Dave,

I understand that a stress fracture will not show up on plain film X-Rays for about 6 weeks.  I also do not think that you can see much 'pre-stress' fracture evidence.  Please, someone, correct me if I am wrong.  A bone scan will show up a 'hot spot' though.

To everyone,

About the patient in question.  He had X-Rays today which showed no abnormality.  I saw them and there did appear to me to be a very faint, whispy horizontal line (ie transverse plane line) on the tibial crest of the left tibia, but then there were a few other such lines in other direction near the tibial tuberosity.  The doctor in A&E said he could not see any stress fracture.

As for bone scans, A&E did not refer on and due to other circumstances it will be difficult to obtain a GP appointment before he disappears for a while (the patient not the GP, and we are not talking magic tricks!).

With another colleague (Emma from this list!), we re-examined the patient and decided there was external tibial rotation, slight genu varum, and quite a bit of torsional stress going through the tibia during the bowling action.  This was seen only from the naked eye method in real time life effects!  However, the bowling action is a good one so there would be little effect in training on that aspect.

The increased torsion appears greatest when weight bearing on the metatarsal heads and digits only, and guess what? - tibialis anterior overfires.  This would give evidence to the idea of some muscular involvement, especially as at that point in gait he is unhelped by the orthoses.

We have ruled out a full blown stress fracture but not pre fatigue/stress fracture or periostitis.

Plan at Present:
Rest from weight bearing activities but to include cycling, swimming, eliptical jogging machine thing (no impact), and resistance work with weights to help maintain general muscle strength and bone density.  Calcium supplements to be included in the diet.

This phase to last 3-4 weeks then to gradually return to walking then light jogging and to overal very gradually build up to normal activities again.  The 10% rule applies (do not increase time, speed or distance by mnore than 10% a week).

Temporary orthoses with metatarsal extension of forefoot wedge with first ray cut out.

Any further points please say, also, if you have reason to believe we are wrong with the range of diagnosis or treatment plans, please shout.

I'll let you all know in a month or so how things have progressed.

Thank you all for your continued interest and advice.

Andrew

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