Stress fractures.

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.

Delayed Union of Stress Fracture of the First Rib in a Yoga Instructor: A Case Report.

CASE: We describe the case of a 38-year-old woman, a yoga instructor, who had pain in the right shoulder and scapular region of 4 months' duration while performing yoga. Radiography and computed tomography diagnosed delayed union of a first rib stress fracture. The delayed union of stress fracture of the first rib was successfully treated with the limiting of yoga activity and low-intensity pulsed ultrasound (LIPUS). CONCLUSIONS: Physicians should be aware that even yoga posing can cause stress fractures of the first rib. LIPUS therapy may be effective for delayed union in addition to rest.

Medial tibial stress fracture diagnosis and treatment guidelines.

OBJECTIVES: To validate and make evidence based changes to the Israel Defense Forces medial tibial stress fracture diagnosis and treatment protocol. DESIGN: Prospective cohort study. METHODS: 429 Elite infantry recruits were reviewed for signs and symptoms of medial tibial stress fracture during 14 weeks of basic training. Suspicion of medial tibial stress fracture was based on the presence of pain, tenderness <1/3 the length of the tibia and a positive fulcrum and/or hop test. Recruits with suspected medial tibial stress fractures were initially treated with 10-14 days of rest. Bone scan was performed only when recruits failed to respond to the rest regimen or required immediate diagnosis. RESULTS: 31 Out of 49 recruits with a suspicion of medial tibial stress fracture underwent bone scan, including 8/26 recruits whose symptoms did not resolve after being treated clinically as stress fractures. There was a significantly greater incidence of medial tibial stress fractures when a positive hop test was present in addition to tibial pain and tenderness (p=0.0001), odds ratio 52.04 (95% CL, 2.80-967.74). Medial tibial stress fracture was found to occur when the band of tibial tenderness was ≤10cm in length. Tibial pain scores were not predictive of stress fracture. CONCLUSIONS: This validation study provides the clinician with evidence based guidelines for the clinical diagnosis and treatment of medial stress fractures and their differentiation from shin splints. An initial treatment protocol without the use of imaging was found to be effective in more than two-thirds of the cases.

Bilateral calcaneal insufficiency fractures due to chronic carbamazepine use for trigeminal neuralgia: A case report.

Stress fractures of calcaneus are uncommon cause of heel pain. Stress fractures could be seen in risc groups such as metabolic diseases/medications causing poor bone quality and exposing repetitive microtrauma. Anti-epileptic drug (AED) use is related with poor bone quality and increased fracture risc. Although carbamazepine-induced stress fracture is a well-known entity and there are case reports in other bones such as the femoral neck, bilateral calcaneal insufficiency fractures is an extraordinary location. To the best of our knowledge, this is the first case reporting an insufficiency fracture involving calcaneus in the relevant literature. Due to the rarity of both conditions, we decided to present and discuss this patient. When patients receiving AED treatment present with heel pain without previous plantar fasciitis history or traumatic event, insufficiency fractures should be kept in mind. This case highlights the importance of screening adverse effect of CBZ on bone metabolism in patients with long CBZ use. We report here a 41-year-old lady suffering from bilateral heel pain without trauma history. Her complaining did not respond to analgesics and stretching exercises of plantar fascia. In her past medical history she reported ongoing carbamazepine (CBZ) use over 8 years for trigeminal neuralgia. She had had low bone mineral density; defined as osteopenia. Both calcaneus MRI revealed bilateral stress fractures of calcaneum. She had been advised immobilization for 6 weeks, vitamin D and calcium supplements. CBZ has been stopped by neurology specialist and she had undergone microvascular decompression surgery for intractable pain of trigeminal neuralgia. She is doing well with full recovery from heel pain and trigeminal neuralgia at the end of one year. CBZ use causes poor bone quality through vitamin D metabolism. Heel pain without traumatic event, objective findings of plantar fasciitis and calcaneal spur syndrome in an CBZ using patient insufficiency fracture of calcaneus should be remembered and evaluated rigorously.

Bilateral Patellar Stress Fractures in a Skeletally Immature Athlete: A Case Report.

CASE: This report describes the divergent course and management of bilateral patellar stress fractures in a 17-year-old skeletally immature male athlete. Beginning as bilateral incomplete tension-sided patellar fractures, the right patella healed uneventfully, whereas the left progressed to a complete, mildly displaced transverse fracture that eventually healed with nonoperative treatment measures to include temporary bracing, physical therapy, and vitamin D supplementation. CONCLUSIONS: Patellar stress fractures are exceptionally rare, particularly bilateral injuries in the pediatric population. Diligent workup is necessary for appropriate diagnosis, whereas knowledge of the salient features of these injuries is useful in treatment.

Matrix-associated stem cell transplantation is successful in treating talar osteochondral lesions.

PURPOSE: Osteochondral lesions (OCLs) of the talus are a challenging and increasingly recognized problem in chronic ankle pain. Many novel techniques exist to try and treat this challenging entity. Difficulties associated with treating OCLs include lesion location, size, chronicity, and problems associated with potential graft harvest sites. Matrix-associated stem cell transplantation (MAST) is one such treatment described for larger lesions > 15 mm2 or failed alternative therapies. This cohort study describes a 3 year review of the outcomes of talar lesions treated with MAST. METHODS: A review of all patients treated with MAST by a single surgeon was conducted. Pre-operative radiographs, MRIs, and FAOS outcome questionnaire scores were reviewed. Intraoperative classification was undertaken to correlate with imaging. Post-operative outcomes included FAOS scores, return to sport, revision surgery/failure of treatment, and progression to ankle fusion. RESULTS: In this study, 38 OCLs in 32 patients were identified. Median patient age was 35 years of which (68.8%) were male. Median length of follow-up was 36.7 months (range 12-64 months). (83%) returned to playing sport. Twenty-three patients underwent MAST in the setting of a failed previous operative attempt, with just nine having MAST as a first option. Nine patients out of 32 had a further procedure. Improvements were seen in all domains of the FAOS (p < 0.05). CONCLUSION: MAST has demonstrated encouraging results in lesions which prove challenging to treat, even in a "failed microfracture" cohort. LEVEL OF EVIDENCE: IV.

Treatment of Medial Tibial Stress Syndrome With Radial Soundwave Therapy in Elite Athletes: Current Evidence, Report on Two Cases, and Proposed Treatment Regimen.

Two case reports of high-level athletes with medial tibial stress syndrome (MTSS), 1 an Olympian with an actual stress fracture, are presented. Successful treatment included radial soundwave therapy, pneumatic leg braces, relative rest using an antigravity treadmill, and temporary foot orthoses. Radial soundwave therapy has a high level of evidence for treatment of MTSS. We also present recent evidence of the value of vitamin D assessment. Both patients had a successful outcome with minimal downtime. Finally, a suggested treatment regimen for MTSS is presented.

Stress Fractures: Etiology, Epidemiology, Diagnosis, Treatment, and Prevention.

Stress fractures are part of a continuum of changes in healthy bones in response to repeated mechanical deformation from physical activity. If the activity produces excessive repetitive stress, osteoclastic processes in the bone may proceed at a faster pace than osteoblastic processes, thus weakening the bone and augmenting susceptibility to stress fractures. Overall stress fracture incidence is about three cases per 1,000 in active duty Servicemembers, but it is much higher among Army basic trainees: 19 per 1,000 for men and 80 per 1,000 for women. Well-documented risk factors include female sex, white ethnicity, older age, taller stature, lower aerobic fitness, prior physical inactivity, greater amounts of current physical training, thinner bones, cigarette smoking, and inadequate intake of vitamin D and/or calcium. Individuals with stress fractures present with focal tenderness and local pain that is aggravated by physical activity and reduced by rest. A sudden increase in the volume of physical activity along with other risk factors is often reported. Simple clinical tests can assist in diagnosis, but more definitive imaging tests will eventually need to be conducted if a stress fracture is suspected. Plain radiographs are recommended as the initial imaging test, but magnetic resonance imaging has higher sensitivity and is more likely to detect the injury sooner. Treatment involves first determining if the stress fracture is of higher or lower risk; these are distinguished by anatomical location and whether the bone is loaded in tension (high risk) or compression (lower risk). Lowerrisk stress fractures can be initially treated by reducing loading on the injured bone through a reduction in activity or by substituting other activities. Higher-risk stress fractures should be referred to an orthopedist. Investigated prevention strategies include modifications to physical training programs, use of shock absorbing insoles, vitamin D and calcium supplementation, modifications of military equipment, and leadership education with injury surveillance.

Taking a holistic approach to managing difficult stress fractures.

Stress fractures and other bony stress injuries occur along a spectrum of severity which can impact treatment and prognosis. When treating these injuries, it should be borne in mind that no two stress fractures behave exactly alike. Given that they are not a consistent injury, standardized treatment protocols can be challenging to develop. Treatment should be individualized to the patient or athlete, the causative activity, the anatomical site, and the severity of the injury. A holistic approach to the treatment of the most difficult stress fractures should be taken by orthopedists and sports medicine specialists. This approach is necessary to obtain optimal outcomes, minimize loss of fitness and time away from sports participation, and decrease the risk of recurrence.

Stress fractures in runners.

Stress fractures are a relatively common entity in athletes, in particular, runners. Physicians and health care providers should maintain a high index of suspicion for stress fractures in runners presenting with insidious onset of focal bone tenderness associated with recent changes in training intensity or regimen. It is particularly important to recognize "high-risk" fractures, as these are associated with an increased risk of complication. A patient with confirmed radiographic evidence of a high-risk stress fracture should be evaluated by an orthopedic surgeon. Runners may benefit from orthotics, cushioned sneakers, interval training, and vitamin/calcium supplementation as a means of stress fracture prevention.

Sacral stress fracture in a distance runner.

Sacral stress fractures are uncommon injuries that are associated with repetitive load-bearing activities. The authors describe a 23-year-old male cross-country runner who presented with low back and buttocks pain. Radiographic findings were unremarkable, but a hop test identified a sacral stress fracture. The patient was instructed to stop running and to take calcium and vitamin D supplements. Four months later, his symptoms completely resolved and he began running again. The authors also present a review of the literature, which revealed that patients with sacral stress fractures are likely to have normal neurologic examinations and full active range of motions. However, they will likely describe discomfort with passive hip flexion. The authors recommend the hop test for patients with this type of history and these physical examination findings. If a sacral stress fracture is found, treatment regimens should consist of 4 to 6 weeks of rest with gradual return to activity.

Stress fractures: diagnosis, treatment, and prevention.

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.

[Bilateral stress fracture of the mid-tibial shaft in a professional dancer]. / Obojstranná únavová zlomenina strednej diafýzy tíbie u profesionálneho tanecníka.

Stress fractures of the anterior cortex of the mid-tibial shaft in dancers are rare, with a 1.4 % incidence in injured eli- te dancers. Treatment can be difficult and long-lasting and can seriously influence the dancer's career. The authors pre- sent the case of a 26-year-old professional dancer of a folk dance ensemble who suffered rare simultaneous bilateral mid-tibial shaft stress fractures. A conservative method of treatment with avoiding exercise and dancing activities resulted in the resolution of symptoms and healing of the fractures after 6 months. The patient finished his dancing career because of the necessity of a prolonged therapy interfering with his dancing activities. Current options of the treatment are also presented.

Upper extremity stress fractures and spondylolysis in an adolescent baseball pitcher with an associated endocrine abnormality: a case report.

Lower extremity stress fractures are relatively common among competitive athletes. Stress fractures of the upper extremity, however, are rare and most have been reported in the literature as case reports. We present a case of an adolescent baseball pitcher who had both proximal humeral and ulnar shaft stress fractures, as well as spondylolysis of the lumbar spine. This particular patient also had an underlying endocrine abnormality of secondary hyperparathyroidism with a deficiency in vitamin D. A bone mineral density panel demonstrated a high T score (+2.79 SD above the mean) and the patient's biologic bone age was noted to be 2 years ahead of his chronologic age. The patient was treated with a course of vitamin D and calcium supplementation. After treatment, both the vitamin D and parathyroid hormone returned to normal levels. The upper extremity stress fractures and spondylolysis were managed conservatively and he was able to return to full activity and baseball. For patients who present with multiple stress fractures not associated with consistent high levels of repeated stress, a bone mineral density panel should be considered. If vitamin D deficiency is present, a course of oral supplementation may be considered in the management. An endocrinology consult should also be considered in patients who present with multiple stress fractures. Conservative management of upper extremity stress fractures and spondylolysis was successful in returning this patient back to his previous activity level.

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.

Do capacitively coupled electric fields accelerate tibial stress fracture healing? A randomized controlled trial.

BACKGROUND: Tibial stress fractures increasingly affect athletes and military recruits, with few known effective management options. Electrical stimulation enhances regular fracture healing, but the effect on stress fractures has not been definitively tested. HYPOTHESIS: Capacitively coupled electric field stimulation will accelerate tibial stress fracture healing. STUDY DESIGN: Randomized controlled trial; Level of evidence, 1. METHODS: Twenty men and 24 women with acute posteromedial tibial stress fractures were referred from local clinicians. Subjects were randomly assigned active or placebo capacitively coupled electric field stimulation to be applied for 15 hours per day until healed, given supplemental calcium, and instructed to rest from provocative training. Healing was confirmed when hopping to 10 cm for 30 seconds could be achieved without pain. RESULTS: No difference in time to healing was detected between treatment and placebo groups. Women in the treatment group healed more slowly than did the men (P = .05). Superior treatment compliance was associated with reduced time to healing (P = .003). Rest noncompliance was associated with increased time to healing (P = .05). CONCLUSION: Whole-group analysis did not detect an effect of capacitively coupled electric field stimulation on tibial stress fracture healing; however, greater device use and less weightbearing loading enhanced the effectiveness of the active device. More severe stress fractures healed more quickly with capacitively coupled electric field stimulation. CLINICAL RELEVANCE: Although the use of capacitively coupled electric field stimulation for tibial stress fracture healing may not be efficacious for all, it may be indicated for the more severely injured or elite athlete/recruit whose incentive to return to activity may motivate superior compliance.

Treatment of stress fractures: the fundamentals.

This article is an introduction to the fundamentals of stress fracture management. Extrinsic and intrinsic factors, that may play a role in the development of stress fractures, are discussed and incorporated as possible treatment options. Different treatment modalities including ultrasound and electromagnetic fields are addressed, with an emphasis on literature support.

Musculoskeletal problems of the chest wall in athletes.

Chest pain in the athlete has a wide differential diagnosis. Pain may originate from structures within the thorax, such as the heart, lungs or oesophagus. However, musculoskeletal causes of chest pain must be considered. The aim of this review is to help the clinician to diagnose chest wall pain in athletes by identifying the possible causes, as reported in the literature. Musculoskeletal problems of the chest wall can occur in the ribs, sternum, articulations or myofascial structures. The cause is usually evident in the case of direct trauma. Additionally, athletes' bodies may be subjected to sudden large indirect forces or overuse, and stress fractures of the ribs caused by sporting activity have been extensively reported. These have been associated with golf, rowing and baseball pitching in particular. Stress fractures of the sternum reported in wrestlers cause pain and tenderness of the sternum, as expected. Diagnosis is by bone scan and limitation of activity usually allows healing to occur. The slipping rib syndrome causes intermittent costal margin pain related to posture or movement, and may be diagnosed by the 'hooking manoeuvre', which reproduces pain and sometimes a click. If reassurance and postural advice fail, good results are possible with resection of the mobile rib. The painful xiphoid syndrome is a rare condition that causes pain and tenderness of the xiphoid and is self-limiting. Costochondritis is a self-limiting condition of unknown aetiology that typically presents with pain around the second to fifth costochondral joints. It can be differentiated from Tietze's syndrome in which there is swelling and pain of the articulation. Both conditions eventually settle spontaneously although a corticosteroid injection may be useful in particularly troublesome cases. The intercostal muscles may be injured causing tenderness between the ribs. Other conditions that should be considered include epidemic myalgia, precordial catch syndrome and referred pain from the thoracic spine.

Tibial stress injuries. An aetiological review for the purposes of guiding management.

In the last 30 years, few advances have been made in the management of tibial stress injuries such as tibial stress fracture and medial tibial stress syndrome (MTSS). Tibial overuse injuries are a recognised complication of the chronic, intensive, weight-bearing training commonly practised by athletic and military populations. Generally, the most effective treatment is considered to be rest, often for prolonged periods. This is a course of action that will significantly disrupt an active lifestyle, and sometimes end activity-related careers entirely. There is now considerable knowledge of the nature of tibial stress injuries, such that presently accepted management practices can be critically evaluated and supplemented. Most recent investigations suggest that tibial stress injuries are a consequence of the repetitive tibial strain imposed by loading during chronic weight-bearing activity. Evidence is presented in this article for an association between repeated tibial bending and stress injury as a function of: (i) strain-related modelling (in the case of MTSS), and (ii) a strain-related positive feedback mechanism of remodelling (in the case of stress fracture). Factors that influence the bending response of the tibia to loading are reviewed. Finally, a guide for injury prevention and management based on research observations is presented.

Insufficiency stress fractures of the foot and ankle in postmenopausal women.

Eleven consecutive patients with 12 stress fractures of the foot or ankle were seen between October 1992 and July 1995. Charts were reviewed retrospectively for clinical information. The patients were all postmenopausal females. Average age was 62 years. Onset of symptoms was not associated with a specific episode of trauma. There were eight metatarsal fractures, three distal fibular fractures, and one fracture of the medial malleolus. Fractures were confirmed by radiographs, bone scan, or MRI in 9 of the 11 cases. Nonsurgical treatment utilizing rest, decreased activity, mechanical support, and analgesics resulted in successful union of the fracture except in one patient. Only four of the patients had been taking hormone or calcium supplements before injury. Just one patient had a prior bone density measurement, although four had a definite fracture previously and two had history suggestive of previous stress fracture. A careful history considering risk factors for osteoporosis should be obtained when an insufficiency type stress fracture is diagnosed. Bone density measurements should be considered for patients with this type of injury. Appropriate medical therapy directed at the treatment of the underlying osteoporosis in addition to orthopaedic management of the fracture constitute the treatment objectives. This dual approach may prevent subsequent injury.