Abstract
Objectives:
Tibial stress fractures (TSF) represent a challenging pathology in high demand and high impact athletes and military personnel. These injuries can progress to complete fractures with delayed union, nonunion, and chronic pain, unless patients undergo an extensive period of activity modification. However, in single-sport athletes and active-duty military personnel, these periods of rest are less than ideal. The objective of this study was to evaluate the utility of platelet-rich plasma (PRP) injection as a non-operative adjunct for activity modification in patients with TSF.
Methods:
Following institutional approval, a retrospective review was conducted on patients with stress fracture diagnosis, PRP injection, and at least one post-intervention appointment. Patient charts were reviewed for dates, sex, metabolic status, endocrinologic pathology, imaging (pre and post intervention XR and MRI if completed), management, and clinical status at most recent follow-up. Procedural technique included cleaning of the site with sterile technique, needle placement deep to periosteum of fracture site under ultrasonographic guidance, and injection of PRP.
Results:
A total of 13 tibial stress fractures in 12 patients with a mean age of 25 years were included (12 TSF in females, 1 TSF in a male). Eleven of the fractures occurred in athletes (11/13; 85%). Of the TSF occurring in female patients, six had diagnoses of menstrual irregularities (6/12; 50%). Laboratory / metabolic findings were as follows: low bone density in 1 (1/13; 8%), 25(OH)D levels low in 6 (6/13; 46%), low normal in 2 (2/13; 15%), normal in 2 (2/13; 15%), and disordered eating in 1 (1/13; 8%). Teriparatide was prescribed for one TSF (1/13; 8%), calcitonin for ten TSF (10/13; 77%), and no patients were prescribed bisphosphonates or denosumab. Of the TSF occurring in female patients, 9 were prescribed oral contraceptives (9/12; 75%). All TSF aside from one had documented improvement at most recent follow up. Nine (9/13; 69%) fully recovered while 3 (3/13; 23%) had returned to sport / activity, but still had some pain during or after activity. Of the TSF with post-intervention radiographs, improvements in fracture imaging were present in seven (7/10; 70%). Of the TSF with post-intervention MRI, four had no changes in imaging whereas one had slight worsening.
Conclusions:
PRP injection represents a meaningful adjunct in a case series of patients with anterior tibial stress fractures. While there were no complications in this cohort of patients, further studies should evaluate the longer-term impact of this intervention in larger and more heterogenous patient populations.