Sept. 20, 2005

Kevin Cross, MED, ATC, PT, Susan Saliba, PhD, ATC, PT, UVA Sports Medicine

The return to play following a Jones fracture continues to be an enigma for the competitive soccer player. Surgical screw fixation of the fracture and rehabilitative efforts such as early mobilization, bone stimulators and progressive return to function has permitted a hastened return. However, caution and patience must be applied since re-injury to this area is common. Potential types of re-injury include a fracture with deformation of the screw, incomplete bone healing or non-union and compensatory injuries to the foot from the altered biomechanics. There are inherent risks with competitive sport and the athlete should understand that the Jones Fracture, even when repaired can create significant disability.

Most orthopedic surgeons recommend surgery for an athlete who sustains a Jones fracture to stabilize the bone and apply compression to the fracture site. Therefore, this article will address rehabilitation and functional progression following surgery to repair a Jones fracture. While rehabilitating the soccer player with a post-operative Jones fracture, the physician, athletic trainer, and athlete must be very patient. The typical time line for returning to activity revolves around the anticipated six weeks for complete bone healing, but one must remember that this fracture site has a characteristically poor blood flow. Consequently, its healing rate may be slower than other types of fractures and the new bone may not reach peak strength until much later post-operatively. Also, the traditional guideline of letting pain direct activity progression is not infallible because the athlete may be pain free or there may be only very minimal pain prior to re-injury. There are also many adjacent joints and bones that may generate a pain response due to disrupted mechanics or contact from the screw head. The most important advice for the early stages of rehabilitation following Jones Fracture repair is to appreciate the novel characteristics of the fracture site and, therefore, be patient.

Immobilization

Following surgery to fixate the fracture site with a screw, the patient may be immobilized in a cast for a minimum of two weeks. During the early period, weight bearing is not allowed to prevent movement through the bone. At two weeks, if the screw fixation appears strong via x-ray, and the athlete is relatively pain free, then he or she may be placed into a walking boot and permitted to begin partial weight bearing. To train the athlete for partial weight bearing, a bathroom scale is used to monitor the amount of weight through the injured limb. The amount of weight is calculated and the athlete reinforces this to learn how the prescribed amount feels. The athlete continues to use crutches but will place a maximum of 25% of his or her weight through the surgical foot. If after three days of 25% weight bearing the athlete does not have any pain, he may progress to 50% weight bearing. Using the same guideline, the athlete may progress weight bearing by 25 % every three days while wearing the walking boot until he or she is full weight bearing using the ankle immobilizer. If, at any time, he or she feels the slightest pain at the fracture site, the athlete should reduce the weight bearing through the surgical leg for three consecutive days before attempting to place more weight through the surgical leg when walking. Once the athlete is able to walk with normal weight distribution while wearing a walking boot for three consecutive days, he or she may be progressed to walking in a running shoe with a steel insert to increase the stiffness of the shoe. Running shoes have an increased rocker bottom and assist heel lift to minimize the stress at push off. Additionally, running shoes are generally supportive with good arch stabilization. The athlete should not walk barefoot or in sandals. If x-rays show that the bone appears to be healing well at six weeks after surgery, the athlete may replace the steel shoe insert with a custom orthotic shoe insert. Depending upon the physician's choice and the athlete's comfort, the athlete may be fitted with a rigid or a semi-rigid orthotic.

Treatment and Rehabilitation

The largest benefit to wearing a walking boot at two weeks postoperatively is that the athlete may begin rehabilitating the lower extremity to minimize stiffness and disuse atrophy. The boot should be worn at all times except when performing these exercises. In attempt to enhance the speed of fracture healing, bone stimulators are available and may be prescribed by the physician. Two types of external bone stimulators are available, either using low intensity ultrasound or electromagnetic energy to promote the piezoelectric effect at the bone. The subtle application of these energies has been shown to assist the healing in some cases. The stimulator should be used as prescribed.

To minimize flexibility loss in the foot and ankle, soft tissue mobilization to the foot's bottom surface and the calf muscles can begin as soon as the cast has been removed. Joint mobilization of the adjacent foot and ankle joints, and manual stretching with a towel also promote the flexibility of the ankle. Manual resistance or rubber tubing resistance exercises for ankle dorsiflexion (i.e. pulling foot up) and inversion (i.e. rolling foot in) minimize disuse atrophy. However, the athlete should not perform heel raises or eversion (i.e. rolling foot out) exercises until at least six weeks after the surgery due to the tension placed on the fracture site by the tendons' insertion.

Beginning at two weeks, the athlete may also begin performing strengthening exercises for the foot's intrinsic muscles by performing towel crunches and marble pickups. Beginning at six weeks after surgery, if the x-rays reveal good bone healing, the athlete may add heel raises and general balance exercises to his preexisting rehabilitation program. At this point, the athlete may progress through a general ankle rehabilitation program focusing on balance exercises and a progression of foot intrinsic muscle endurance.

Functional Progression

At six weeks after surgery, the soccer player should begin a fast walking program on a treadmill. The speed should be between 3.7 and 4.0 miles per hour. The athlete should walk for two consecutive days and then rest from walking for one day. The first outing should be 20 minutes, and the duration should increase by five minutes for each pair of consecutive days. If the athlete experiences pain, he or she should rest from walking until he or she becomes pain free during activities of daily living. The soccer player should then reenter the program at the previous duration that was not painful. Once the athlete can walk for 45 minutes for two consecutive days without pain, he or she should begin jogging for 15 minutes. An additional 30 minutes of fast walking should be incorporated to maintain the same volume of activity. The progression of jogging duration should be the same as the progression for walking duration. All jogging should be performed on a treadmill or a level grass surface in good supportive shoes.

Once the athlete can jog for 30 minutes without pain, he or she may progress straight running by beginning acceleration and deceleration activity on a level grass surface. Intensity progression should begin at 50% of the perceived maximum speed and progress every three sessions by 25% of the athlete's perceived maximum. Volume progression can vary dependent upon the sport but should not exceed a total of 10 repetitions in the first session. Early on, emphasis should be on long distances to decelerate, and gradually, the athlete should be made to decelerate in a shorter distance. Once the athlete can perform wind sprints at near maximum speed, he may begin cutting and sport specific activities. The cutting angle should initially be acute to the athlete's vertical path of running, i.e. 30 degrees. As the volume and intensity of the cutting activities and agility drills increase, the cutting angle should become more obtuse. Evaluating the total time of activity is used to assess the total volume of work. As previously noted with all functional progressions, the athlete should initially participate in no more than two consecutive days of cutting and sport specific activities before receiving a day of rest to allow the healing bone to repair the microstresses. Repetitive activity using angles between 90 and 180 degrees from the athlete's vertical running path, i.e. suicides, should be avoided until approximately 4-5 months. The repetitive sharp cutting drills seem to empirically cause problems with the Jones Fracture. Although soccer demands this type of cutting at times, a heavy volume of training to change directions while rapidly decelerating places a great deal of stress at the Jones Fracture. Therefore, more time should be anticipated for a return to full drills although the soccer player may be functionally able to play.

Footwear

Regarding footwear, soccer players returning to sport from a Jones Fracture repair should wear turf shoes or running shoes with their orthotics to do all warm-up activities and conditioning. Shoes with more rigid soles are initially preferred. Cleats should only be worn for specifically performing the sport during practice. Additionally the soccer player should select cleats that have a larger number of studs dispersed across the bottom. Additionally, attention should be paid to the location of the studs on the outside of the cleat, so that a stud is not located directly under the location of the fracture.

Cardiovascular

Beginning at approximately four week after the surgery, the patient may begin riding a stationary bicycle. The athlete should always wear the walking boot or a running shoe with a steel insert while riding the bike. Once he or she has progressed the fast walking to 30 minutes, the player may begin using weight bearing machines for cardiovascular fitness. Examples would include Versa-climber, elliptical, and Step-Mill. Also at approximately 4-6 weeks, the patient may begin running in deep water since the calf muscles do not put an excessive amount of stress on the fracture site at this time. Once the athlete begins performing acceleration and decelerations, distance running can be initiated. Finally, incorporating Fartlek training programs into the functional progression integrates jogging and acceleration activity to stress the cardiovascular system.

Conclusion

These guidelines are very general and are susceptible to the scrutiny of the athlete's athletic trainer and surgeon who should be closely monitoring the athlete's progress. There may be instances where the athlete may safely be accelerated through one part of the functional program. However, one should remember that neither the presence nor the intensity of pain is a consistent indicator of potential re-injury in the region of Jones fractures. Also, it is probably not the force of one specific incident but rather the accumulation of many painless microstresses across many weeks that create a failed Jones fracture repair.