are pain free, a graded return to impact activities can begin and is progressed according to symptoms and physical findings. In football, where uncomplicated lower limb stress fractures are predominant and running is the aggravating activity, a progressive walking programme as described by Brukner et al (11) works well (table 6).

Once 45 minutes of brisk walking

1 of the rehab plan. It is essential that any fitness work be carried out in a way that avoids loading the bone (15). Common modalities used for fitness maintenance include; cycling, swimming, deep water running and rowing machines. Deep water running is especially

useful for footballers as it closely simulates movement patterns of the sport (15). See table 5 for a weekly water running and strength programme.

Modification of risk factors High recurrence rates in athletes mean that small adjustments of modifiable risk factors which contribute to the total load placed upon a bone are an essential component of the management plan. Training errors make up the most common changeable risk factors that must be identified and discussed. A training error includes a sudden or rapid increase in training volume or intensity at a rate that exceeds the bone’s ability to adapt (10) and preseason training is a good example of this. What may be appropriate for some players may be

PLAYERS MAY BE EXCESSIVE FOR OTHERS AND IN TEAM SPORTS SUCH AS FOOTBALL, INDIVIDUALISED TRAINING PROGRAMMES ARE DIFFICULT TO IMPLEMENT, SO THE EDUCATION OF COACHES IS IMPORTANT

with an understanding of elite sport are useful to help reduce the repetitive forces placed on lower limb bones in football. At Portsmouth FC we have the added concern of academy players accumulating a high number of weekly playing minutes as U18 players are often called upon in mid-week fixtures for the reserve XI adding further risk on young bones.

TIP: To combat the risk we advise our coaching staff that U18 players should play no more than 90 competitive playing minutes per week, this is not always received with a warm welcome in professional football but prevention is always better than cure.

excessive for others. In team sports such as football, individualised training programmes are difficult to implement so the education of coaches is important to protect vulnerable players from too much load.

The detection of intrinsic biomechanical abnormalities and impairments in flexibility are a priority for both treatment and future prevention. The skills of a podiatrist

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Electrical stimulation Various methods of electrical stimulation have been used to produce positive effects on healing of non-union or traumatic fractures, but there is no evidence base to support the efficacy of such treatment in stress fractures. The application of low intensity pulsed ultrasound to promote fracture repair is becoming more popular in sports medicine but is only recommended for the treatment of stress fracture sites that are prone to delayed or non-union and in elite athletes (13).

Phase 2

The healing bone is weak so a progressive increase in load is needed to allow adaptive increases in bone strength. When normal daily activities

WHAT MAY BE APPROPRIATE FOR SOME

is achieved without pain, slow jogging for increasing periods can begin and progress in duration up to 45 minutes. Next, pace can be increased progressively through to a full sprint, after which functional tasks such as hopping and agility skills can gradually be introduced.

It is not uncommon for players to experience some discomfort over the fracture site during the graded return to fitness but if bone pain occurs, activity should be ceased for one to two days. Once normal daily activities are pain free, the programme should be resumed at the level below which pain occurred. It is important in this part of a player’s rehabilitation that they be clinically reassessed every two weeks to check progress and evaluate any related symptoms or local signs. Follow up with radiography, bone scan, CT or MRI is not usually necessary as radiological healing lags behind clinical healing (3).

When the player returns to full training it is important to allow adequate recovery time after hard sessions or training weeks. Brukner et al (11), state that this can be achieved by alternating hard and easy training sessions to reduce stress on the injured area.

PREVENTION At Portsmouth we have worked hard to educate our coaching staff on the hazards that stress fractures pose and have advised new ways of working to reduced the risks. We recommend that running or football sessions are limited to one per day and any second period of training on double days should consist of activities which do not place excessive pounding load on young bones. For example; circuit training, weights, CV work in the gym, swimming or core stability. All players are actively encouraged to report symptoms early so that any stress response can be detected

sportEX medicine 2010;43(Jan):22-27