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CASE REPORT
Year : 2013  |  Volume : 13  |  Issue : 2  |  Page : 107-109

Role of therapeutic ultrasound in healing of tibial stress fracture in a runner: A case study


Department of Physical and Rehabilitation Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India

Date of Web Publication20-Dec-2013

Correspondence Address:
Mohammad Hassan Manzer
Department of Physical and Rehabilitation Medicine, Postgraduate Institute of Medical Education and Research, Sector-12, Chandigarh - 160 012
India
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DOI: 10.4103/1319-6308.123399

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  Abstract 

Stress fractures are a recognized complication of the chronic, intensive, weight-bearing training familiar to athletic, dance and military populations. Various studies have suggested that ultrasound therapy promotes healing in stress fractures. Some authors have even studied its role in the diagnosis of stress fractures. A 20-year-old male, runner presented with complains of pain in the anterior margin of the lower end of left tibia during walking and increases with running. Application of ultrasound on continuous mode for diagnosis of stress fracture precipitated the pain in 28 second at the site of tenderness. The subject was administered low intensity pulse ultrasound. Subject was re tested after 4 weeks of treatment. The patient has reported a significant improvement in pain during his functional activities after completion of treatment. The time duration of awareness of pain with the application of continuous ultrasound for the diagnosis of stress fracture increased to 58 seconds. This case demonstrates that low intensity pulse ultrasound may be effective in treatment of stress fracture and therapeutic ultrasound may be utilized for the diagnosis of stress fracture on the basis of time duration of awareness of pain and comparing it with the sound side.

  Abstract in Arabic 

الكسور الجهدية هي مضاعفة ملازمة للتدريب المزمن العنيف الشديد الذي يتضمن تحميل الوزن عند الرياضيين، والراقصين وأفراد الجيش. افترضت دراسات متعددة أن العلاج بالأمواج فوق الصوتية يشجع شفاء الكسر الجهدي وقد درس بعض المؤلفين دورها في التشخيص. اشتكى عداء عمره 20 سنة من ألم في الحافة الأمامية من نهاية الظنبوب اليسري خلال المشي تزداد أثناء الركض . وأتضح أن تطبيق الأمواج فوق الصوتية بنمط مستمر لتشخيص الكسر الجهدي زاد من حدة الألم خلال 28 ثانية في مكان المضض. تم تطبيق ذبذبات أمواج فوق صوتية منخفضة الشدة . وتم إعادة فحص المريض بعد اربع أسابيع من هذا العلاج . أظهر المريض تحسناً واضحاً في الألم خلال نشاطاته الوظيفية بعد إتمام العلاج. تم زيادة وقت تطبيق العلاج الذي يؤدي للشعور بالألم إلى 58 ثانية. في الخلاصة لقد أظهر هذه الحالة أن الأمواج فوق الصوتية قليلة شدة الذبذبات يمكن أن تكون فعالة في علاج الكسور الجهدية كما يمكن استعمال الأمواج الصوتية العلاجية لتشخيص الكسر الجهدي باحتساب المدة التي يشعر فيها المريض بالألم مقارنة بالطرف الأخر السليم.


Keywords: Low intensity pulse ultrasound, stress fracture, ultrasound


How to cite this article:
Manzer MH. Role of therapeutic ultrasound in healing of tibial stress fracture in a runner: A case study. Saudi J Sports Med 2013;13:107-9

How to cite this URL:
Manzer MH. Role of therapeutic ultrasound in healing of tibial stress fracture in a runner: A case study. Saudi J Sports Med [serial online] 2013 [cited 2021 Dec 2];13:107-9. Available from: https://www.sjosm.org/text.asp?2013/13/2/107/123399


  Introduction Top


Stress fractures are a recognized complication of the chronic, intensive, weight-bearing training familiar to athletic, dance and military populations. They result from repetitive sub-threshold loading that exceeds the bone's intrinsic ability to repair itself. Stress fracture is commonly seen in athletes especially when participants increase their training frequency, duration, intensity or abruptly change their activity.

Various studies have suggested that ultrasound therapy (UST) promotes healing in stress fractures. Although the mechanism by which ultrasound accelerates bone healing is uncertain, experts believe that ultrasound waves stimulate bone tissue to regenerate by causing small, controlled stresses in the bone cells, which increases blood flow in the area and mobilizes calcium. Because of the mechanical pressure that ultrasound waves deliver to the stress fracture site, some authors have even studied its role in the diagnosis of stress fractures.


  Case Report Top


A 20-year-old male, runner presented with complains of pain in the anterior margin of the lower end of left tibia during walking and increases with running. Pain is more marked during the toe off phase of the gait cycle during walking. Pain started gradually when he increased his distance of running suddenly from 3 km to 5 km. Pain initially occurred only after the finish of running. He continued running for 1 month when ultimately the condition worsened with continuous pain and finally stopped him from running and even started interfering in walking. He took rest from running for 1 month, but there was no improvement in the symptom. Finally after 2 month of initial onset of symptom he visited Orthopedic Department of Post Graduate Institute of Medical Education and Research (PGIMER) for t/t. Patient was asked to undergo magnetic resonance imaging (MRI). A diagnosis of Grade 3 stress fracture in lower mid shaft of the tibia was made by MRI. Patient was then sent to the Physiotherapy Department of PGIMER for t/t.

Pain is increased after movement and decreases with rest and after warm up. Medication did not relieve any of his symptoms.

On observation, there was a marked swelling in the anterior lower end of tibia. Anterior view showed no malalignment. No pronation or any other foot deformity was observed. On examination range of motion of the ankle joint was normal. Resisted isometric movement was pain free for plantar flexion, dorsiflexion, eversion and inversion. Single limb toe standing on left lower limb precipitated the pain when the patient was taking the heel to the ground. Running was painful and hopping precipitated severe pain. There was marked tenderness in lower anteromedial border of tibia.

The intensity of pain on numeric pain rating scale was marked by the patient as 7 out of 10 on stopping after run. To make the correlation with MRI application of ultrasound on continuous mode as set by the PULSON 200 for diagnosis of stress fracture precipitated the pain in 28 s at the site of tenderness [Figure 1]. Application of ultrasound on the sound side in the same area corresponding to the site of tenderness on the affected side precipitated the pain in 1 min 26 s. They have used a frequency of 1.1 MHz, duty cycle 100%, effective radiation area 4 cm 2 as the diagnostic parameter for stress fracture. The plan of management consisted of low intensity pulse ultrasound (LIPUS) and advice. The subject was administered a daily 20 min session with UST machine using a frequency of 3 MHz, power of 0.8 W/cm 2 , pulse mode with a duty cycle of 20% 0 for 5 days/week for 4 weeks. Ultrasound machine used for the treatment was SONOPULS 992 (Enraf Nonius). Subject continued all the functional activities during treatment without brace. Subject was advised to avoid pain provoking activities. Subject was re tested after 4 weeks of treatment. Single limb toe standing on the left lower limb precipitated no pain. Running and hopping precipitated no pain. Application of ultrasound on continuous mode as set by the PULSON 200 for diagnosis of stress fracture precipitated the pain in 58 s after the completion of treatment.
Figure 1: Site of tenderness is encircled

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  Discussion Top


The patient has reported a significant improvement in pain during his functional activities after completion of treatment with LIPUS. The time duration of awareness of pain with the application of continuous ultrasound with parameters set by PULSON 200 for the diagnosis of stress fracture increased from 28 s to 58 s.

Brand et al. [1] evaluated the efficacy of LIPUS for treatment of lower extremity stress fracture and concluded that treatment of tibial stress fractures with daily LIPUS was effective in pain relief and early return to vigorous activity without bracing for patients with posterior-medial stress fractures.

Romani et al. [2] carried out a study to determine whether 1 MHz of continuous ultrasound can identify tibial stress fractures and found that a protocol using visual analog scores after the application of 1 MHz continuous ultrasound is not sensitive for identifying subjects with tibial stress fractures.


  Conclusion Top


This case demonstrates that LIPUS may be effective in treatment of stress fracture and therapeutic ultrasound may be utilized for the diagnosis of stress fracture on the basis of time duration of awareness of pain and comparing it with the sound side.

 
  References Top

1.Brand JC Jr, Brindle T, Nyland J, Caborn DN, Johnson DL. Does pulsed low intensity ultrasound allow early return to normal activities when treating stress fractures? A review of one tarsal navicular and eight tibial stress fractures. Iowa Orthop J 1999;19:26-30.  Back to cited text no. 1
[PUBMED]    
2.Romani WA, Perrin DH, Dussault RG, Ball DW, Kahler DM. Identification of tibial stress fractures using therapeutic continuous ultrasound. J Orthop Sports Phys Ther 2000;30:444-52.  Back to cited text no. 2
[PUBMED]    


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  In this article
Abstract
Introduction
Case Report
Discussion
Conclusion
References
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