Tuesday, 5 September 2017

The Stress is Killing Me

A lot of trees have been sacrificed in the name of better understanding bone stress injuries to the lower limb. Brukner and Khan’s latest edition of Clinical Sports Medicine devotes a whole chapter to their management... in feet.  Admittedly with good reason; they are debilitating and difficult to treat.  However, at the risk of being seen to harp again on my favourite theme of “what about the hand”, what about the hand? If B & K don’t mention them, and do they even exist? 

The answer is of course yes, it’s just that they are rarer. A Spanish paper in 2010 reported that only 12 cases of stress fractures to the metacarpals had ever been written up. The authors of that paper then published a case series of 7 tennis players with stress fractures of a metacarpal. All were adolescents, and all had altered their training or some aspect of their game prior to this injury (1). Volker Schoffl, that rock-climbing, x-gaming hand surgeon in Germany also published a paper on bony oedema in climbers (2). Aside from that there are a few case studies, but not a lot.

I've got almost too much in common with this guy!
So if they’re not talked about much, are we talking about the same thing? Well, essentially yes. B & K devoted a chapter to this subject; I’m going to try to paraphrase them in 150 words. Actually, I’m just going to copy what Stuart Warden wrote because it’s nice and succinct… (3) “A bony stress injury (BSI)represents the inability of bone to withstand repetitive mechanical loading, which results in structural fatigue and localised bone pain and tenderness. It occurs along a pathology continuum beginning with a stress reaction, which can progress to a stress fracture, and ultimately a complete bone fracture”. Thank you Stuart. Of course there is a lot more too it, and his chapter is a good read so get into it if you want to know more. 

Should be obvious.
MRI stress #. Not my patient
“Treatment then is what?” I hear you protocol driven fiends out there screaming. Rest and controlled load says Stuart, among other pearls. But let me make this a bit more personal, this is what I did...
·    Tennis player, bone pain in second metacarpal, had come on strongly over the period of a clay court tournament but had likely been festering for some time. Essentially the pain was so severe he could no longer hold his racquet and hit a forehand with any force. Stress reaction confirmed on MRI, dorsal interossei inflamed also which made anatomical sense. 

·         -Weeks one to two, rest in hand forearm orthosis overnight, hand based radial metacarpal joint immobilisation orthosis during the day, coming out for gentle range, modalities and very light massage only. Pain with turning on tap.
·         -Week three initiate very light isometrics to the interossei. Shadow racquet swings with large diameter light cardboard roll – NO PAIN. Decreased splint use, taps almost ok. Continue overnight splinting, stop day splint.
·         -Week four introduce light grip vs theraputty, continue to build load. Roll ball on racquet head. Grip rolled up towel.
·         -Week five to six, continue to build load, isometrics well tolerated now, introduce graded hitting ie soft balls, no forehands just yet. Progress putty density, light gym weights.
At this point, I passed him back to the tennis physios as the interossei were now pain free to heavy loading, although forceful grip was uncomfortable especially when hitting, and he still had pain with palpation of the second metacarpal. However my outcome measures had all been met, and it was felt he needed to focus on the tennis side of things.

Not my patient btw. Just a funny photo.
It is now 4 months since he last hit a tennis ball in anger, but he has finally been given the green light to resume competition. That’s a long time off for something that was initially seen as a short term reaction to increased activity. The time frame does does however, fit published case studies (1,4). It’s also likely that this stress reaction was in fact a fracture. I can absolutely guarantee that if any of the team involved with this injury come across any similar injury that occurs in another tennis players metacarpal will be taken just as seriously as if it had occurred in a metatarsal. “What about the hand” indeed! All part of my cunning plan. 

Look after those fingers,


(1)    Balius, R. et al. Stress fractures of the metacarpal bones in adolescent tennis players: a case series. American Journal of Sports Medicine 2010 38:6 pp 1215-1220
(2)    Hochholzer, T., Schoffl, V. Overuse bone marrow oedema of the hands in sport climbers. Sport Orthop Traumatol 2013 29:3 pp 219-24
(3)    Warden, Stuart. “Sports Injuries: Overuse” in Brukner, P & Khan, K. Clinical Sports Medicine 5th ed. 2017
(4)    Duarte, M. Metacarpal stress fracture in an amatuer tennis player; an uncommon fracture. Revista Brasilera de Orthopedia June 2017.