Working Diagnosis:
Inferior Pole Patellar Stress Fracture

Treatment:
The team orthopedic surgeon was consulted to discuss surgical versus medical management options. He chose non surgical management. Athlete was removed from play, and placed in a knee immobilizer. He was made non weightbearing on crutches for two weeks. He was then allowed to weight bear in extension in immobilizer for another four weeks. He was then allowed to start graded physical therapy with isometrics progressing to more dynamic strengthening. At this time he was allowed to remove immobilizer around the house.

Outcome:
He remained out of soccer for the remaining two weeks of the season. And after the eight weeks of therapy, he was able to start limited functional soccer activities. His follow up radiographs showed the fracture has healed well, and he did not require any surgical intervention.

Author's Comments:
Stress Fractures are the result of high repetition loads below yield strength, muscular weakness, and muscle contraction, which initiates a disturbance in bone remodeling.(Crowther and Sarangi 2005). This is usually self-limited and resolves with rest, but you should have high index of suspicion and low threshold for obtaining special plain radiographs. Stress Fractures of the lower extremities are common and seen frequently, especially in the Tibia (50%), the metatarsals (9%), the femur (7%) and the fibula (6%). Stress fractures of the patella are less common however, noting less than ten distal third patella fractures in case studies (Mason 1996). In these cases most (six of seven) noted a prodrome of symptoms weeks to months prior to fracture. Of these cases four of eleven were middle third patella stress fractures.
This case was unusual not only for location (patella) but acuity of onset to presentation. Although this athlete noted occasional anterior knee pain he was able to compete at a high level with no missed time from play until this stress fracture presented clinically. Once a diagnosis of stress fracture is made, the decision of surgical or non-surgical management needs to be made. Non-surgical options, including casting or bracing in extension, is often appropriate. Based on data from traumatic lower pole patella fractures (Bostrom 1972) only 8% were displaced more than 4 mm and none required surgical intervention. For those in competitive sports who desire quicker return to play, one may decide on internal fixation using tension band wiring but more typically this is for mid patella fractures. Prognosis seems favorable based on outcomes of such cases and most return to their previous level of activity

References:
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