Stress Fractures In Athletes Research Articles

Surgical Treatment of Diaphyseal Stress Fractures of the Fifth Metatarsal in Competitive Athletes

Proximal diaphyseal stress fractures of the fifth metatarsal are common in athletes. Conservative treatment has been shown to result in high rates of delayed union, nonunion, and refracture, so internal fixation has become the treatment of choice in competitive athletes. Twenty top-level athletes with diaphyseal stress fractures fixed with intramedullary malleolar screws were evaluated. Functional outcome was assessed by American Orthopaedic Foot and Ankle Society midfoot score. Static and dynamic maximum vertical force and peak plantar pressures were evaluated with a computerized pedobarograph. Mean follow-up from surgery to interview was 10.3 years (range, 3.5-19.0 years). Clinical healing was 95%, and there has been one refracture (5%). The mean time from surgery to return to sport was 9 weeks (range, 5-14 weeks). Twelve athletes (60%) returned to a higher level of training, 7 (35%) to the same level, and 1 (5%) to a lower level compared with the level of training before injury. Average American Orthopaedic Foot and Ankle Society midfoot score was 93.8 (range, 85-100). During the computerized pedobarographic evaluations, 18 patients (90%) presented with varus of the metatarsus and the midfoot and 2 (10%) presented with a normal plantigrade foot. Intramedullary malleolar screws can yield reliable and effective healing of fifth metatarsal stress fractures in athletes. Varus of the metatarsus and the midfoot were predisposing factors for stress fractures in this population of competitive athletes, and all were recommended to wear orthoses until their competitive careers were completed.

Blinded-Read of Bone Scintigraphy

This study evaluated the use of bone scintigraphy (BS) for the diagnosis of stress fractures in athletes and its validity for the prediction of healing time, with a focus on foot injuries. In our retrospective study, 84 athletes with a total of 93 suspected stress fractures (foot, n = 66; others, n = 27) were included. A blinded-read of BS was performed by 3 observers. The standard of reference was established by an interdisciplinary truth-panel using all imaging data (scintigraphic, radiographic, and magnetic resonance imaging) and follow-up data (>12 month). Sensitivity, specificity, positive predictive value, negative predictive value, and accuracy for diagnosing stress fractures were calculated. Stress injuries were rated according to a 5-point grading score (0-4) and associated to the healing time. For the diagnosis of stress injuries (n = 50/93), mean sensitivity, specificity, positive predictive value, negative predictive value, and accuracy were 97.3%, 67.4%, 77.7%, 95.6%, and 83.5%, respectively. Interobserver analysis showed a high agreement between all 3 readers (mean κ = 0.83). In univariate analysis healing time of grade 3 to 4 stress injuries was significantly higher (median, 87 days; interquartile range, 69-132 days) compared with grade 1 to 2 lesions (median, 63 days; interquartile range, 43-95 days; P = 0.0067). Moreover, healing time of scintigraphic high grade stress injuries was significantly longer in a general linear model with adjustment for cofactors (grade, 3-4 vs. 1-2; P = 0.033). BS is a sensitive and reliable method for the diagnosis of stress injuries. In addition, the simplified classification for mild and severe stress injuries allows an estimation of healing time.

Percutaneous Cannulated Screw Fixation of Fifth Proximal Metatarsal Stress Fracture in Athletes

The purpose of this study was to know utility of percutaneous cannulated screw fixation of fifth proximal metatarsal stress fractures in athletes by assessment of radiological and clinical outcome. This study examined clinical and radiological union time of eleven cases of percutaneous screw fixation, which used the 4.0 mm cannulated screw, of fifth proximal metatarsal stress fracture in athletes. Type I of Torg classification is 7 cases, type II is 3 cases and type III is 1 case. All the cases showed fracture union, and all the patients resumed their athletics at the final follow-up. None of the cases complained of refracture or pain around where they had surgery, and visual analogue scale of pain, and American Orthopedic Foot and Ankle Society score was 0.73 and 93.4. The results of the study confirm that percutaneous screw fixation, which used the cannulated screw, of fifth proximal metatarsal stress fracture would help athletes resume their athletics in early stages.

Analysis of stress fractures in athletes based on our clinical experience

To analyze stress fractures in athletes based on experience from our sports medicine clinic. We investigated the association between stress fractures and age, sex, sports level, sports activity, and skeletal site in athletes seen at our sports medicine clinic between September 1991 and April 2009. Stress fractures of the pars interarticularis were excluded from this analysis. During this period (18 years and 8 mo), 14276 patients (9215 males and 5061 females) consulted our clinic because of sports-related injuries, and 263 patients (1.8%) [171 males (1.9%) and 92 females (1.8%)] sustained stress fractures. The average age of the patients with stress fractures was 20.2 years (range 10-46 years); 112 patients (42.6%) were 15-19 years of age and 90 (34.2%) were 20-24 years of age. Altogether, 90 patients (34.2%) were active at a high recreational level and 173 (65.8%) at a competitive level. The highest proportion of stress fractures was seen in basketball athletes (21.3%), followed by baseball (13.7%), track and field (11.4%), rowing (9.5%), soccer (8.4%), aerobics (5.3%), and classical ballet (4.9%). The most common sites of stress fractures in these patients were the tibia (44.1%), followed by the rib (14.1%), metatarsal bone (12.9%), ulnar olecranon (8.7%) and pelvis (8.4%). The sites of the stress fractures varied from sport to sport. The ulnar olecranon was the most common stress fracture site in baseball players, and the rib was the most common in rowers. Basketball and classical ballet athletes predominantly sustained stress fractures of the tibia and metatarsal bone. Track and field and soccer athletes predominantly sustained stress fractures of the tibia and pubic bone. Aerobics athletes predominantly sustained stress fractures of the tibia. Middle and long distance female runners who sustained multiple stress fractures had the female athlete triad. The results of this analysis showed that stress fractures were seen in high-level young athletes, with similar proportions for males and females, and that particular sports were associated with specific sites for stress fractures. Middle and long distance female runners who suffered from multiple stress fractures had the female athlete triad.

Stress Fractures of the Metacarpal Bones in Adolescent Tennis Players

Background: There are 12 reported cases of metacarpal stress fractures in athletes, with only 4 of them involving the second metacarpal. Purpose: The authors describe stress fracture of the second metacarpal bone in teenaged tennis players and the relationship with sport intensity and type of grip used. They also demonstrate that magnetic resonance imaging is the diagnostic study of choice to differentiate this entity from the most common cause of pain in this region of the hand in tennis players—the carpal boss. Study Design: Case series; Level of evidence, 4. Methods: Seven adolescent tennis players (mean age, 16.5 years; 6 female, 1 male) with dorsal hand pain produced by playing tennis were examined by radiographs and initial magnetic resonance imaging. In 2 cases, bone scintigraphy was performed. In the first 2 cases, the presumptive diagnosis was a carpal boss, but with this experience, the diagnostic evaluation of the last 5 cases was oriented toward a stress reaction at this level. Radiologic follow-up was performed. The authors also evaluated the grip type used by each tennis player. Results: Clinical evaluation and imaging studies resulted in a diagnosis of stress injury of the second metatarsal in 6 of 7 cases, with the seventh case involving the third metacarpal. Initial imaging was positive in 3 cases, revealing an increased signal in the marrow without hairline crack and cortical thickening of the shaft or simply an increased signal in the marrow. In all cases, there was a history of recent increase in the sport training load. Six of the 7 tennis players were using a semi-Western or Western grip. Conclusion: Stress fractures of the second metacarpal are characteristic of adolescent tennis players and are associated with an increased intensity of tennis play and may be associated with use of the semi-Western or Western grip. Magnetic resonance imaging is the most useful tool for obtaining a definitive diagnosis.

Does Shoe Insole Modification Prevent Stress Fractures? A Systematic Review

Stress fractures can be debilitating in athletes and military personnel. Insoles may lower stress fracture rates by improving biomechanics, lessening fatigue, and attenuating impact. The objective of this study was to systematically review the best evidence on the use of insoles as a method of stress fracture prevention in a high-risk population. Using MEDLINE, Cochrane, Current Controlled Trials, UK National Research Register, ScienceDirect, CINAHL, and EMBASE, a review of randomized (level I) and quasi-randomized (level II) controlled trials was performed using an insole as the intervention and stress fracture incidence as the primary outcome measure. Five trials were included, and a random effects model was used to generate a summary estimate and an overall odds ratio. One study found a significant reduction in overall stress fracture incidence using a semirigid insole, while four studies found no overall reduction in military personnel. However, when the data are pooled, orthotic use was beneficial. When stratified by site, there was a reduction in femoral and tibial stress fracture incidence. Shoe insoles may reduce the overall femoral and tibial stress fracture incidence during military training. It is unclear if the use of insoles would prevent stress fractures in athletes. Additional studies are necessary to determine the efficacy of insoles in an athletic population.

Comparison of 4.5- and 5.5-mm Cannulated Stainless Steel Screws for Fifth Metatarsal Jones Fracture Fixation

Complications including delayed and nonunions, and extensive time nonweightbearing with conservative treatment of fifth metatarsal Jones fractures, have led authors to recommend surgical fixation for this fracture in athletes who wish to return to activity quickly. The optimal surgical procedure, however, has not been determined. The purpose of this study was to evaluate the effectiveness of 5.5-mm cannulated screw fixation for fifth metatarsal stress fractures in athletes and compare them to an earlier cohort treated with a 4.5-mm screw. Twenty athletes were treated surgically with a 5.5-mm cannulated screw and postoperatively wore a removable walking boot, applied cold compression, initiated immediate range of motion, and used crutches for 1 week. Fractures were evaluated for clinical and radiographic healing. These findings were compared to a group that used 4.5-mm screws. Average radiographic healing was 96.7% and all fractures healed clinically. Athletes returned to sports in an average of 9.3 weeks. There were three re-injuries that were treated with 2 weeks in a walking boot. No patients have required screw removal or have experienced pain at the hardware site, besides the three re-injuries. When compared to the earlier study, no differences were found. However, there were no re-fractures in the 4.5-mm study, but there were three bent screws. The current study demonstrates the clinical effectiveness of the 5.5-mm screw. However, with the numbers available, we were unable to demonstrate significant improvement over the 4.5-mm screw and thus cannot conclude that a larger screw is more effective.

Use of bisphosphonates for the treatment of stress fractures in athletes

A literature review was performed to investigate the potential role of bisphosphonates for the treatment of stress fractures in athletes. Given the inhibitory action on osteoclast-mediated bone resorption, short-term suppression of bone remodeling using bisphosphonates could potentially treat stress fractures and prevent stress fractures from becoming regular fractures. To date, while there are some animal studies showing the scientific basis of bisphosphonates on stress fractures, there is still no conclusive evidence to prove any effect of bisphosphonates on stress fracture healing in humans. Further well-designed clinical trials should be carried out to establish their usefulness and safety. Until the results are available, it is prudent to limit the use of bisphosphonates for the treatment of stress fractures.

Position of the New Zealand Dietetic Association (Inc): Nutrition for exercise and sport in New Zealand

Position of the New Zealand Dietetic Association (Inc): Nutrition for exercise and sport in New Zealand

Section Modulus is the Optimum Geometric Predictor for Stress Fractures and Medial Tibial Stress Syndrome in both Male and Female Athletes

Background Various tibial dimensions and geometric parameters have been linked to stress fractures in athletes and military recruits, but many mechanical parameters have still not been investigated. Hypotheses Sedentary people, athletes with medial tibial stress syndrome, and athletes with stress fractures have smaller tibial geometric dimensions and parameters than do uninjured athletes. Study Design Cohort study; Level of evidence, 3. Methods Using a total of 88 subjects, male and female patients with either a tibial stress fracture or medial tibial stress syndrome were compared with both uninjured aerobically active controls and uninjured sedentary controls. Tibial scout radiographs and cross-sectional computed tomography images of all subjects were scanned at the junction of the midthird and distal third of the tibia. Tibial dimensions were measured directly from the films; other parameters were calculated numerically. Results Uninjured exercising men have a greater tibial cortical cross-sectional area than do their sedentary and injured counterparts, resulting in a greater value of some other cross-sectional geometric parameters, particularly the section modulus. However, for women, the cross-sectional areas are either not different or only marginally different, and there are few tibial dimensions or geometric parameters that distinguish the uninjured exercisers from the sedentary and injured subjects. In women, the main difference between the groups was the distribution of cortical bone about the centroid as a result of the different values of section modulus. Last, medial tibial stress syndrome subjects had smaller tibial cross-sectional dimensions than did their uninjured exercising counterparts, suggesting that medial tibial stress syndrome is not just a soft-tissue injury but also a bony injury. Conclusion The results show that in men, the cross-sectional area and the section modulus are the key parameters in the tibia to distinguish exercise and injury status, whereas for women, it is the section modulus only.

Surgical Technique for Navicular Stress Fractures in Athletes

Surgical Technique for Navicular Stress Fractures in Athletes

Chronic Anterior Midtibial Stress Fractures in Athletes Treated With Reamed Intramedullary Nailing

Chronic Anterior Midtibial Stress Fractures in Athletes Treated With Reamed Intramedullary Nailing

Management of Proximal Humeral and First Rib Stress Fractures

Stress fractures in athletes classically are seen in the bones of the lower extremity, often in association with repetitive weight-bearing activities. Upper-extremity stress fractures are relatively uncommon and are mostly described in the literature as individual case reports or small series. It is important to consider the diagnosis of stress fracture in athletes with upper limb pain of bony origin associated with overuse. These injuries typically are the result of intense repetitive motions in the young athlete. Proximal humeral stress fractures most often are seen in athletes engaged in overhead activities, whereas both throwers and weightlifters are at risk of developing stress fractures of the first rib. The diagnosis can be made with the use of adequate history, physical examination, and plain radiographs. These fractures commonly heal with conservative management of analgesics and activity modification and very rarely need any type of surgical intervention.

Stress fractures of the femoral shaft in athletes: a new treatment algorithm

Background: Femoral shaft stress fractures in athletes are not common but pose a great diagnostic challenge to clinicians. Because of few clinical signs, diagnosis and treatment are often delayed. Furthermore,...

Stress fractures in adolescent competitive athletes with open physis

There have been no studies devoted exclusively to stress fractures in competitive athletes with immature skeletal systems so far. The object of this case series was to describe special features of stress fractures in athletes with immature skeletal systems, with special reference to sport-specific strain, diagnosis and treatment results. The study population was made up of 19 children and adolescents with a total of 21 stress fractures. The average observation period was 4.83 years [standard deviation (SD) 2.69] and the average age at diagnosis, 14.04 years (SD 4.7). The lower extremity was affected in most of our cases. In adolescent athletes, endurance sports appear to lead preferentially to stress fractures in the region of the metatarsal bones, while sports requiring sudden stops at high speed appear to increase the risk of fractures in the region of the tibial diaphysis (P=0.0322). Most (20 of 21) of the fractures in this study were treated conservatively with refraining from athletic activity and reduction of stress/weight-bearing for an average of 6.73 weeks (SD 2.91). In five cases the extremity was in addition immobilized in a plaster cast for 5.32 weeks (SD 2.21). Complete healing was achieved in 14 cases. In seven cases, however, the treatment did not lead to a satisfactory outcome. Most of the patients whose symptoms persisted over a long period had fractures in the tibia and were engaged in sports requiring frequent sudden stops. Our data suggest that stress fractures in athletes, whose skeletal systems are still immature, lead to a clinical picture that does not always culminate in a good outcome of treatment. We therefore recommend a thorough and early diagnostic investigation (including MRI) and consistent treatment whenever a patient's history and clinical picture give any indication that a stress fracture might be present.

Preventing and managing stress fractures in athletes

Stress fractures are common overuse injuries of bone resulting from the repeated application of submaximal load. Factors that reduce bone strength or increase the load applied to bone can place an athlete at risk of developing a stress fracture. These factors include low bone density, menstrual disturbances, inadequate dietary intake and eating disorders, training errors, inadequate muscle function and biomechanical features. Identification of the at-risk athlete can allow prevention strategies to be implemented. Diagnosis of a stress fracture is generally made clinically but investigations such as bone scan, CT or MRI can be performed to confirm the diagnosis, grade the stage of the bone response and localize the site. Most stress fractures will heal with modified rest and permit return to sport around 8 weeks. However, there is a group of stress fractures that requires additional treatment and special consideration. Treatment of the typical stress fracture requires pain management, modification (or cessation) of the aggravating activity, muscle strengthening and maintenance of aerobic fitness, identification and subsequent modification of risk factors and gradual resumption of bone loading activities. The use of braces has been shown to reduce the time to return to full activity in some lower limb stress fractures. Similarly the use of electrical stimulation and ultrasound may be helpful. Recovery should be monitored clinically.

Chronic Anterior Midtibial Stress Fractures in Athletes Treated with Reamed Intramedullary Nailing

Background A chronic anterior midtibial stress fracture is a serious, difficult-to-treat injury that can adversely affect an athlete's career. Hypothesis The use of a reamed intramedullary nail for a chronic anterior tibial stress fracture is a safe and effective treatment for an athlete. Study Design Case series; Level of evidence, 4. Methods Seven collegiate-level athletes with 11 chronic anterior midtibial stress fractures were treated with reamed intramedullary nailing between 1997 and 2000. These patients were followed for a mean duration of 17 months. Results The mean age of the patients at the time of stress fracture diagnosis was 17 years. Seven of the fractures occurred in male athletes, whereas 4 occurred in female athletes. All patients had failed nonoperative treatment, including rest, activity modification, use of an orthosis, and low-intensity ultrasound stimulation, for a minimum of 4 months. Patients had experienced symptoms for a mean duration of 12 months. Clinical and radiological union occurred at a mean of 2.7 and 3 months, respectively. The mean duration for return to sports after surgery was 4 months. At last follow-up, all patients had full range of motion at the knee and ankle joints and were satisfied with the results. One patient developed bursitis at the tibial nail insertion site that was resolved with a steroid injection. Another patient sustained a traumatic fracture of the distal tibia 1 year after intramedullary nailing of the tibial stress fracture. This fracture healed with nonoperative treatment. No other complications were observed. Conclusion Intramedullary nailing of the tibia for chronic stress fracture has a high union rate, allows for a low complication rate, and allows for an early return to competitive sports. This procedure is an excellent alternative treatment for those fractures that have failed nonsurgical treatment.

Treatment of Stress Fractures in Athletes With Intravenous Pamidronate

To determine if the use of a second-generation biphosphonate, pamidronate, is an effective treatment option for stress fractures in intercollegiate athletes. Pamidronate is successfully used to increase bone mass in patients with Charcot arthropathy and osteoporosis. Case series. Academic sports medicine clinic with primary responsibility for intercollegiate athletics. Five intercollegiate female athletes. Intravenous pamidronate administered weekly for a total of 5 treatments. Athletes' ability to continue training without restrictions. Four of 5 treated athletes were able to continue training and competition within 1 week of treatment. Pamidronate may be a useful adjunct to the treatment of stress fractures.

Stress fractures in athletes: risk factors, diagnosis, and management.

Stress fractures in athletes: risk factors, diagnosis, and management.

Stress fractures in athletes: review of 196 cases

The purpose of this study was to investigate theassociation of stress fractures with age, sex, sport level,sporting activity, and skeletal site in athletes seen at oursports medicine clinic between September 1991 and May 2001.During these 10 years, 10 726 patients (6415 males, 3861females) visited our clinic because of sport-related injuries,and 196 patients [125 males (1.9%), 71 females (1.8%)]sustained stress fractures. The average age of the patients withstress fractures was 20.1 years (range 10–46 years); 84 patients(42.6%) were 15–19 years of age, and 68 (34.7%) were 20–24years of age. Altogether, 74 patients (37.8%) were active atthe high recreational level and 122 (62.2%) at the competitivelevel. The sites of the stress fractures varied from sport tosport. The ulnar olecranon was the most common stressfracture site among baseball athletes and the rib among therowing athletes. Classical ballet, aerobics, tennis, and volleyballathletes predominantly sustained stress fractures of thetibial shaft. Basketball athletes predominantly sustained stressfractures of the tibial shaft and medial malleolus and themetatarsal bone, whereas track and field and soccer athletespredominantly sustained stress fractures of the tibial shaftand pubic bone. Our results show that stress fractures areseen even in high-level adolescent athletes, with similarproportions for males and females, and that particular sportsare associated with specific sites for stress fractures.