Treatment Of Stress Fractures Research Articles

Spatiotemporal Characterization of Microstructure Morphology, Mechanical Properties and Bone Remodeling of Rat Tibia Under Uniaxial Compressive Overload Loading.

Bone tissue is subjected to increased mechanical stress during high-intensity work. Inadequate bone remodeling reparability can result in the continuous accumulation of microdamage, leading to stress fractures. The aim of this work was to investigate the characteristics and repair mechanisms of tibial microdamage under several degrees of overload. Also, we aimed at better understanding the effects of overload on the multi-scale structure and mechanical properties of bone. Sixty 5-month female rats were divided into three groups with different time points. Micro-CT was used to evaluate the three-dimensional microstructure, and three-point bending, quasi-static fracture toughness and creep mechanical test were carried out to evaluate the mechanical properties. SEM was used to observe the morphological characteristics of fracture surfaces. Section staining was used to count the microdamage parameters and numbers of osteoblasts and osteoclasts. The microarchitectures of cancellous and cortical bones in the three overload groups showed different degrees of damage. Overload led to a messy crystal structure of cortical bone, with slender microcracks mixed in, and a large number of broken fibers of cancellous bone. The properties associated with the elastic plasticity, fracture toughness, and viscoelasticity of cortical bone reduced in three groups, with that corresponding to day 30 presenting the highest damage. The accumulation of microdamage mainly occurred in the first 14days, that is, the crack density peaked on day 14. Peak-targeted bone remodeling of cortical and cancellous bones occurred mainly between days 14 and 30. The influence of overload mechanical environment on bone quality at different time points was deeply investigated, which is of great significance for the etiology and treatment of stress fractures.

Discrepancies in the prevalence, risk factors, diagnosis, and treatment of stress fractures between long-distance runners and sprinters: A qualitative review of systematic reviews

This qualitative review of systematic reviews consolidates current knowledge on stress fractures among endurance athletes and sprinters, including epidemiology, risk factors, diagnosis, and treatment strategies. A search across PubMed, Web of Science, SCOPUS, Science Direct, and Google Scholar, limiting results to articles published within the last year, yielded 90 relevant articles. Initial search results were narrowed down to 56 articles following abstract screening, with an additional article obtained through direct author correspondence. Stress fractures, a subset of bone stress injuries, result from persistent mechanical pressure surpassing bone regeneration capacity. They predominantly affect lower extremities, notably the tibia and metatarsals in endurance runners, and the toe phalanx in sprinters. Various risk factors contribute to stress fracture susceptibility, including gender, nutritional deficiencies, biomechanical factors, and psychological aspects like perfectionism and fear of failure. Diagnosis involves detailed patient history, clinical examination, and imaging modalities such as MRI, which remains the gold standard. Treatment emphasizes rest, gradual return to activity, and addressing underlying risk factors. Surgical intervention is reserved for high-risk fractures or cases of non-union. Preventive measures encompass nutritional optimization, biomechanical assessment, appropriate footwear, and psychological support. Notably, strategies targeting the Female Athlete Triad and ensuring adequate energy availability are crucial in both endurance and sprinting athletes. While more research directly comparing distance runners to sprinters is warranted, along with more sprinting-related research in general, this review provides a comprehensive understanding of stress fractures in endurance athletes and sprinters, aiding clinicians in diagnosis, management, and prevention strategies to optimize athlete health and performance.

Proportion of Navy Recruits Diagnosed With Symptomatic Stress Fractures During Training and Monetary Impact of These Injuries.

Lower extremity stress fractures result in lost time from work and sport and incur costs in the military when they occur in service members. Hypovitaminosis D has been identified as key risk factor in these injuries. An estimated 33% to 90% of collegiate and professional athletes have deficient vitamin D levels. Other branches of the United States military have evaluated the risk factors for stress fractures during basic training, including vitamin D deficiency. To the best of our knowledge, a study evaluating the correlation between these injuries and vitamin D deficiency in US Navy recruits and a cost analysis of these injuries has not been performed. Cutbacks in military medical staffing mean more active-duty personnel are being deferred for care to civilian providers. Consequently, data that previously were only pertinent to military medical providers have now expanded to the nonmilitary medical community. We therefore asked: (1) What proportion of US Navy recruits experience symptomatic lower extremity stress fractures, and what proportion of those recruits had hypovitaminosis vitamin D on laboratory testing? (2) What are the rehabilitation costs involved in the treatment of lower extremity stress fractures, including the associated costs of lost training time? (3) Is there a cost difference in the treatment of stress fractures between recruits with lower extremity stress fractures who have vitamin D deficiency and those without vitamin D deficiency? We retrospectively evaluated the electronic medical record at Naval Recruit Training Command in Great Lakes, IL, USA, of all active-duty males and females trained from 2009 until 2015. We used ICD-9 and ICD-10 diagnosis codes to identify those diagnosed with symptomatic lower extremity stress fractures. Data collected included geographic region of birth, preexisting vitamin D deficiency, vitamin D level at the time of diagnosis, medical history, BMI, age, sex, self-reported race or ethnicity, hospitalization days, days lost from training, and the number of physical therapy, primary care, and specialty visits. To ascertain the proportion of recruits who developed symptomatic stress fractures, we divided the number of recruits who were diagnosed with a stress fracture by the total number who trained over that span of time, which was 204,774 individuals. During the span of this study, 45% (494 of 1098) of recruits diagnosed with a symptomatic stress fracture were female and 55% (604 of 1098) were male, with a mean ± SD age of 24 ± 4 years. We defined hypovitaminosis D as a vitamin D level lower than 40 ng/mL. Levels less than 40 ng/mL were defined as low normal and levels less than 30 ng/mL as deficient. Vitamin D levels were obtained at the discretion of the individual treating provider without standardization of protocol. Cost was defined as physical therapy visits, primary care visits, orthopaedic visits, diagnostic imaging costs, laboratory costs, hospitalizations, if applicable, and days lost from training. Diagnostic studies and laboratory tests were incorporated as indirect costs into initial and follow-up physical therapy visits. Evaluation and management code fee schedules for initial visits and follow-up visits were used as direct costs. We obtained these data from the Centers for Medicare & Medicaid Services website. Per capita cost was calculated by taking the total cost and dividing it by the study population. Days lost from training is based on a standardized government military salary of recruits to include room and board. We found that 0.5% (1098 of 204,774) of recruits developed a symptomatic lower extremity stress fracture. Of the recruits who had vitamin D levels drawn at the time of stress fracture, 95% (416 of 437 [95% confidence interval (CI) 94% to 98%]; p > 0.99) had hypovitaminosis D (≤ 40 ng/mL) and 82% (360 of 437 [95% CI 79% to 86%]; p > 0.99) had deficient levels (≤ 30 ng/mL) on laboratory testing, when evaluated. The total treatment cost was USD 9506 per recruit. Days lost in training was a median of 56 days (4 to 108) for a per capita cost of USD 5447 per recruit. Recruits with deficient vitamin D levels (levels ≤ 30 ng/mL) incurred more physical therapy treatment costs than did those with low-normal vitamin D levels (levels 31 to 40 ng/mL) (mean difference USD 965 [95% CI 2 to 1928]; p = 0.049). The cost of lost training and rehabilitation associated with symptomatic lower extremity stress fractures represents a major financial burden. Screening for and treatment of vitamin D deficiencies before recruit training could offer a cost-effective solution to decreasing the stress fracture risk. Recognition and treatment of these deficiencies has a role beyond the military, as hypovitaminosis and stress fractures are common in collegiate or professional athletes. Level III, prognostic study.

«Переломи неспроможності» тазового кільця

Надані дані літератури щодо термінології, причинних факторів, особливостей клінічних проявів, діагностики та лікування стресових переломів. Стресові переломи поділяються на дві групи — «втомні» переломи (fatigue fractures) і переломи, обумовлені неспроможністю кісткової тканини, — «переломи неспроможності» (insufficiency fractures). «Втомні» переломи визначаються як результат тривалої дії на кістку надмірних навантажень, що повторюються, у практично здорових і фізично активних людей. Загальна патофізіологія «переломів неспроможності» полягає в невідповідності між міцністю кістки і величиною навантаження, що на неї припадає, — від низької енергії до фізіологічного (повсякденні навантаження, зумовлені масою власного тіла). Подані власні клінічні спостереження «переломів неспроможності» тазового кільця. Труднощі діагностики «переломів неспроможності» тазового кільця обумовлені недостатньою інформованістю ортопедів щодо можливих причин їх розвитку та клінічних проявів.

Diagnosis of Stress fractures in military trainees: a large-scale cohort

IntroductionThe Israel Defense Forces (IDF) has strict protocols for the diagnosis and treatment of stress fractures wherein diagnosis is clinical with imaging used for persistent symptoms only. The purpose of...

Intermittent Parathyroid Hormone Accelerates Stress Fracture Healing More Effectively Following Cessation of Bisphosphonate Treatment.

ABSTRACTParathyroid hormone (PTH) and bisphosphonates (BPs), including alendronate (ALN), have opposing effects on bone dynamics. The extent to which PTH remains effective in the treatment of stress fracture (SFx) in the presence of an ongoing BP treatment has not been tested. SFx was induced in 150 female Wistar rats, divided into five equal groups (n = 30). All rats were pretreated with ALN (1 μg/kg−1/day−1) for 14 days prior to SFx induction, followed by ALN cessation or continuation for the duration of the experiment; this was combined with daily PTH (8 μg/100 g−1/day−1) on SFx induction for 14 days, followed by cessation or continuation of ALN after SFx induction or an equivalent vehicle as a control. Ulnas were examined 2 weeks or 6 weeks following SFx. Two toluidine blue‐ and two tartrate‐resistant acid phosphatase‐stained sections were examined for histomorphometric analysis using Osteomeasure software. There was a significant interaction between the effects of time and treatment type on the woven bone width and apposition rate, as well as an improvement in the woven bone architecture. However, woven bone variables remained unaffected by the cessation or continuation of ALN. Cessation of ALN increased osteoclast number when compared with the ALN‐PTH continuation group (p = 0.006), and vehicle (p = 0.024) after 2 weeks. There was a significant interaction between the effects of time and treatment type on the number of osteoclasts per unit BMU area and length. The number of osteoclasts per unit BMU area and length was significantly greater in ALN cessation groups. It was concluded that intermittent short‐duration iPTH treatment effectively increased remodeling of SFx with a concurrent BP treatment, provided that BP was ceased at the time of SFx. Our results could help develop shorter iPTH treatment protocols for the clinical management of SFxs and guide clinical decision‐making to cease BP treatment in cases of SFx. © 2020 The Authors. JBMR Plus published by Wiley Periodicals LLC. on behalf of American Society for Bone and Mineral Research.

Stress fractures of the foot and ankle, part 1: biomechanics of bone and principles of imaging and treatment.

A stress fracture is a focal failure of bone induced by the summation of repetitive forces, which overwhelms the normal bone remodeling cycle. This review, the first of two parts, discusses the general principles of stress fractures of the foot and ankle. This includes bone structure, biomechanics of stress applied to bone, bone remodeling, risk factors for stress fracture, and general principles of imaging and treatment of stress fractures. Cortical bone and trabecular bone have a contrasting macrostructure, which leads to differing resistances to externally applied forces. The variable and often confusing imaging appearance of stress fractures of the foot and ankle can largely be attributed to the different imaging appearance of bony remodeling of trabecular and cortical bone. Risk factors for stress fracture can be divided into intrinsic and extrinsic factors. Stress fractures subject to compressive forces are considered low-risk and are treated with activity modification and correction of any modifiable risk factors. Stress fractures subject to tensile forces and/or located in regions of decreased vascularity are considered high risk, with additional treatment options including restricted weight-bearing or surgery.

Calcium and bone metabolism across women's life stages. Stress fracture in female athletes.

Stress fractures are common overuse injuries in athletes, especially in long-distance runner, jumping sports and gymnastics in female athletes. The pathology of stress fracture mainly includes repeated biomechanical loading, which leads to bone micro-damage and failure of bone structure. Female athlete triad(FAT), which includes low energy availability with or without an eating disorder, functional hypothalamic amenorrhea, and osteoporosis, is a serious healthcare concern in female athletes. For prevention and treatment of stress fracture, management of biomechanical factors modifying the load applied to a bone is important, and especially in female athletes, management for FAT is one of the important factors. This report outlines the current knowledge on the epidemiology, diagnosis, treatment and prevention of stress fracture, relating to FAT in female athletes.

Stress fractures in football

Football (soccer) is one of the most popular sports in the world with high-reported injury rates; many injuries are potentially career ending. Stress fractures represent the inability of a normal or weakened bone to withstand repeated stresses and are reported to account for 0.5% of all football-related injuries. The pathophysiology of stress factors is multifactorial and involves a complex interplay of several extrinsic and intrinsic factors. A high degree of suspicion and adequate imaging is necessary to diagnose these injuries, as plain radiographs may miss the diagnosis in many cases. Once the diagnosis of a stress fracture has been confirmed, treatment consists of activity modification and relative or complete rest, depending on the site and nature of the stress fracture. Surgical intervention may be necessary in the ‘high-risk’ stress fractures, which are prone to displacement, delayed union and non-union. This review looks at the epidemiology, aetiopathogenesis, classification, diagnosis and treatment of stress fractures in football.

Fractures and Dislocations of the Tarsal Navicular.

Fractures of the tarsal navicular are commonly the result of trauma or chronic overload. Because of its complex anatomy and blood supply, the tarsal navicular is susceptible to osteonecrosis, and injury to this bone can lead to posttraumatic arthrosis of the surrounding joints. Diagnosis of the injury, especially in patients with stress fractures, can require a high index of suspicion and the use of advanced imaging. The treatment of stress fracture is controversial and ranges from immobilization in a non-weight-bearing cast or boot to internal fixation with or without bone grafting. Traumatic fractures are treated with open reduction and internal fixation with or without external fixation for medial and lateral column stabilization. To avoid a poor outcome, concomitant injuries must be recognized and treated. Despite appropriate treatment, patients may ultimately require fusion procedures to address ongoing pain and disability.

Non-Union of a Tibial Stress Fracture in a Young Female Taking Bisphosphonate Medication

The authors present the case of a 27 yr old female who failed conservative management for a tibial stress fracture. The patient was known to suffer from “Female Athlete Triad” and as a consequence of decreased bone mineral density had been started on long-term bisphosphonates. Though this medication has been proposed as a treatment for stress fractures, an anabolic homeostatic bone state is required; this is known to be deficient in the presence of eating disorder and low body mass index. A non-fibrous atrophic non-union was found at the time of surgery. The patient has responded well to operative fixation including bone graft and modification of risk factors, which included stopping bisphosphonate therapy.

Role of therapeutic ultrasound in healing of tibial stress fracture in a runner: A case study

Stress fractures are a recognized complication of the chronic, intensive, weight-bearing training familiar to athletic, dance and military populations. Various studies have suggested that ultrasound therapy promotes healing in stress fractures. Some authors have even studied its role in the diagnosis of stress fractures. A 20-year-old male, runner presented with complains of pain in the anterior margin of the lower end of left tibia during walking and increases with running. Application of ultrasound on continuous mode for diagnosis of stress fracture precipitated the pain in 28 second at the site of tenderness. The subject was administered low intensity pulse ultrasound. Subject was re tested after 4 weeks of treatment. The patient has reported a significant improvement in pain during his functional activities after completion of treatment. The time duration of awareness of pain with the application of continuous ultrasound for the diagnosis of stress fracture increased to 58 seconds. This case demonstrates that low intensity pulse ultrasound may be effective in treatment of stress fracture and therapeutic ultrasound may be utilized for the diagnosis of stress fracture on the basis of time duration of awareness of pain and comparing it with the sound side.

Stress fractures of the base of the metatarsal bones in young trainee ballet dancers

Classical ballet is an art form requiring extraordinary physical activity, characterised by rigorous training. These can lead to many overuse injuries arising from repetitive minor trauma. The purpose of this paper is to report our experience in the diagnosis and treatment of stress fractures at the base of the second and third metatarsal bones in young ballet dancers. We considered 150 trainee ballet dancers from the Ballet Schools of "Teatro Alla Scala" of Milan from 2005 to 2007. Nineteen of them presented with stress fractures of the base of the metatarsal bones. We treated 18 dancers with external shockwave therapy (ESWT) and one with pulsed electromagnetic fields (EMF) and low-intensity ultrasound (US); all patients were recommended rest. In all cases good results were obtained. The best approach to metatarsal stress fractures is to diagnose them early through clinical examination and then through X-ray and MRI. ESWT gave good results, with a relatively short time of rest from the patients' activities and a return to dancing without pain.

Shock Waves in the Treatment of Stress Fractures

In soccer players, lower extremity stress fractures are common injuries and are the result of repetitive use damage that exceeds the intrinsic ability of the bone to repair itself. They may be treated conservatively but this may cause long-term complications, such as delayed union, muscle atrophy and chronic pain. Stress fractures that fail to respond to this management require surgical treatment, which is also not without risks and complications. Extracorporeal shock wave therapy (ESWT) has been used successfully on fracture complications, such as delayed union and nonunion. As such, we want to examine ESWT in the management of stress fractures. In this article, we present a retrospective study of 10 athletes affected by chronic stress fractures of the fifth metatarsus and tibia that received three to four sessions of low-middle energy ESWT. At the follow-up (8 wk on average), the clinical and radiography results were excellent and enabled all players to gradually return to sports activities. These reports show that ESWT is a noninvasive and effective treatment for resistant stress fractures in soccer players. (E-mail: b.moretti@ortop2.uniba.it (B.M.), angelanotarnicola@yahoo.it (A.N.))

Do not use bisphosphonates without scientific evidence, neither in treatment nor prophylactic, in the treatment of stress fractures

Stress fractures are common in athletes and can end the career because of its long time for healing [1, 2, 4, 5, 14]. In military recruits, especially in basic training, it has led to modification of the type of training, the time for the repetitions and the load [9, 10]. The researchers are trying hard to get a solution to the problem, not only with different types of surgery but also by medical treatment [4, 11]. Bisphosphonates have been used for several years to treat osteoporosis by its function to increase bone mass and decrease fracture risk as the osteoclast activity depresses [8]. It is a potent drug, used in the treatment of severe diseases like Paget’s disease, bone tumors and metastases. A stress fracture is an overuse injury and the mechanism depends on the load of the bone and if the load gives more strain and strain rate than the bone can stand, then a stress fracture occur [10]. Animal model experiments have suggested that suppression of bone remodeling can prevent stress fractures [2, 3, 8]. There are contradictive signals whether it is possible or not to detect any biochemical markers in the blood of recruits or athletes with increased bone remodeling as a sign for stress fracture [1]. The effect of bisphosphonates on fracture healing has also been discussed, though they suppress bone remodeling—some researchers have reported larger callus and delayed maturation of the fracture in animal models and some other report no problem with fracture callus remodeling unless very high doses of bisphosphonates are used [7, 8]. On the contrary, other reports propose that bisphosphonates may enhance fracture repair, probably by stabilizing the fracture callus. Others include the improved osseointegration of metal implants in treated ovariectomized rats, or improved distraction osteogenesis, conserving bone architecture after osteonecrosis [6]. Bisphosphonates are known to reduce pain in different bone conditions as osteolytic metastasis, multiple myeloma, and localized transient osteoporosis [15]. A report of one female runner with LTO of the navicular bone, treated with bisphosphonates—were pain—free after few days and then she had a complete resolution of the oedema in the tarsal navicular. This is though only one case [12]. In fatigue loading, no studies using bisphosphonates have proven any effect, but conclusions are that longer treatment than 2 weeks are needed to get effect on fatigue, and a combination of glucocorticoid and alendronate in mice, lowered the apoptotic effect of bisphosphonates on osteoclasts. The half-life of bisphosphonates in bone is very long—1 to 10 years, and depends on the rate of bone remodeling, it is also suggested that bisphosphonates buried in the bone, is inactive, at least as long as it is sequestered there. Alendronate has been shown to inhibit normal microdamage repair that arises from a marked suppression of bone remodeling, which in turn results in accumulation of microdamage. The doses were much higher than those to treat human osteoporosis [13]. Some studies shows that long-term use of bisphosphonates for osteoporosis therapy appears to be safe, however, there are studies that reveal deficiencies in bone formation, and some studies suggest that bisphosphonates treatment I. Ekenman (&) Kungstensg 59, 113 29 Stockholm, Sweden e-mail: Ingrid.ekenman@telia.com

Operative Treatment of Stress Fractures of the Metatarsals

A common presenting complaint in athletes and nonathletes alike, metatarsal stress fractures may be a source of persistent pain and loss of lower limb use, resulting in loss of recreational and vocational performance. Although most fractures respond to traditional conservative treatments, some may require more aggressive intervention on the part of the treating orthopaedic surgeon. The identification of these particular problem fractures and the search for associated conditions is important for the optimal outcome of these injuries. Attention to surgical technique is important; the options for adjunctive procedures are presented.

Fracture de fatigue chez le sportif et prise en charge intensive de rééducation

Objective. – The aim of this work was to review the literature for the place of extensive rehabilitation for athletes with stress fractures. Method. – We searched the Medline and Embase databases using the keywords stress fracture, sports, rehabilitation, management and treatment. Only French and English articles were included, and articles about bone physiology, animal models, and spine and chest localisations were excluded. From 468 scientific articles, 62 were chosen because they corresponded to literary reviews or to therapeutic evaluations. Results. – Treatment of stress fracture is justified according to risk factors, stress-fracture complications, the precocity of diagnosis, the therapeutic method and when the athlete needs to return to the sport. The most common treatment is discontinuing the sport, followed by rest. The progressive resumption of sport is rarely described but must take into account mechanical constraints that can be controlled by the use of shoes adapted to a supple ground. Some treatments such as immobilization by pneumatic splint surgery or use of electric fields are controversial. Conclusion. – Extensive treatment of stress fractures is mainly dedicated to high-level athletes who need to regain previous physical capacities as soon as possible.

Stress Fracture on the 4th Metatarsal Bone after Treatment of Stress Fracture on the 5th Metatarsal Bone: A Case Report

Stress Fracture on the 4th Metatarsal Bone after Treatment of Stress Fracture on the 5th Metatarsal Bone: A Case Report

Principles of stress fracture management

PREVIEWStress fracture occurs when forces applied to a bone exceed the bone's strength. Many such fractures are the result of athletic activities, including running, dance, Australian-rules football, aerobics, and gymnastics. As participation in these activities increases, the incidence of injury is increasing, and stress fractures are often seen in the primary care office. In this article, the first of two articles on stress fractures, Drs Perron, Brady, and Keats present general information about the pathogenesis, diagnosis, and treatment of stress fractures. The second article, which describes diagnosis and treatment of several specific fractures, will appear in a subsequent issue.

ROLE OF ULTRASOUND THERAPY IN THE TREATMENT OF STRESS FRACTURES

Repetitive stress of exercise when exceeds bone's ability to remodel itself, leads to stress fractures. Stress fractures are the leading cause of morbidity amongst recruits during training and account for the maximum number of lost manpower days during training. Basic treatment for stress fractures is rest from aggravating activities for 4 to 8 weeks. Ultrasound has been reported to speed up healing of stress fractures, though it has not yet definitively been proven effective in the treatment of stress fractures. A study has been carried out to find out the efficacy of Ultrasound therapy (UST) in the treatment of stress fractures. A total of 75 cases of stress fractures, positive on radiograph, were studied. Of these 32 cases comprised the control group and underwent conventional therapy while 45 cases were treated with UST as out-door patients. Mean duration of treatment in conventional therapy including sick leave was 75.3 days and mean hospitalization period was 37.28 days. Mean duration of treatment with UST was 15.05 days. Results of the study prove that UST speeds up healing of stress fractures and drastically reduces the time required to return to training, thus saving the lost number of manpower days.