Review

Authors: Tatiana Munhoz da Rocha Lemos Costa, Victoria Zeghbi Cochenski Borba, Renata Gonçalves Pinheiro Correa...

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

Meta-Analysis

Authors: Clare E Milner, Eric Foch, Joseph M Gonzales...

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

Review

Authors: Stuart J Warden, W Brent Edwards, Richard W Willy...

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

Review

Authors: Beat Knechtle, Zbigniew Jastrzębski, Lee Hill...

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

Review

Authors: Deepak S Patel, Matt Roth, Neha Kapil...

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

Authors: Jeremy D Schroeder, Sean P Turner, Emily Buck...

Hip fractures are common causes of disability, with mortality rates reaching 30% at one year. Nonmodifiable risk factors include lower socioeconomic status, older age, female sex, prior fracture, metabolic bone disease, and bony malignancy. Modifiable risk factors include low body mass index, having osteoporosis, increased fall risk, medications that increase fall risk or decrease bone mineral density, and substance use. Hip fractures present with anterior groin pain, inability to bear weight, or a shortened, abducted, externally rotated limb. Plain radiography is usually sufficient for diagnosis, but magnetic resonance imaging should be obtained if suspicion of fracture persists despite normal radiography. Operative management within 24 to 48 hours of the fracture optimizes outcomes. Fractures are usually managed by surgery, with the approach based on fracture type and location; spinal or general anesthesia can be used. Nonsurgical management can be considered for patients who are not good surgical candidates. Pre- and postoperative antistaphylococcal antibiotics are given to prevent joint infection. Medications for venous thromboembolism prophylaxis are also recommended. Physicians should be alert for the presence of delirium, which is a common postoperative complication. Early postoperative mobilization, followed by rehabilitation, improves outcomes. Subsequent care focuses on prevention, with increased physical activity, home safety assessments, and minimizing polypharmacy. Two less common hip fractures can also occur: femoral neck stress fractures and insufficiency fractures. Femoral neck stress fractures typically occur in dancers 20 to 30 years of age, endurance athletes, and military service members, often because of training overload. Insufficiency fractures due to compromised bone strength occur without trauma in postmenopausal women. If not recognized and treated, these fractures can progress to complete and displaced fractures with high rates of nonunion and avascular necrosis.

Topics: Female; Humans; Fractures, Stress; Hip Fractures; Femoral Neck Fractures; Osteoporosis; Bone Density

PubMed: 36521464
DOI: No ID Found

Review

Authors: Junko Ochi, Taiki Nozaki, Akimoto Nimura...

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

Authors: Stuart J Warden, W Brent Edwards, Richard W Willy...

BACKGROUND

Low-risk bone stress injuries (BSIs) of the tibia and metatarsal diaphyses account for more than half of BSIs in runners. They interrupt training and are managed using noninvasive approaches that are designed to achieve a speedy but safe return to running.

CLINICAL QUESTION

What is the optimal load to manage low-risk tibial and metatarsal BSIs and safely return to running?

KEY RESULTS

Optimal load can be guided by knowledge of the BSI healing process and is symptom driven. At all stages, the optimal load does not produce symptoms during, after, or the day following loading.

CLINICAL APPLICATION

A period of initial load reduction, via partial or non-weight bearing, is typically needed to alleviate presenting symptoms. Analgesics or nonsteroidal anti-inflammatory drugs may be used in the short term (sooner than 7 days), but only for resting pain and night pain. Healing supplements (eg, low-intensity pulsed ultrasound and/or recombinant parathyroid hormone therapy) may be attempted to influence tissue healing. Athletes can maintain cardiopulmonary fitness via cross-training, while simultaneously addressing musculoskeletal fitness. A return-to-run program can be initiated once an athlete is pain free during daily activities for 5 consecutive days. Progress is directed by symptom provocation and initially focuses on increasing running volume before speed. Optimal loading should be continued following return to running and may include jump training and/or gait retraining to reduce subsequent BSI risk. The optimal loading approach to managing low-risk tibial and metatarsal BSIs is clinically successful, but requires further scientific validation. .

Topics: Athletic Injuries; Clinical Reasoning; Fractures, Stress; Humans; Metatarsal Bones; Return to Sport; Running; Tibia

PubMed: 33962529
DOI: 10.2519/jospt.2021.9982

Authors: Tatsuya Ishizu, Suguru Torii, Motoko Taguchi...

OBJECTIVES

The aim of the present study was to identify the habitual dietary intake and stress fractures history among sport types and to determine the factors related to the risk of stress fractures among Japanese female collegiate athletes.

METHODS

This study involved 589 Japanese female collegiate athletes. We investigated habitual dietary intake (food frequency questionnaire), eating attitude (EAT-26), demographics, training status, participation in sports events, history of injury in their career, and menstrual status using a self-reported questionnaire. A multivariate logistic regression analysis was conducted to determine the risk factors associated with stress fractures.

RESULTS

Thirty percent of the total participants had a history of stress fractures, although most participants had no risk of eating disorders. Most Japanese female collegiate athletes consumed less than the dietary reference intake levels for the general Japanese female population aged 18-29 years and the athletes' dietary guideline for key bone-health nutrients such as calcium and vitamin D. The multivariate logistic regression analysis revealed body mass index (BMI; OR, 0.91; 95% CI, 0.82-0.99) and energy intake (EI; OR, 0.99; 95% CI, 0.99-0.99) as significant and independent factors in the history of stress fractures among Japanese female collegiate athletes ( = 0.047 and  = 0.039, respectively).

CONCLUSIONS

Japanese female collegiate athletes failed to meet energy and nutrient recommendations; BMI and EI were significantly associated with stress fractures, a diet that includes an appropriate amount of energy is essential.

Topics: Athletes; Female; Fractures, Stress; Humans; Japan; Nutritional Status; Sports

PubMed: 34125657
DOI: 10.1080/07315724.2021.1920068

Review

Authors: Elizabeth Shane, David Burr, Bo Abrahamsen...

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