fitch et al.,4 tarsal navicular stress
fractures occur in explosive athletic activities that involve
sprinting, jumping, and hurdling. They have been reported
in basketball players, jumpers, sprinters, hurdlers, and mid-
dle-distance runners. Previous studies have shown that rel-
atively short first metatarsal or long second metatarsal
bones were common findings in patients.2° These anatomical
279
variations have caused the stresses, especially the shear
stress, to be concentrated on the tarsal navicular bone as a
result of greater force being transmitted through the second
metatarsal and the intermediate cuneiform bones. The force
would be increased in an excessively pronated foot, which
has actually been the case with skaters who performed
intensive jumping exercises on the inner edge of the skate.
Previous reports have indicated potential difficulties in
the treatment of Jones’ fractures. These include prolonged
immobilization, high propensity for delayed union and non-
union, and refracture.2, 3, 9, 13, 19 Only recently Torg et aI.l9
have noticed and reported a correlation between roentgen-
ographic manifestations of these fractures and their re-
sponse to specific methods of treatment. Torg et aI.,19 Leh-
man et all and Pecina et a1,l5 have all developed classifi-
cations of these fractures and treatment plans based upon
roentgenographic criteria. According to their reports, pa-
tients should be surgically treated upon initial signs of
intramedullary sclerosis. Surgery helps speed fracture union
and returns an athlete to his or her regular athletic activities
in a short period of time, as was the case in our surgically
treated patient.
In conclusion, it may be emphasized that stress fractures
in figure skaters are not rare and should, therefore, always
be considered as a possibility in skaters.
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