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Archives of Endocrinology and Metabolism Nov 2022Stress fractures (SF) represent 10%-20% of all injuries in sport medicine. An SF occurs when abnormal and repetitive loading is applied on normal bone: The body cannot... (Review)
Review
Stress fractures (SF) represent 10%-20% of all injuries in sport medicine. An SF occurs when abnormal and repetitive loading is applied on normal bone: The body cannot adapt quickly enough, leading to microdamage and fracture. The etiology is multifactorial with numerous risk factors involved. Diagnosis of SF can be achieved by identifying intrinsic and extrinsic factors, obtaining a good history, performing a physical exam, and ordering laboratory and imaging studies (magnetic resonance imaging is the current gold standard). Relative energy deficiency in sport (RED-S) is a known risk factor. In addition, for women, it is very important know the menstrual status to identify long periods of amenorrhea in the past and the present. Early detection is important to improve the chance of symptom resolution with conservative treatment. Common presentation involves complaints of localized pain, with or without swelling, and tenderness on palpation of bony structures that begins earlier in training and progressively worsens with activity over a 2- to 3-week period. Appropriate classification of SF based on type, location, grading, and low or high risk is critical in guiding treatment strategies and influencing the time to return to sport. Stress injuries at low-risk sites are typically managed conservatively. Studies have suggested that calcium and vitamin D supplementation might be helpful. Moreover, other treatment regimens are not well established. Understanding better the pathophysiology of SFs and the potential utility of current and future bone-active therapeutics may well yield approaches that could treat SFs more effectively.
Topics: Humans; Female; Fractures, Stress; Risk Factors; Bone and Bones; Calcium, Dietary; Magnetic Resonance Imaging
PubMed: 36382766
DOI: 10.20945/2359-3997000000562 -
Medicina (Kaunas, Lithuania) Mar 2021There are numerous risk factors for stress fractures that have been identified in literature. Among different risk factors, a prolonged lack of vitamin D (25(OH)D) can... (Review)
Review
There are numerous risk factors for stress fractures that have been identified in literature. Among different risk factors, a prolonged lack of vitamin D (25(OH)D) can lead to stress fractures in athletes since 25(OH)D insufficiency is associated with an increased incidence of a fracture. A 25(OH)D value of <75.8 nmol/L is a risk factor for a stress fracture. 25(OH)D deficiency is, however, only one of several potential risk factors. Well-documented risk factors for a stress fracture include female sex, white ethnicity, older age, taller stature, lower aerobic fitness, prior physical inactivity, greater amounts of current physical training, thinner bones, 25(OH)D deficiency, iron deficiency, menstrual disturbances, and inadequate intake of 25(OH)D and/or calcium. Stress fractures are not uncommon in athletes and affect around 20% of all competitors. Most athletes with a stress fracture are under 25 years of age. Stress fractures can affect every sporty person, from weekend athletes to top athletes. Stress fractures are common in certain sports disciplines such as basketball, baseball, athletics, rowing, soccer, aerobics, and classical ballet. The lower extremity is increasingly affected for stress fractures with the locations of the tibia, metatarsalia and pelvis. Regarding prevention and therapy, 25(OH)D seems to play an important role. Athletes should have an evaluation of 25(OH)D -dependent calcium homeostasis based on laboratory tests of 25-OH-D, calcium, creatinine, and parathyroid hormone. In case of a deficiency of 25(OH)D, normal blood levels of ≥30 ng/mL may be restored by optimizing the athlete's lifestyle and, if appropriate, an oral substitution of 25(OH)D. Very recent studies suggested that the prevalence of stress fractures decreased when athletes are supplemented daily with 800 IU 25(OH)D and 2000 mg calcium. Recommendations of daily 25(OH)D intake may go up to 2000 IU of 25(OH)D per day.
Topics: Aged; Dietary Supplements; Female; Fractures, Stress; Humans; Vitamin D; Vitamin D Deficiency; Vitamins
PubMed: 33804459
DOI: 10.3390/medicina57030223 -
American Family Physician Jan 2011Stress fractures are common injuries in athletes and military recruits. These injuries occur more commonly in lower extremities than in upper extremities. Stress... (Review)
Review
Stress fractures are common injuries in athletes and military recruits. These injuries occur more commonly in lower extremities than in upper extremities. Stress fractures should be considered in patients who present with tenderness or edema after a recent increase in activity or repeated activity with limited rest. The differential diagnosis varies based on location, but commonly includes tendinopathy, compartment syndrome, and nerve or artery entrapment syndrome. Medial tibial stress syndrome (shin splints) can be distinguished from tibial stress fractures by diffuse tenderness along the length of the posteromedial tibial shaft and a lack of edema. When stress fracture is suspected, plain radiography should be obtained initially and, if negative, may be repeated after two to three weeks for greater accuracy. If an urgent diagnosis is needed, triple-phase bone scintigraphy or magnetic resonance imaging should be considered. Both modalities have a similar sensitivity, but magnetic resonance imaging has greater specificity. Treatment of stress fractures consists of activity modification, including the use of nonweight-bearing crutches if needed for pain relief. Analgesics are appropriate to relieve pain, and pneumatic bracing can be used to facilitate healing. After the pain is resolved and the examination shows improvement, patients may gradually increase their level of activity. Surgical consultation may be appropriate for patients with stress fractures in high-risk locations, nonunion, or recurrent stress fractures. Prevention of stress fractures has been studied in military personnel, but more research is needed in other populations.
Topics: Algorithms; Anti-Inflammatory Agents, Non-Steroidal; Bone Density Conservation Agents; Calcium, Dietary; Crutches; Diagnosis, Differential; Diagnostic Imaging; Electric Stimulation Therapy; Etidronic Acid; Fracture Healing; Fractures, Stress; Humans; Orthotic Devices; Pain; Risedronic Acid; Risk Factors; Ultrasonic Therapy; Vitamin D
PubMed: 21888126
DOI: No ID Found -
Journal of Sport and Health Science May 2023Tibial stress fracture (TSF) is an overuse running injury with a long recovery period. While many running studies refer to biomechanical risk factors for TSF, only a few... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Tibial stress fracture (TSF) is an overuse running injury with a long recovery period. While many running studies refer to biomechanical risk factors for TSF, only a few have compared biomechanics in runners with TSF to controls. The aim of this systematic review and meta-analysis was to evaluate biomechanics in runners with TSF compared to controls.
METHODS
Electronic databases PubMed, Web of Science, SPORTDiscus, Scopus, Cochrane, and CINAHL were searched. Risk of bias was assessed and meta-analysis conducted for variables reported in 3 or more studies.
RESULTS
The search retrieved 359 unique records, but only the 14 that compared runners with TSF to controls were included in the review. Most studies were retrospective, 2 were prospective, and most had a small sample size (5-30 per group). Many variables were not significantly different between groups. Meta-analysis of peak impact, active, and braking ground reaction forces found no significant differences between groups. Individual studies found larger tibial peak anterior tensile stress, peak posterior compressive stress, peak axial acceleration, peak rearfoot eversion, and hip adduction in the TSF group.
CONCLUSION
Meta-analysis indicated that discrete ground reaction force variables were not statistically significantly different in runners with TSF compared to controls. In individual included studies, many biomechanical variables were not statistically significantly different between groups. However, many were reported by only a single study, and sample sizes were small. We encourage additional studies with larger sample sizes of runners with TSF and controls and adequate statistical power to confirm or refute these findings.
Topics: Humans; Fractures, Stress; Biomechanical Phenomena; Retrospective Studies; Prospective Studies; Foot; Cumulative Trauma Disorders
PubMed: 36481573
DOI: 10.1016/j.jshs.2022.12.002 -
Current Osteoporosis Reports Jun 2021Bone stress injuries (BSIs) occur at inopportune times to invariably interrupt training. All BSIs in runners occur due to an "error" in workload wherein the interaction... (Review)
Review
Bone stress injuries (BSIs) occur at inopportune times to invariably interrupt training. All BSIs in runners occur due to an "error" in workload wherein the interaction between the number and magnitude of bone tissue loading cycles exceeds the ability of the tissue to resist the repetitive loads. There is not a single optimal bone workload, rather a range which is influenced by the prevailing scenario. In prepubertal athletes, optimal bone workload consists of low-repetitions of fast, high-magnitude, multidirectional loads introduced a few times per day to induce bone adaptation. Premature sports specialization should be avoided so as to develop a robust skeleton that is structurally optimized to withstand multidirectional loading. In the mature skeleton, optimal workload enables gains in running performance but minimizes bone damage accumulation by sensibly progressing training, particularly training intensity. When indicated (e.g., following repeated BSIs), attempts to reduce bone loading magnitude should be considered, such as increasing running cadence. Determining the optimal bone workload for an individual athlete to prevent and manage BSIs requires consistent monitoring. In the future, it may be possible to clinically determine bone loads at the tissue level to facilitate workload progressions and prescriptions.
Topics: Biomechanical Phenomena; Fractures, Stress; Humans; Physical Education and Training; Risk Factors; Running; Shoes; Weight-Bearing
PubMed: 33635519
DOI: 10.1007/s11914-021-00666-y -
Japanese Journal of Radiology May 2022Subchondral insufficiency fracture of the knee (SIFK) is a common cause of knee joint pain in older adults. SIFK is a type of stress fracture that occurs when repetitive... (Review)
Review
Subchondral insufficiency fracture of the knee (SIFK) is a common cause of knee joint pain in older adults. SIFK is a type of stress fracture that occurs when repetitive and excessive stress is applied to the subchondral bone. If the fracture does not heal, the lesion develops into osteonecrosis and results in osteochondral collapse, requiring surgical management. Because of these clinical features, SIFK was initially termed "spontaneous osteonecrosis of the knee (SONK)" in the pre-MRI era. SONK is now categorized as an advanced SIFK lesion in the spectrum of this disease, and some authors believe the term "SONK" is a misnomer. MRI plays a significant role in the early diagnosis of SIFK. A subchondral T2 hypointense line of the affected condyle with extended bone marrow edema-like signal intensity are characteristic findings on MRI. The large lesion size and the presence of osteochondral collapse on imaging are associated with an increased risk of osteoarthritis. However, bone marrow edema-like signal intensity and osteochondral collapse alone are not specific to SIFK, and other osteochondral lesions, including avascular necrosis, osteochondral dissecans, and osteoarthritis should be considered. Chondral lesions and meniscal abnormalities, including posterior root tears, are also found in many patients with SIFK, and they are considered to be related to the development of SIFK. We review the clinical and imaging findings, including the anatomy and terminology history of SIFK, as well as its differential diagnoses. Radiologists should be familiar with these imaging features and clinical presentations for appropriate management.
Topics: Aged; Diagnosis, Differential; Edema; Fractures, Stress; Humans; Knee Injuries; Magnetic Resonance Imaging; Osteoarthritis; Osteonecrosis; Retrospective Studies
PubMed: 34843043
DOI: 10.1007/s11604-021-01224-3 -
Journal of Bone and Mineral Research :... Jan 2014Bisphosphonates (BPs) and denosumab reduce the risk of spine and nonspine fractures. Atypical femur fractures (AFFs) located in the subtrochanteric region and diaphysis... (Review)
Review
Bisphosphonates (BPs) and denosumab reduce the risk of spine and nonspine fractures. Atypical femur fractures (AFFs) located in the subtrochanteric region and diaphysis of the femur have been reported in patients taking BPs and in patients on denosumab, but they also occur in patients with no exposure to these drugs. In this report, we review studies on the epidemiology, pathogenesis, and medical management of AFFs, published since 2010. This newer evidence suggests that AFFs are stress or insufficiency fractures. The original case definition was revised to highlight radiographic features that distinguish AFFs from ordinary osteoporotic femoral diaphyseal fractures and to provide guidance on the importance of their transverse orientation. The requirement that fractures be noncomminuted was relaxed to include minimal comminution. The periosteal stress reaction at the fracture site was changed from a minor to a major feature. The association with specific diseases and drug exposures was removed from the minor features, because it was considered that these associations should be sought rather than be included in the case definition. Studies with radiographic review consistently report significant associations between AFFs and BP use, although the strength of associations and magnitude of effect vary. Although the relative risk of patients with AFFs taking BPs is high, the absolute risk of AFFs in patients on BPs is low, ranging from 3.2 to 50 cases per 100,000 person-years. However, long-term use may be associated with higher risk (∼100 per 100,000 person-years). BPs localize in areas that are developing stress fractures; suppression of targeted intracortical remodeling at the site of an AFF could impair the processes by which stress fractures normally heal. When BPs are stopped, risk of an AFF may decline. Lower limb geometry and Asian ethnicity may contribute to the risk of AFFs. There is inconsistent evidence that teriparatide may advance healing of AFFs.
Topics: Aged; Antibodies, Monoclonal, Humanized; Bone Density Conservation Agents; Denosumab; Diaphyses; Diphosphonates; Female; Femoral Fractures; Fractures, Stress; Humans; Male; Middle Aged; Radiography; Risk Factors
PubMed: 23712442
DOI: 10.1002/jbmr.1998 -
Sports Health 2017The health of the skeletal system is important for athletes young and old. From the early benefits of exercise on bones to the importance of osteoporosis prevention and... (Review)
Review
CONTEXT
The health of the skeletal system is important for athletes young and old. From the early benefits of exercise on bones to the importance of osteoporosis prevention and treatment, bone health affects the ability to be active throughout life.
EVIDENCE ACQUISITION
PubMed articles dating from 1986 to 2016 were used for the review. Relevant terms such as keywords and section titles of the article were searched and articles identified were reviewed for relevance to this article.
STUDY DESIGN
Clinical review.
LEVEL OF EVIDENCE
Levels 1 through 4 evidence included.
RESULTS
There is strong evidence that exercise benefits bone health at every age and is a critical factor in osteoporosis prevention and treatment. Vitamin D, calcium, and hormones play vital roles in ensuring optimal bone health. When there is an imbalance between exercise and nutrition, as seen in the female athlete triad, bone health is compromised and can lead to bone stress injuries and early osteoporosis. Both of these can lead to morbidity and lost time from training and competition. Thus, early recognition and appropriate treatment of the female athlete triad and other stress fracture risk factors are vital to preventing long-term bone health problems.
CONCLUSION
To optimize bone health, adequate nutrition, appropriate weightbearing exercise, strength training, and adequate calcium and vitamin D are necessary throughout life.
Topics: Bone Density; Calcium, Dietary; Exercise; Female; Female Athlete Triad Syndrome; Fractures, Stress; Hormones; Humans; Osteoporosis; Risk Factors; Sports Nutritional Physiological Phenomena; Vitamin D; Vitamin D Deficiency
PubMed: 27821574
DOI: 10.1177/1941738116677732 -
Equine Veterinary Journal Mar 2023Equine tibial fractures are relatively infrequent in racing and non-racing sport horses, but limitations in successful treatment of tibial fractures in adult horses... (Review)
Review
Equine tibial fractures are relatively infrequent in racing and non-racing sport horses, but limitations in successful treatment of tibial fractures in adult horses result in relatively high mortality compared with other musculoskeletal injuries. The aetiology of tibial fracture can be classified into two general categories: traumatic impact or fatigue failure. Tibial stress fractures, also known as fatigue fractures, are often rated as the second most common stress fracture in racing Thoroughbreds; young age, early stage in race training, and initiation of training after a period of rest are the reported risk factors. Both impact and fatigue fracture propagation are dependent on the magnitude of force applied and on the local composition/alignment of mineralised collagen in the tibial lamella. Extensive research has characterised the pattern of strain distribution and stress remodelling within the equine tibia, but in vivo measurement of load and angular moments are currently not feasible. Further research is warranted to correlate biomechanical theory of tibia fatigue fracture propagation with current histopathological data. Preventative measures for fatigue fractures aim to optimise diagnostic efficiency, reduce the interval between injury and diagnosis and modify racing and training conditions to reduce non-specific fracture risk. Treatment options for complete tibial fractures in adult horses are limited, but with careful case selection, successful outcomes have been reported after open reduction and internal fixation. On the other hand, tibial stress fractures and minimally displaced incomplete fractures are typically treated conservatively and have good prognosis for athletic recovery. This review aims to describe the current literature regarding tibial fracture aetiology, prevalence, risk factors, fracture biomechanics, treatment, prognosis and prevention.
Topics: Horses; Animals; Fractures, Stress; Physical Conditioning, Animal; Tibial Fractures; Sports; Prognosis; Horse Diseases
PubMed: 35569040
DOI: 10.1111/evj.13599 -
American Family Physician Oct 2003Lower extremity stress fractures are common injuries most often associated with participation in sports involving running, jumping, or repetitive stress. The initial... (Review)
Review
Lower extremity stress fractures are common injuries most often associated with participation in sports involving running, jumping, or repetitive stress. The initial diagnosis can be made by identifying localized bone pain that increases with weight bearing or repetitive use. Plain film radiographs are frequently unrevealing. Confirmation of a stress fracture is best made using triple phase nuclear medicine bone scan or magnetic resonance imaging. Prevention of stress fractures is most effectively accomplished by increasing the level of exercise slowly, adequately warming up and stretching before exercise, and using cushioned insoles and appropriate footwear. Treatment involves rest of the injured bone, followed by a gradual return to the sport once free of pain. Recent evidence supports the use of air splinting to reduce pain and decrease the time until return to full participation or intensity of exercise.
Topics: Fractures, Stress; Humans; Lower Extremity; Risk Factors
PubMed: 14596439
DOI: No ID Found