Stress Fractures In Athletes Research Articles

Stress fracture of athletes as a cause of groin pain

In this article, suitable imaging of stress reactions and stress fractures in athletes will be examined. Diagnostic procedures include X‑ray, computed tomography (CT), magnetic resonance imaging (MRI), and bone scintigraphy. MRI represents the gold standard for these types of injuries. Of all imaging techniques, MRI shows the highest sensitivity in terms of diagnostic and prognostic aspects in stress reactions and stress fractures. Early performance of MRI to evaluate the staging, therapy and prognosis of the healing process is recommended.

Tension band plating of an anterior tibial stress fracture nonunion in an elite athlete, initially treated with intramedullary nailing: a case report

BackgroundLeg pain in athletes is a common condition and is often related to tibial stress fracture. When non-operative treatment fails, the optimal surgical treatment is controversial. The aim of this study was to report a case of tension band plating of an anterior tibial stress fracture nonunion, treated previously with intramedullary nailing. To the best of our knowledge, this is the first reported case in which tension band plating was placed without removing the preexisting intramedullary nail.Case presentationThe tibial shaft is a common location of stress fracture in athletes. Anterior tibial stress fractures are difficult to manage. When conservative treatment fails, intramedullary nailing is the mainstay of treatment. However, nonunion is a serious complication. In our case, a non-united anterior tibial stress fracture, treated with intramedullary nailing, was addressed with the application of a compression prebended plate over the nail in a 23-year-old French man of African origin who is an elite football player. At 3-months postoperatively he was pain free and started light exercises. At 6-months postoperatively, complete radiologic union of the fracture was evident. He was symptom free; he resumed at that time a full training program and he returned to play football at preinjury high competition level.ConclusionsCompression plating is a valuable method of treating non-united anterior tibial stress fractures. We believe that anterior tension band plating is superior to intramedullary nailing in managing anterior tibial stress fractures, not only after failure of intramedullary nailing, but also as a first-line surgical treatment. This technique offers advantages, such as no violation of the extensor mechanism and risk of anterior knee pain, and directly addresses the underlying problem of distraction forces acting on the anterior tibial cortex and compromising fracture healing. Especially in high-level athletes, who cannot tolerate prolonged inactivity, early surgical intervention of anterior tibial stress fractures with tension band plating is a reliable option that can accelerate recovery.

Outcomes of Surgical Treatment for Anterior Tibial Stress Fractures in Athletes: A Systematic Review

Background: Although most anterior tibial stress fractures heal with nonoperative treatment, some may require surgical management. To our knowledge, no systematic review has been conducted regarding surgical treatment strategies for the management of chronic anterior tibial stress fractures from which general conclusions can be drawn regarding optimal treatment in high-performance athletes. Purpose: This systematic review was conducted to evaluate the surgical outcomes of anterior tibial stress fractures in high-performance athletes. Study Design: Systematic review; Level of evidence, 4. Methods: In February 2017, a systematic review of the PubMed, MEDLINE, Cochrane, SPORTDiscus, and CINAHL databases was performed to identify studies that reported surgical outcomes for anterior tibial stress fractures. Articles meeting the inclusion criteria were screened, and reported outcome measures were documented. Results: A total of 12 studies, published between 1984 and 2015, reporting outcomes for the surgical treatment of anterior tibial stress fractures were included in this review. All studies were retrospective case series. Collectively, surgical outcomes for 115 patients (74 males; 41 females) with 123 fractures were evaluated in this review. The overall mean follow-up was 23.3 months. The most common surgical treatment method reported in the literature was compression plating (n = 52) followed by drilling (n = 33). Symptom resolution was achieved in 108 of 123 surgically treated fractures (87.8%). There were 32 reports of complications, resulting in an overall complication rate of 27.8%. Subsequent tibial fractures were reported in 8 patients (7.0%). Moreover, a total of 17 patients (14.8%) underwent a subsequent procedure after their initial surgery. Following surgical treatment for anterior tibial stress fracture, 94.7% of patients were able to return to sports. Conclusion: The available literature indicates that surgical treatment of anterior tibial stress fractures is associated with a high rate of symptom resolution and return to play in athletes, although the high complication rate and potential need for subsequent procedures are important considerations for surgeons and patients.

Navicular Stress Fracture Outcomes in Athletes: Analysis of 62 Injuries

The optimal treatment modalities for navicular stress fractures in athletes is currently unknown for this season-ending injury. The present study evaluated factors that might be significant and affect healing outcomes, specifically focusing on the return to activity (RTA) time and a decreased desired activity (DDA) after treatment in athletes. Such considerations included previous navicular stress fractures, patient demographic data and type of sport, and initiation time of treatment. The data from 59 patients with 62 fractures were prospectively analyzed from May 2005 through July 2016. The results showed a significant correlation between a previous navicular stress fracture and decreased desired activity. The average duration of symptoms before receiving definitive treatment was 8.8 months. Computed tomography as the initial imaging modality correlated positively with a correct diagnosis (1.00). In contrast, magnetic resonance imaging, when used initially, was only 71% accurate. Runners constituted most of the cohort at 38 (61.3%). Ten other athletes were involved in jumping sports. Of the 62 injuries, 21 (33.9%) were in elite or professional athletes, all of whom were able to RTA, with 1 patient, a 38-year-old world record holding runner, having a DDA. Seven refractures (11.2%) occurred an average >5 years after the initial injury, predominantly in those aged <21 years, none with previous surgery. Eight patients (12.9%) developed postinjury arthrosis, including 1 with DDA. Patients who underwent open reduction and internal fixation had a RTA of 4.56 months compared with those who had undergone nonoperative treatment, who had an average RTA of 3.97 months. Seven patients (11.2%) underwent screw removal and required a longer RTA. Overall, of the 62 injuries, the patients with 57 of the injuries (91.9%) were able to RTA at their preinjury level.

Stress fracture in athletes

Stress fractures are widely encountered in sport medicine and rheumatology. Stress fractures result from abnormal and repetitive loading on normal bone that lead to microdamage and then fracture. They occur after sudden increase in physical activity. They appear mostly at lower limbs. Women are at higher risk than men. Patients complain of mechanical pain. Clinical findings include focused pain and sometimes swelling. No biological test is useful for diagnosis. Plain radiographs are normal in early stage disease. MRI is the gold standard to confirm stress fracture. Treatments of stress fracture always involve rest and analgesics. Non-steroidal anti-inflammatory should be use cautiously because they may inhibit callus formation. Extracorporeal shockwave may be a new approach for SF not healing with rest. Surgical treatment is often needed in high risk stress fracture of delayed healing, non-union or complete fracture.

Twelve-weeks Oral Spray Vitamin D3 Supplementation Does Not Alter Bone Turnover Markers In Collegiate Gaelic Footballers

Vitamin D deficiency is associated with increased bone remodelling activity. Quantification of reference-standard bone turnover markers total procollagen type 1 N-terminal propeptide (P1NP) (bone formation) and beta C-terminal telopeptide of type I collagen (β-CTx) (bone resorption) therefore enable detection of subtle perturbations in bone remodelling that may result from vitamin D inadequacy and indicate an increased risk of stress fracture in athletes. PURPOSE: To investigate the effect of wintertime vitamin D3 supplementation using an oral spray on bone turnover markers in Irish athletes compared to placebo. METHODS: Stored samples from a randomised, double-blind, placebo-controlled trial conducted in Gaelic footballers (3000IU (75μg) vitamin D3 daily versus placebo for 12-weeks, n=42) were analysed for P1NP and β-CTx. Dietary vitamin D and calcium intake as well as total 25-hydroxyvitamin D (25OHD) data were available from the previous study. RESULTS: Overall, 72% of athletes presented with a 25(OH)D concentration <50nmol/L, and 5 exhibited vitamin D deficiency (<30nmol/L) at baseline. Dietary vitamin D and calcium intakes averaged 5.9±4.3μg/day and 1037±651mg/day respectively. Daily supplementation with 3000IU (75μg) vitamin D3 significantly increased mean ± SD 25(OH)D compared to no significant change in the placebo group (vitamin D; 47.37±13.29 to 83.68±32.98nmol/L (+79%) vs. placebo; 43.10±22.00 to 49.22±25.40 (+14%) P=0.006). However, ANCOVA revealed no significant difference in mean ± SD change from baseline for P1NP (-8.72±18.83 vs. -5.04±21.13μg/L, P=0.413) or β-CTx concentrations (-0.09±0.18 vs. -0.10±0.21μg/L, P =0.627) when compared to placebo. CONCLUSION: In this study, 12-weeks vitamin D3 supplementation using an oral spray solution did not influence bone turnover when compared to placebo, despite increasing mean 25(OH)D concentration by 79%. Vitamin D inadequacy (<50nmol/L) is apparent in collegiate Gaelic footballers however future interventions, aiming to test change over time in bone turnover as a primary outcome, should consider a longer intervention in athletes with vitamin D deficiency (<30nmol/L).

Lower limb stress fractures in sport: Optimising their management and outcome.

Stress fractures in sport are becoming increasing more common, comprising up to 10% of all of sporting injuries. Around 90% of such injuries are located in the lower limb. This articles aims to define the optimal management of lower limb stress fractures in the athlete, with a view to maximise return rates and minimise return times to sport. Treatment planning of this condition is specific to the location of the injury. However, there remains a clear division of stress fractures by “high” and “low” risk. “Low risk” stress fractures are those with a low probability of fracture propagation, delayed union, or non-union, and so can be managed reliably with rest and exercise limitation. These include stress fractures of the Postero-Medial Tibial Diaphysis, Metatarsal Shafts, Distal Fibula, Medial Femoral Neck, Femoral Shaft and Calcaneus. “High risk” stress fractures, in contrast, have increased rates of fracture propagation, displacement, delayed and non-union, and so require immediate cessation of activity, with orthopaedic referral, to assess the need for surgical intervention. These include stress fractures of the Anterior Tibial Diaphysis, Fifth Metatarsal Base, Medial Malleolus, Lateral Femoral Neck, Tarsal Navicular and Great Toe Sesamoids. In order to establish the optimal methods for managing these injuries, we present and review the current evidence which guides the treatment of stress fractures in athletes. From this, we note an increased role for surgical management of certain high risk stress fractures to improve return times and rates to sport. Following this, key recommendations are provided for the management of the common stress fracture types seen in the athlete. Five case reports are also presented to illustrate the application of sport-focussed lower limb stress fracture treatment in the clinical setting.

Review on Stress Fractures

Stress fractures represent the end product of the failure of bone to adequately adapt to the mechanical loads experienced during physical activity. Limited epidemiological data suggest that these are common injuries in the sporting population, particularly in association with weight-bearing activities such as running and dancing. A number of factors may increase the risk of stress fracture, including female gender, genetic determinants, menstrual disturbances, low bone density, body composition, biomechanical variants, nutritional intake, and training errors. Diagnosis of a stress fracture is often made on clinical findings but appropriate imaging techniques may be needed in some cases. Although the majority of stress fractures will heal without complications in a relatively short time frame, there are a number of stress fractures that require specific additional treatment. These include fractures of the femoral neck, anterior tibial cortex, tarsal navicular, proximal fifth metatarsal, and sesamoids. This article reviews stress fractures in athletes concentrating on etiology, epidemiology, risk factors, diagnosis, and treatment. Further details are provided for the difficult stress fractures.

Stress fracture and premenstrual syndrome in Japanese adolescent athletes: a cross-sectional study

ObjectivesTo investigate the relationship between the occurrence of stress fracture and premenstrual syndrome (PMS)/premenstrual dysphoric disorder (PMDD) in Japanese adolescent athletes.DesignCross-sectional study.SettingOsaka, Japan.ParticipantsA school-based survey on menstruation and school life...

Recurrent Fracture After Anterior Tension Band Plating With Bilateral Tibial Stress Fracture in a Basketball Player: A Case Report.

The tibial shaft is the most common location of stress fractures in athletes. Tibial stress fractures are divided into 2 groups, anterior and posterior, based on location. Posterior tibial cortex fractures are more common and respond well to conservative treatment. Fractures in the anterior cortex are less common, accounting for only 4.6% of stress fractures,14 and they often heal poorly because of relatively poor vascularity and constant tension exerted by posterior muscle forces. In the absence of operative treatment, a persistently painful stress fracture may result in delayed union, nonunion, or even complete fracture. Different surgical treatment procedures have been described, but there is no consensus on the best approach for anterior tibial stress fractures. Intramedullary nailing is an established technique for treating delayed or nonunion tibial stress fractures.10 Recently, several authors have reported that anterior tension band plating offers a number of advantages over intramedullary nailing for anterior tibial stress fractures in athletes.3,7,13,20 We report on the surgical treatment, via exchange intramedullary nailing, of a new stress fracture that developed after anterior tension band plating treatment of an existing stress fracture.

Stress fractures in athletes: A literature review

Stress fractures are commonly seen in athletes. The lower extremities are more frequently involved than the upper extremities. Stress fractures usually occur after a recent increase in activity or repeated activity with limited rest. A high index of suspicion and timely diagnosis are crucial in order to avoid the severe secondary damage that can occur. Although stress fractures are significant for all patients, in athletic individuals they may bring about the end of their sporting careers. Treatment usually is conservative including activity modification and analgesics to relieve pain. Orthopedic surgeon consultation is indicated in patients with recurrent fractures, nonunion, or fractures in high-risk locations. This article reviews the latest scientific literature in reference to stress fractures in athletes. It goes some way to explaining the principles, approach and guidelines for the management.

Greater Polar Moment of Inertia at the Tibia in Athletes Who Develop Stress Fractures.

Background:Several previous investigations have determined potential risk factors for stress fractures in athletes and military personnel.Purpose:To determine factors associated with the development of stress fractures in female athletes.Study Design:Case-control study; Level of evidence, 3.Methods:A total of 88 female athletes (cross-country, n = 29; soccer, n = 15; swimming, n = 9; track and field, n = 14; volleyball, n = 12; and basketball, n = 9) aged 18 to 24 years were recruited to participate in a longitudinal bone study and had their left distal tibia at the 4%, 20%, and 66% sites scanned by peripheral quantitative computed tomography (pQCT). Patients included 23 athletes who developed stress fractures during the following year (cases). Whole body, hip, and spine scans were obtained using dual-energy x-ray absorptiometry (DXA). Analysis of covariance was used to determine differences in bone parameters between cases and controls after adjusting for height, lower leg length, lean mass, fat mass, and sport.Results:No differences were observed between cases and controls in any of the DXA measurements. Cases had significantly greater unadjusted trabecular bone mineral content (BMC), greater polar moment of inertia (PMI) at the 20% site, and greater cortical BMC at the 66% site; however, after adjusting for covariates, the differences became nonsignificant. When analyses were repeated using all individuals who had ever had a stress fracture as cases (n = 31) and after controlling for covariates, periosteal circumference was greater in the cases than the controls (71.1 ± 0.7 vs 69.4 ± 0.5 mm, respectively; P = .04).Conclusion:A history of stress fractures is associated with larger bones. These findings are important because larger bones were previously reported to be protective against fractures and stress fractures, but study findings indicate that may not always be true. One explanation could be that individuals who sustain stress fractures have greater loading that results in greater periosteal circumference but also results in the development of stress fractures.

Tension Band Plating of a Nonunion Anterior Tibial Stress Fracture in an Athlete

The authors present a rare technique of tension band plating of the anterior tibia in the setting of a nonunion stress fracture. Surgical management with an intramedullary nail is a viable and proven option for treating such injuries. However, in treating elite athletes, legitimate concerns exist regarding the surgical disruption of the extensor mechanism and the risk of anterior knee pain associated with intramedullary nail use. The described surgical technique demonstrates the use of tension band plating as an effective treatment of delayed union and nonunion anterior tibial stress fractures in athletes without the potential risks of intramedullary nail insertion.

Determinants of stress fracture risk in United States Military Academy cadets

BackgroundPrior studies have identified some risk factors for stress fracture in athletes and military recruits. ObjectiveTo determine whether historical factors, physical measures, biochemical variables of skeletal metabolism, genetic factors, bone density (BMD) and bone size could predict risk of stress fracture over 4years in physically fit cadets at the US Military Academy (USMA). MethodsBaseline surveys, assessments of height, weight, scores on the Army Physical Fitness Test, and peripheral BMD were obtained in all cadets (755 men, 136 women), and central BMD in a subset. Blood samples were analyzed for variables of calcium homeostasis, bone turnover, and selected hormones and genetic factors. Stress fractures were adjudicated by review of orthopedic notes and imaging reports. Results5.7% of male and 19.1% of female cadets had at least 1 stress fracture (58% metatarsal and 29% tibial), most within 3months of entry to USMA. In males, risk of stress fracture was higher in those who exercised <7h per week during the prior year (RR 2.31; CI 1.29,4.12), and in those with smaller tibial cortical area (RR 1.12; CI 1.03,1.23), lower tibial bone mineral content (RR 1.11; CI 1.03,1.20) and smaller femoral neck diameter (RR 1.35, CI 1.01, 1.81). In women, higher stress fracture risk was seen in those with shorter time since menarche (RR 1.44 per year; CI 1.19, 1.73) and smaller femoral neck diameter (RR 1.16; CI 1.01, 1.33.). ConclusionAlthough prior physical training in men, length of prior estrogen exposure in women and leg bone dimensions in both genders played a role, the maximum variance explained by all of these factors was below 10%. We conclude these factors play a minor role in the development of stress fractures in physically fit USMA cadets.

Fourth Metatarsal Base Stress Fractures in Athletes

Metatarsal stress fractures account for approximately 28% of all stress fractures reported in the literature. Second and third metatarsal stress fractures are most common, followed by fractures of the fourth and fifth metatarsal. Reports in the literature suggest that proximal fourth metatarsal stress fractures have the same propensity for delayed healing and nonunion as do fifth metatarsal stress fractures. There is a paucity of literature on operative management of fourth metatarsal fractures. This study reports the results of operative management of fourth metatarsal stress fractures in athletes. A retrospective review with prospectively collected data was undertaken to evaluate utility of operative care of fourth metatarsal stress fractures in an athletic population desiring early return to sports. Eleven athletes over a 13-year period were enrolled with proximal fourth metatarsal stress fractures. The American Orthopaedic Foot & Ankle Society (AOFAS) Midfoot scores were obtained pre- and postoperatively. Midfoot alignment, including the presence or absence of metatarsus adductus, radiographic time to healing, and time to return to sports were also recorded. All patients were treated with operative open reduction and internal plate fixation with calcaneal autograft. Four of the 11 patients had metatarsus adductus. All had evidence of radiographic healing prior to return to activity, all returned to sports at an average of 12 weeks post surgery, and all would choose surgery again given the same injury. The AOFAS Midfoot scale improved from an average of 55 preoperatively to 94 postoperatively (P < .001) CONCLUSION: Our study suggests that operative repair of fourth metatarsal stress fractures hastens time of healing and return to sports in athletes. It also supports the theory that there is a correlation between metatarsus adductus lateral metatarsal stress fractures. Level IV, retrospective case series.

Bilateral Proximal Tibial Stress Fractures at the Epiphyseal Scar

Siparsky PN, Kanaan MG, Garrett WE Jr. Bilateral Proximal Tibial Stress Fractures at the Epiphyseal Scar. The Duke Orthop J 2013;3(1):71-73.

Medial Malleolar Stress Fracture in Athletes: Diagnosis and Operative Treatment

Stress fractures are common overuse injuries in athletes. Medial malleolar stress fractures are rare but they have an important clinical relevance because of their tendency to cause considerable disability and loss of time in sports without proper treatment. The diagnosis of medial malleolar stress fracture is often a challenge and it is therefore often delayed which may cause even further problems in the treatment. The purpose of this study was to increase the awareness of medial malleolar stress fractures as a possible cause for medial ankle pain and to stress the importance of MRI in the diagnostics as well as to evaluate the results of surgical treatment. Between 1995 and 2008, a total of ten athletes with a medial malleolar stress fracture were operated at our centre. All operated cases during those years were included in the study. The cases were retrospectively analyzed. Return to pre-injury level of sport was evaluated and considered as an indicator of successful treatment. Initially all standard radiographs were negative whereas in MRI the fractures were all visible. After operative treatment all medial malleolar stress fractures healed clinically in three to four months and all except one of the athletes were able to return to their pre-injury level of sports. Early MRI is recommended if a medial malleolar stress fracture is suspected. Surgical treatment seems to result in rapid healing of the fracture and return to sports. In our opinion early surgery should be considered especially in athletes.

Stress fractures of the pelvis and legs in athletes: a review.

Context:Stress fractures are common injuries in athletes, often difficult to diagnose. A stress fracture is a fatigue-induced fracture of bone caused by repeated applications of stress over time.Evidence Acquisition:PubMed articles published from 1974 to January 2012.Results:Intrinsic and extrinsic factors may predict the risk of stress fractures in athletes, including bone health, training, nutrition, and biomechanical factors. Based on their location, stress fractures may be categorized as low- or high-risk, depending on the likelihood of the injury developing into a complete fracture. Treatment for these injuries varies substantially and must account for the risk level of the fractured bone, the stage of fracture development, and the needs of the patient. High-risk fractures include the anterior tibia, lateral femoral neck, patella, medial malleolus, and femoral head. Low-risk fractures include the posteromedial tibia, fibula, medial femoral shaft, and pelvis. Magnetic resonance is the imaging test of choice for diagnosis.Conclusions:These injuries can lead to substantial lost time from participation. Treatment will vary by fracture location, but most stress fractures will heal with rest and modified weightbearing. Some may require more aggressive intervention, such as prolonged nonweightbearing movement or surgery. Contributing factors should also be addressed prior to return to sports.

Paper 15: Surgical Treatment of Chronic Stress Fractures in Athletes

During 25 years (1982-2007) 170 chronic, painful, risk or nonunion stress fractures in athletes and dancers were treated surgically. The patients represented several sports events, mainly track and field athletics. Endurance athletes, as runners, cross-country skiers, orienteerers and triathlonists were represented with the biggest number of these stress fractures (appr. 65% of all operations). There were 131 stress fracture operations in males (77%) and 39 in females (23%) in the series. The mean age of the patients was 23 years (14-37 years). The number of operations/bones in the material were: anterior mid-tibia 49, tarsal navicular 25, sesamoid bones of the first MTP joint 16, metatarsal bones 15, tarsal bones 14, medial malleolus 12, and patella 7 cases. There were from 1 to 5 stress fracture operations in the following bones/sites: proximal tibia, femoral shaft, femoral neck, pubis, olecranon, humeral shaft, distal fibula, first rib, calcaneal bone, cuboid bone, pisiform bone and hamulus ossis hamati of the wrist. The fracture caused local pain and training/competing was usually not possible. The diagnosis was done by radiographs (100%). It was confirmed by Technetium scan (30%) and MRI (23%). CT examination was used in a few cases. All patients were treated at first conservatively by rest from causative training, non weight- bearing, crutches, casts, local ultrasound, magnetotherapy, osteoporosis medicines, D-vitamin and extra calcium. Delayed or non-union developed in 125 cases (76%). The risk for a complete fracture was estimated in 21 cases (12.5%) and in the rest of the cases, persistent pain and non healing was indication for surgery. A complete fracture had occurred 14 times, during training or competition. Different surgical techniques were used in the treatment. High risk stress fractures, as femoral neck, distal femoral shaft, mid-tibia, patella, tarsal navicular and MT V basis were treated with internal fixation (nail, screws, plates or tension band method). Pseudoarthrosis surgery included sometims curettage and bone grafting. Some stress fractures were treated with drilling of the fracture site. Postoperative treatment consisted of short immobilization, non weight-bearing and rest, followed by early isometric exercises, swimming, water training, bicycling, weight training and gym trainig. The patients were followed clinically and by radiographs as long as the healing had occurred and the end result was clear. The training pause depended on the bone and surgical treatment method. The patients were able to return to there sports 2-12 months after surgery. The patients were followed appr. for 2 years. The result from surgery was good or excellent in 86 per cent of the cases. All these athletes were able to come back to the same level as before. There were some complications and recurrences in the series. A reoperation was needed in 9 cases. Removal of the osteosynthesis material was done in 91 cases.

Lower extremity and pelvic stress fractures in athletes

Stress fractures occur following excessive use and are commonly seen in athletes, in whom the lower limbs are frequently involved. Delayed diagnosis and management of these injuries can result in significant long-term damage and athlete morbidity. A high index of suspicion may facilitate diagnosis, but clinical presentation may be non-specific. In this regard, imaging in the form of plain radiograph, CT, MRI and bone scintigraphy may be of value. This article reviews the incidence, presentation, radiological findings and management options for athletes with stress fractures of the lower limb.