Patella

Stress fractures of the patella are exceedingly rare. The first cases appearing in the orthopedic literature were presented by Devas 17 and M ller 18 . Despite the paucity of information on patellar stress fractures available in orthopedic literature, the rare occurrence of this condition has been seen predominantly in two patient populations, young athletes 18-25 and cerebral palsy patients 26-28 . As found in the literature, patellar stress fractures present with pain, swelling, and localized...

Carolyn M Sofka MD

Department of Radiology and Imaging, Hospitalfor Special Surgery, 535 East 70th Street, New York, NY 10021, USA Stress injuries are a common cause of pain and morbidity in both professional and recreational athletes. The early diagnosis of such injuries is imperative to halt the progression of disease, which may result in a complete fracture. Stress fractures occur when unusual stresses are applied to normal bones that have not remodeled themselves enough to handle increased stress. This...

Humerus

Stress fractures have been described in baseball pitchers, a tennis player, a javelin thrower, a body-builder, weight lifters, a softball player, and a cricket player 39-49 . Humeral stress fractures in throwing athletes such as baseball pitchers most commonly are spiral fractures that involve the middle and distal third of the humerus 40,43-46 . These fractures predominate in two main age groups adolescent Little League pitchers and healthy middle-aged pitchers 44-46 , although, Polu and...

Anatomic Variation

Variations in anatomy have been implicated as a cause for lower-extremity stress fractures. An example of this is Morton's foot with a short, hypermobile first ray and a long second ray. In a study of second metatarsal fractures in ballet dancers by Khan and colleagues 31 , six of the eight case reports were noted to have Morton's foot. Giladi and coworkers 32 reported the higher incidence of tibial stress fractures in male recruits who had greater passive external rotation of the hip (> 60...

F

Fig. 1. (A) Compression-type femoral neck stress fracture in a child. T1-weighted MR image reveals nonspecific edema, which could be consistent with a stress fracture. (B) Compression-type femoral neck stress fracture in a child. T2-weighted MR image reveals edema and definitive fracture line in the femoral neck. Fig. 2. (A) Adult femoral neck fracture. T1-weighted MR image shows nonspecific changes in the right femoral neck but no definite fracture. (B) Adult femoral neck fracture. STIR MRI...

Paul S Sherbondy MD Wayne J Sebastianelli MD

Penn State Orthopaedics, 1850 East Park Avenue, Suite 112, University Park, PA 16803, USA Stress fractures of the medial malleolus and distal fibula are injuries that occur infrequently. Of the two, fibular stress fractures are encountered more frequently. Fibular stress fractures account for 4.6 to 21 of all stress factures and are the third to fifth most common stress fracture 1-3 . Epidemiologic studies of stress fractures often do not distinguish between proximal, middle, and distal...

Electrical and Electromagnetic Fields

The clinical effect of electrical and electromagnetic fields on enhancing stress fracture healing is not clearly defined by the literature. Most studies deal with their effect on delayed unions or nonunions and are not specifically designed to evaluate the efficacy on stress fractures. Two studies 41,42 often sited in support of electromagnetic field treatment were unblinded without controls. Compounding the confusion is the various options in which a current may be directed to the fracture...

Summary

Metatarsal fractures represent a relatively common injury, especially in athletes. Treatment remains relatively straightforward for the traumatic metatarsal injury. Traditional stress fractures typically heal with decreased activity. The problematic proximal fifth metatarsal fracture (Jones fracture) frequently requires surgical intervention in the patient who wants to avoid non-weight-bearing cast immobilization. The authors current treatment for this fracture includes the option of...

Stress Fractures In The Lumbar Spine

The lumbar spine consists of five lumbar vertebrae joined to the sacrum at the pelvis. Stress fractures of the lumbar vertebral column are relatively common, and the site of injury depends on the direction in which the stress is applied 17 . The main components of lumbar motion are believed to occur at the L3-L4 and L5-S1 levels 7 . Fractures of the pedicle 21-23 and sacrum 24-29 occur, but fractures of the pars are most frequent 17,30,31 . Risk Factors for Stress Fractures in the Lumbar Spine...

Michael J DeFranco MDa Michael Recht MDb Jean Schils MDb Richard D Parker MDa

ADepartment of Orthopaedic Surgery, A-41, The Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA b'Emergency Radiology, Department of Radiology, RC-35, The Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH44195, USA Stress fractures are common injuries of the lower extremities in athletes and military recruits. Indeed, stress fractures account for approximately 10 of all injuries seen by sports medicine specialists 1 . The fourth most common type of stress fracture occurs in the...

Scapula

Stress fractures of the scapula in athletes are rare. There have been four reported cases in the literature a gymnast, a jogger using hand-held weights, a professional American football player with a stress fracture at the base of the acromial process, and a trap shooter with a fracture in the coracoid process 4,28-31 . The jogger had been jogging with weights for an 8-week period when he presented with a 2-week history of shoulder pain 29 . A bone scan revealed a linear band of increased...

Parathyroid Hormone

PTH plays a significant role in both intra- and extracellular calcium homeostasis 12 . Although the overall effect of PTH is to conserve calcium in the body, an anabolic effect on bone was discovered in 1932 13 . Selye found that rats given a daily injection of PTH developed denser bones, but a large dose of the hormone resulted in bone resorption 13 . The availability of purified PTH in the 1970s led to a variety of animal studies assessing the role of PTH in fracture healing. The anabolic...

Michael C Koester Md Atc Kurt P Spindler MD

Vanderbilt Sports Medicine, Medical Center East, South Tower, Suite 3200, Nashville, TN 37232, USA Bone fractures are a known risk of athletic participation. Hame and colleagues 1 found a fracture incidence of 5.9 in collegiate athletes over a 15-year observation period. Stress fractures represented nearly 25 of all of the reported fractures. Although much less common than soft tissue injuries, fractures typically result in significant time lost from activity. Recovery is time-dependent and...

Hormonal Factors

Low estrogen environments in the female athlete are associated with loss of bone-mineral density, predisposing the athlete to stress fracture. Myburgh and colleagues 29 found that runners who had decreased bone-mineral density were at greater risk for stress fracture. Several studies have shown that amenor-rheic and oligomenorrheic athletes are especially at high risk of bone loss 34,37 . A complete menstrual history is required whenever a diagnosis of stress fracture is made in the young...

Intravenous Pamidronate

Stewart and colleagues 46 reported on the use of intravenous pamidronate on five symptomatic collegiate athletes who had tibial stress fractures. Pamidro-nate is a second-generation bisphosphonate that is currently used in the treatment of osteoporosis, hypercalcemia, and metastatic bone disease. It is thought to affect osteoclastic activity by binding to calcium phosphate crystals. With decreased osteoclastic activity, the osteoblasts may catch up, allowing the bone to heal. A 30-mg test dose...

Diagnosis

Most athletes who have stress fractures present with an insidious onset of progressive pain in a focal area 17 . Initially, pain is present only with activity and may be associated with localized muscular soreness. As the fracture continues to develop, the pain usually begins to affect performance, and with continued training, pain persists into activities of daily living. In more severe cases, pain becomes continual. Physical examination usually demonstrates tenderness within a localized area....

Demographic Factors

Most studies have found that women have a higher incidence of stress fractures compared with men. This higher incidence probably is multifactorial, secondary at least in part to gender-associated risk factors such as dietary deficiencies, menstrual irregularities, lower BMD, and narrower bone width. Gender differences in muscle physiology, especially neuromuscular control, also may be to blame because several studies have shown that women have a slower rate of force development in the muscle...

Delayed Menarche

Female athletes generally reach menarche at a later age than female nonathletes do, particularly those in certain sports such as ballet, running, and gymnastics 70,71 . Delayed menarche may cause lower peak bone mass attainment or may be a marker for other possible influences on stress fracture risk, such as low body fat, low body weight, future menstrual disturbance, or excessive training. The effect of this delay on bone health and the risk of stress fractures have not been well studied...

Radius

Stress fractures of the radius have been described in gymnasts, a tennis player, a pool player, a cyclist, and a badminton player 83-91 . Stress fractures of the distal radial growth plate are seen frequently in young gymnasts 83,84,87,89 . Ahluwalia and colleagues 88 have reported a skeletally mature female gymnast who presented with bilateral radial stress fractures, which were diagnosed by radionuclide imaging. Loosli and Leslie 85 have described a female tennis player in her 20s who...

Vitamin D And Calcium Supplementation

Adequate dietary intake of vitamin D and calcium is essential to building and maintaining healthy bones. Animal studies have shown increased mechanical strength of the callous and other beneficial effects with vitamin D treatment after a fracture 30-32 . Given the few potentially harmful side effects, calcium and vitamin D supplementation have long been advocated in an effort to augment bone healing. In the only trial reported in the literature, Doetsch and colleagues 33 examined the role of...

Gary B Fetzer MD Rick W Wright MD

Department of Orthopaedic Surgery, Washington University in St. Louis School of Medicine, Barnes-Jewish Hospital, One Barnes-Jewish Hospital Plaza, West Pavilion,, Suite 11300, St. Louis, MO 63110, USA he forefoot has been described to serve two primary functions (1) pro vide a broad rigid platform for weight bearing and (2) provide a mobile platform to accommodate uneven ground while ambulating 1 . The metatarsal bones, phalanges, and surrounding structures provide this platform. Fractures of...

Clinics In Sports Medicine

Anyone who routinely works in a training room is intimately familiar with the stress associated with treating stress fractures it is not simply a matter of telling an athlete to rest, it is convincing them to join you on a difficult and complex journey that does not always have a definable endpoint. This issue of the Clinics in Sports Medicine offers an up-to-date roadmap for that journey. Dr. Kaeding has hired the best guides available for the trip so strap on your backpack and join us. Dr....

Evaluation And Diagnosis

Bearing radiographs, if tolerated, can be helpful for evaluation. Evaluation of the tarsometatarsal joints, the tarsal bones, and the phalanges is important to identify associated fractures or joint involvement (subluxation dislocation). Radiographic classification of metatarsal fractures has been described by the Orthopaedic Trauma Association however, this classification is useful only for descriptive purposes and does little for predicting overall stability, treatment, or outcome 1,2 ....

Study Design

Three separate study designs predominate in the stress fracture literature case series, prospective cohorts, and retrospective cohorts. A case series consists of a population of individuals who have experienced the exposure and have developed the outcome of interest. Risk factors cannot be determined, nor can anything of interest be learned regarding the population at risk. Injury data reported without a denominator can describe only injury frequency 6 . Few conclusions can be drawn about the...

Rebecca A Snyder BAa Michael C Koester MD ATCa Warren R Dunn MD MPHb

AVanderbilt Sports Medicine, Medical Center East, South Tower, Suite 3200, Nashville, TN 37232, USA Heath Services Research Center, 6000 Medical Center East, North Tower, Nashville, TN37232-8300, USA Stress fractures are a frequent cause of injury in competitive and recreational athletes. The pathophysiology of stress fracture has been well described in the literature. Data regarding the epidemiology of stress fractures in athletes, including injury patterns and risk factors, are lacking....

Ribs

Rib stress fractures have been reported in several sports, including rowing, rugby, golf, weightlifting, volleyball, gymnastics, judo, tennis, table tennis, baseball, basketball, soccer, javelin throwing, backpacking, and wind surfing 8-23 . Muscular forces are predominately responsible for these stress fractures 24 . Muscles that attach to ribs are used during upper-extremity movements, trunk rotation, bending, and breathing. The stress placed on the ribs by the muscles during repetitive...

Sternum

Although they are rare, stress fractures of the sternum have been reported in a wrestler 5 , a golfer 6 , and an athlete performing strenuous abdominal exercises 7 . In the case of the wrestler 5 , the patient had pain after weeks of modified training in preparation for a competition. The pain then suddenly increased during activity. Results of a standard radiograph were normal, but a technetium bone scan revealed an increased uptake in the sternum, exactly where his pain was located. The...

Case Examples

The authors' institution has had considerable experience with tension-sided tibial stress fractures in competitive athletes. This fracture has been found to be difficult with respect to bony healing. Tibial nailing has been successful in some but not all athletes who have this condition. There is no single algorithm that can drive treatment decisions. As the following case examples illustrate, each athlete must be individually assessed, and treatment and work-up decisions must be made based on...

Stress Fracture Characteristics

Fifteen studies provided sufficient details to allow a review of anatomic fracture sites, but the studies are of limited value in assessing fracture occurrence by sport. Few inferences can be made regarding specific injury patterns because of the heterogeneity of the study populations and inconsistent methodology. Variations in exposure will affect fracture patterns. In addition to the volume of activity, other potentially confounding variables include sports or activities, climate, and...

Extrinsic Factors

A high training volume is a major risk factor in stress fracture development. Multiple studies in runners have demonstrated that higher weekly running mileage correlates with an increased incidence of stress fractures 20 and overall running injuries 21-23 . Ballet dancers who train for more than 5 hours per day have a significantly higher risk for stress fractures than those who train for less than 5 hours daily 24 . Abrupt or rapid changes in duration, frequency, or intensity of training...

Anatomy And Biomechanics

Sixty-four-year-old male who engaged in vigorous ethnic dancing and extensive walking during a 3-week vacation. (A) Subtle periosteal reaction of the lateral cortex of the distal fibula (arrows) with confirmation of stress fracture (B) on a bone scan (circle). Fig. 1. Sixty-four-year-old male who engaged in vigorous ethnic dancing and extensive walking during a 3-week vacation. (A) Subtle periosteal reaction of the lateral cortex of the distal fibula (arrows) with confirmation of stress...

Management Of And Returntoplay Strategies For Highrisk Fractures

Return-to-play considerations for athletes who have high-risk stress fractures are more difficult than for low-risk stress fractures (Table 2). In general, return should be recommended only after proper treatment and complete healing of the injury. As previously mentioned, high-risk stress fractures have more frequent complications such as delayed union, nonunion, and refracture. High-risk stress fractures also have a significantly poorer prognosis should they progress to complete fracture. The...

Nonsteroidal Antiinflammatory Drugs

Primarily known as mediators of inflammation, prostaglandins also play an important role in bone metabolism and repair. Prostaglandins are derived from arachidonic acid in an enzymatic reaction catalyzed by cyclooxygenase (COX)-1 and COX-2. Previous convention held that COX-1 was constitutively produced and acted to maintain physiologic homeostasis (mainly gastrointestinal and renal function), whereas COX-2 acted as a stress response gene responsible for prostaglandin production at sites of...

Treatment

After the diagnosis of tibial stress fracture has been made by history, physical examination, and imaging modalities, treatment needs to be initiated. The typical tibial stress fracture that occurs on the posteromedial portion of the tibia usually responds to a period of rest followed by gradual resumption of activities. It is also important to identify and modify any risk factors. Training regimen and footwear are easily correctable. Intrinsic causes such as nutritional, hormonal, or other...

The Female Athlete Triad

The female athlete triad refers to an interrelated problem consisting of disordered eating, amenorrhea, and osteoporosis. Hoch and colleagues 93 have also found that amenorrheic athletes have reduced brachial artery endothelium-dependent flow-mediated vasodilation compared with oligomenorrheic and eumenorrheic athletes. Furthermore, in a 2-year follow-up study, the original amenorrheic athletes were found to have a significant improvement in BMD with different combinations of estrogen and...

Ulna

Stress fractures of the ulna have been described in baseball and softball pitchers, tennis players, volleyball players, weight lifters, bowlers, riflemen, a golfer, a polo player, a kendo player, and a baton twirler 67-82 . These athletes present with pain in the region of the ulnar shaft during and after activities and, on physical examination, have tenderness over the ulnar shaft. Radiographs demonstrate either a small crack in the cortex or subtle periosteal reaction at the site of the...

Proximal Fibula

Only 10 reports of proximal fibula stress fracture in athletes were found at the time the literature search was performed for this article. However, there have been numerous reports of fatigue fracture in the military 11,12 . Fibular injuries were associated with repetitive jumping and subsequent landing in parachute school recruits. The incidence of fibular stress fractures in athletes has not been reported. Biomechanical studies have shown that the fibula receives between 6.4 and 16.7 of the...

Bisphosphonates

Over the past decade, bisphosphonates have been widely used to treat a variety of bone diseases. The marked inhibitory action of bisphosphonates on osteoclast-mediated bone resorption has led to success in the treatment of pathologic processes with increased bone turnover such as Paget's disease, bone tumors, and osteoporosis. More recently, investigators have speculated on whether bisphosphonates can play an important role in fracture repair by enhancing the healing process and limiting disuse...

Morbidity And Outcomes

The available literature offers few data in regard to outcomes and recurrence rates following a stress fracture. Sullivan and colleagues 27 have reported that seven of 51 athletes who had a stress fracture had suffered a radiologically proven fracture before study enrollment. Bennell and colleagues 1 have found that 60 of athletes with a stress fracture over their prospective 12-month observation period had experienced a previous stress fracture. There was a strong recruitment bias in this...

Metatarsal Shaft Fractures

The anatomy of the forefoot has previously been described 1,2,6,7 . The first metatarsal is most important for weight-bearing activities because it bears approximately one third the body's weight through its two sesamoid bones under the metatarsal head 1,5 . The first metatarsal is stronger than the lesser metatarsals despite its shorter and wider bony structure. Strong, thick ligaments form the capsule and stabilize its base at the first tarsometatarsal joint. Two strong muscle-tendon units...

Grant Lloyd Jones MD

The Ohio State University Sports Medicine Center, 2050 Kenny Road, Columbus, OH 43221, USA Stress fractures occur typically in the lower extremity, caused by impact loading from running, walking, or jumping. In one large series, Matheson and colleagues 1 reported on 320 stress fractures, in which 90 occurred in the lower extremity. However, upper-extremity stress fractures are now being recognized more frequently. These fractures occur either as a result of repetitive loading at the point of...

Jason J Diehl MDa Thomas M Best MD PhDa Christopher C Kaeding MDb

ADivision of Sports Medicine, Department of Family Medicine, The Ohio State University Sports Medicine Center, 2050 Kenny Road, Columbus, OH 43221, USA Division of Sports Medicine, Department of Orthopedics, The Ohio State University Sports Medicine Center, 2050 Kenny Road, Columbus, OH 43221, USA tress reactions and stress fractures are fatigue-failure injuries of bone that are commonly diagnosed in competitive, occupational, and recreational athletes. These overuse injuries result in a...

Metacarpals

Metacarpal stress fractures are rare but have been reported in a softball pitcher, tennis players, and a rower 93-96 . The second metacarpal was affected in both of the tennis players 94,96 . The authors in both of these tennis case studies suggest that increased training intensity combined with changes in stroke biomechanics and racket grip predisposed the second metacarpals to fracture. The movement of the second carpometacarpal joint is relatively limited, except for flexion and extension....

Distal Femur

Distal Femoral Stress Fracture

The incidence of distal femoral stress fractures in the civilian athletic population is unknown. Various cohort studies have analyzed the occurrence of stress fractures in military recruits. An Israeli study documented that 9.2 of recruits who suffered from any stress fracture sustained a stress fracture to the distal femur. None of these recruits experienced any symptoms before basic training 44 . The diagnosis of femoral stress fractures should be kept in mind when a patient presents with a...

Sacral Stress Fractures

A once uncommon cause of lower back and buttock pain, sacral stress fractures are being reported now with increasing frequency in the medical literature 6,24-29,71-74 . In 1989, Volpin and colleagues 75 reported the first series of sacral stress fractures among a health population. In their study, they identified three military recruits with stress fractures of the sacral wing. Since then, there have been numerous case reports of sacral stress fractures in athletes, particularly long distance...

Olecranon

Four distinct types of olecranon stress fractures have been reported in the literature. Two fracture types occur in skeletally mature athletes, fractures of the olecranon tip and oblique fractures through the midportion of the olecranon and two types occur in skeletally immature athletes, transverse fractures and osteochondroses 4,51-53 . Tip fractures occur in the proximal third of the olecranon and are seen typically in throwers 54 . Slocum 55 theorizes that the fractures could result from...

Clavicle

Clavicular stress fractures have been reported in a javelin thrower, a rower, a gymnast, a diver, a weight lifter, a human tower stuntman, and a baseball player 32-38 . The fractures in the rower and gymnast involved the medial third of the clavicle 33,34 . The lightweight rower presented with increasing pain in her medial clavicular area after rapidly increasing her training intensity over a 3- to 4-week period, after a 5-month period of rest 33 . Plain radiographs demonstrated a right medial...

Spondylolysis

Spina Bifida Occulta Pain

Spondylolysis, a stress fracture of the pars interarticularis (the part of the lamina located between the superior and inferior articular processes of the vertebrae), is one of the most common conditions associated with lower back pain in adolescent athletes 35 . In the adolescent athlete population, the fracture of the pars interarticularis occurs at a time of spinal growth in the posterior elements, as well as anterior elements of the attached growth plate 36 . A recent study at Children's...

Proximal Fifth Metatarsal Fractures

5th Metatarsal Tuberosity Fracture

In 1902, Sir Robert Jones 21 was the first to describe a fracture of the proximal fifth metatarsal. Since this first report, extensive clinical research and basic science reports have characterized fractures in this region and demonstrated that some fractures of the proximal fifth metatarsal are troublesome to treat 4,22-31 . Thus, all fractures at the proximal end of the fifth metatarsal cannot be considered together when discussing mechanism of injury, treatment options, and outcomes. Anatomy...

Principles Of Diagnosis

Diagnosing femoral stress fractures requires a high degree of suspicion, a detailed medical history, thorough physical examination, and, in most cases, confirmation by an imaging study. Early diagnosis can be difficult. In 75 of the initial examinations, the diagnosis may be missed or the condition may be misdiagnosed 37 . In some cases, the diagnosis may be delayed by 4 to 12 weeks 7 . Additionally, 18 of midshaft and 51 of distal femoral stress fractures in athletes and military recruits are...

Conventional Radiographs

0278-5919 06 - see front matter doi 10.1016 j.csm.2005.08.009 2005 Elsevier Inc. All rights reserved. Fig. 1. A Lateral view radiograph of the proximal calf demonstrating endosteal remodeling and cortical thickening arrow consistent with a stress fracture. A faint radiolucent fracture plane is present. B Sagittal high-resolution fast spin echo MRI of the leg in the same patient demonstrating moderate cortical thickening and a faint cortical fracture line arrow . Fig. 1. A Lateral view...

Mri

MRI, like nuclear medicine, is sensitive to detecting early marrow changes and early stress reactions. MRI also provides a detailed anatomic evaluation of the regional soft tissues and can be used to quantify the quality of the endosteal and cortical bone. MRI can be used to evaluate both the appendicular as well as the axial skeleton. MRI provides a comprehensive evaluation of the area in question, providing morphologic as well as functional information. MRI can demonstrate the status of the...

References

1 Kaplan FS, Hayes WC, Keaveny TM, et al. Form and function of bone. In Simon SR, editor. Orthopaedic basic science. Rosemont IL American Academy of Orthopaedic Surgeons 1994. p. 127-94. 2 Monteleone Jr GP. Stress fractures in the athlete. Orthop Clin North Am 1995 26 3 423-32. 3 Markey KL. Stress fractures. Clin Sports Med 1987 6 2 405-25. 4 Nattiv A, Armsey Jr TD. Stress injury to bone in the female athlete. Clin Sports Med 1997 16 2 197-224. 5 Theintz G, Buchs B, Rizzoli R, et al....

Diagnostic Imaging

Plain radiographs are useful in the initial evaluation of an athlete in whom a stress fracture is suspected. In more advanced or established cases, cortical or medullary fracture lines, regional osteopenia, sclerosis, and callus formation may be noted. Unfortunately, radiographs are initially negative in up to 70 of stress fractures and may not show evidence of injury for 2 to 4 weeks after symptoms begin 28 . In two of the largest series of medial malleolar stress fractures, Shelbourne and...