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The early diagnosis of stress fractures is a challenge in daily primary care practice. Point of care ultrasound (POCUS) can be helpful in the diagnosis of early signs of an incipient stress fracture. A 52-year-old woman presented with a history of chronic overuse in the left forefoot. A sonographic examination in the area of the reported pain point on the third metatarsal (consistent with a marching fracture) showed a clear accumulation of fluid, corresponding to subperiosteal hematoma. After only two weeks of resting the forefoot, a repeat examination using POCUS showed clear callus formation. This confirmed the suspected diagnosis of an early stage stress fracture. This case shows a sensible and easy-to-learn way of using POCUS in general practice. POCUS in combination with clinical examination and anamnesis is a cost-effective and timely diagnostic option without radiation exposure.

Knochen ist elastisch und verformbar. Kehrt aber ein Knochen nach Trauma, chronischem Zug, Druck oder Torsion nicht in die alte Position zurück, verbleiben Schmerzen im Knochen und in den beteiligten, nicht dehnbaren Faszien, Sehnen, Kapsel- und Bandstrukturen. Nachdem mit dem Strain-Relief-Konzept im vorigen Heft die theoretischen Grundlagen eines neuen manuellen Verfahrens zur Behandlung chronischer Schmerzen im Bewegungsapparat vorgestellt wurden [4] , widmet sich dieser Beitrag der praktischen Anwendung. Am Beispiel der unteren Extremität wird gezeigt, wie man manuell das ossäre Gewebe vom Strain befreien kann und damit erfolgreich Schmerzen mindert oder sogar beseitigt. Bone is elastic and deformable. However, if a bone does not return to its former position after trauma, chronic traction, pressure or torsion, pain will remain in the bone and in the non-stretchable fascia, tendons, capsule and ligament structures involved. Following the introduction of the theoretical basis of a new manual method for the treatment of chronic pain in the musculoskeletal system in the previous issue with the strain relief concept [4] , this article is dedicated to the practical application. Using the lower extremity as an example, it demonstrates how the osseous tissue can manually be freed from the strain, thus successfully reducing or even eliminating pain. [ABSTRACT FROM AUTHOR]

Führt eine Dauerbelastung und -beanspruchung oder ein Trauma zur Überschreitung der Elastizitätsgrenze des Knochens, kann es zu einer leichten plastisch-elastischen Verformung der ossären Strukturen kommen. Kehrt der Knochen nicht in seine ursprüngliche neutrale Form zurück, entsteht bzw. verbleibt eine chronische Spannung in der trabekulären Matrix. Das wiederum führt zu einem dauerhaften Zug/Druck auf die beteiligten, nachweislich nicht dehnbaren Faszien-, Kapsel-, Band- und Sehnenstrukturen mit einer zwangsläufigen Aktivierung der darin verwobenen Schmerzrezeptoren. Chronische, mitunter therapieresistente Beschwerden im Knochen selbst und in den mit ihm verankerten Strukturen sind die Folge. In diesem Artikel wird mit dem (Knochen-)Strain Relief ein neues konservatives Behandlungskonzept vorgestellt, mit dessen Hilfe manuell pathologische, nicht sichtbare Knochen„verformungen" in die anatomische Ausgangslage zurückgebogen/-gedreht/-gedrückt werden können, um die permanenten Spannungen, Scherungen oder Zug auf Faszien und Sehnen zu minimieren und damit chronische Schmerzen sehr erfolgreich zu mindern oder sogar zu beseitigen. If a permanent load and stress exceeds the elastic limit of the bone, a slight plastic-elastic deformation of the osseous structures may occur. If the bone does not return to its original neutral shape a chronic tension in the trabecular matrix develops or remains. This in turn leads to permanent traction/pressure on the involved fascia, capsule, ligament and tendon structures, which have been shown to be non-extensible, with inevitable activation of the pain receptors interwoven within them. Chronic, sometimes therapy-resistant complaints in the bone area are the result. This article introduces (Bone) Strain Relief, a new conservative treatment concept that can be used to manually bend/rotate/push pathological, invisible bone "deformities" back into their original anatomical position in order to minimize the permanent tension/shear/pull on fascia and tendons and thus very successfully reduce or even eliminate chronic pain. [ABSTRACT FROM AUTHOR]

Stress fractures and other bony stress injuries occur along a spectrum of severity which can impact treatment and prognosis. When treating these injuries, it should be borne in mind that no two stress fractures behave exactly alike. Given that they are not a consistent injury, standardized treatment protocols can be challenging to develop. Treatment should be individualized to the patient or athlete, the causative activity, the anatomical site, and the severity of the injury. A holistic approach to the treatment of the most difficult stress fractures should be taken by orthopedists and sports medicine specialists. This approach is necessary to obtain optimal outcomes, minimize loss of fitness and time away from sports participation, and decrease the risk of recurrence. [ABSTRACT FROM AUTHOR]

Vitamin D is an essential, fat-soluble nutrient that is a key modulator of bone health. Despite the gaining popularity throughout published medical studies, no consensus has been reached regarding a serum vitamin D level that will guarantee adequate skeletal health in a patient with an increased functional demand. The purpose of the present investigation was to examine the serum concentrations of vitamin D in patients with confirmed stress fractures. A total of 124 patients were included in our retrospective cohort study. Of the 124 patients, 53 had vitamin D levels measured within 3 months of diagnosis. An association was seen in patients with a stress fracture and vitamin D level measured, as 44 (83.02%) of the 53 patients had a serum 25-hydroxyvitamin D level <40 ng/mL. Although an association was seen at our institution in patients with stress fractures and a serum vitamin D concentration <40 ng/mL, a larger and prospective investigation is warranted to further understand the effect of vitamin D level and stress fracture prevention in an active, nonmilitary population. [ABSTRACT FROM AUTHOR]

Abstract: Aim: The aim of the present study was the assessment of metatarsal head loading in combat boots of the German armed forces. With respect to the prevention of metatarsal stress fractures, we evaluated how cushioning insoles (made of EVA foam or neoprene) achieved a load reduction in comparison with conventional insoles. Material and methods: Local pressure, force and impulse values were determined with the pedar-m expert in-shoe pressure measurement system applied in 26 volunteers during walking with four different insoles made of synthetic mesh, EVA foam and neoprene. Data analysis was performed with SAS and tested for statistical differences with non-parametric tests (with p <0.05 as a significance level). Results: For the peak pressures under the metatarsal heads (MT) the following order was found: MT-II>MT-III>MT-I>MT-IV>MT-V. A comparison of the insoles indicated that the neoprene insole resulted in the lowest peak pressures with significant load reductions under MT-III to MT-V (p <0.00001). Furthermore, the impulse values under MT-II to MT-V were significantly lower with neoprene insoles (p <0.0002). However, the subjects rated the conventional insoles as more comfortable and better fitting than the newly developed insoles. Discussion/conclusion: The cushioning insoles were superior to the conventional insoles with respect to the plantar pressure distribution. With respect to the load reduction we can conclude that the modified insoles might be able to reduce the incidence of march fractures. The biomechanical advantage does not appear to be related to personal preferences. [Copyright &y& Elsevier]

Proximal stress fractures of the second metatarsal are rare. They have been reported mainly in classical ballet dancers. Non-operative treatment has usually led to good results and rapid return to full activities. We present a series of nine cases with stress fractures of the proximal second metatarsal. The patients were all actively involved in sports. None of them were dancers. In all of these patients non-operative treatment lasting for an average of 13 months had failed. All of the patients were operated on using the same method. In the operation drilling was performed around and through the fracture line. The patients were followed for an average of 38 months. All except one of the patients were able to return to their prior level of activity within 4–6 months. In conclusion if non-operative treatment fails surgery seems to give good results in most patients with a stress fracture of the proximal second metatarsal. [ABSTRACT FROM AUTHOR]