Abstract
The diagnosis of stress fractures is based on clinical assessment and on imaging modalities. Simple radiography (X-rays), scintigraphy (bone scan), and computerized tomography (CT) are widely used, though today magnetic resonance (MRI) is accepted as the more safe and accurate diagnostic tool. Differential diagnosis may include a variety of pathologic conditions, as tumors, infections, metabolic diseases, or normal growth variations. Treatment is essentially conservative and may include relative rest, various modalities as external support, shock waves (SW), low-intensity pulsed ultrasound (LIPU), and occasionally surgical intervention.
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References
Abel MS (1985) Jogger’s fracture and other stress fractures of the lumbo-sacral spine. Skeletal Radiol 13(3):221–227
Adriaensen ME, Mulhall KJ, Borghans RA, Magill P, Kavanagh EC (2009) Transient osteoporosis of the hip and spontaneous osteonecrosis of the knee: a common aetiology? Ir J Med Sci. 2012 Sep; 181(3):341–343. Epub 2009, doi: 10.1007/s11845-009-0407-4
Allen MJ, O’Dwyer FG, Barnes MR, Belton IP, Finlay DB (1995) The value of 99 cm-MDP bone scans in young patients with exercise-induced lower leg pain. Nucl Med Commun 16(2):88–91
Arendt EA, Griffiths HJ (1997) The use of MR imaging in the assessment and clinical management of stress reaction of bone in high performance athletes. Clin Sports Med 16:291–306
Banal F, Gandjbakhch F, Foltz V, Goldcher A, Etchepare F, Rozenberg S, Koeger AC, Bourgeois P, Fautrel B (2009) Sensitivity and specificity of ultrasonography in early diagnosis of metatarsal bone stress fractures: a pilot study of 37 patients. J Rheumatol 36(8):1715–1719. Epub 30 June2009
Batt ME (1995) Shin splints-a review of terminology. Clin J Sport Med 5(1):53–57
Beck BR, Matheson GO, Bergman G, Norling T, Fredericson M, Hoffman AR, Marcus R (2008) Do capacitively coupled electric fields accelerate tibial stress fracture healing? A randomized controlled trial. Am J Sports Med 36(3):545–553
Blank S (1987) Transverse tibial stress fractures – a special problem. Am J Sports Med 15(6):597
Breithaupt J (1855) Zur pathologie der mensclichen fusses. Med Zeitung 24:169–171
Buttaro M, Della-Valle AG, Morandi A, Sabas M, Pietrani M, Piccaluga F (2003) Insufficiency subchondral fracture of the femoral head: report of 4 cases and review of the literature. J Arthroplasty 18(3):377–382
Clement DB (1987) Stress fractures of the foot and ankle. Med Sport Sci 23:56–70
Conway JJ (1986) Radionuclide bone scintigraphy in pediatric orthopedics. Ped Clin North Am 33(6):1313
Davies AG, Clarke AW, Gilmore J, Wotherspoon M, Connell DA (2009) Review: imaging of groin pain in the athlete. Skeletal Radiol (2010) 39:629–644. Published online: 27 August 2009
Derman EW, Schwellnus MP (1996) Stress fractures and bone stress injuries of the hip and pelvis. S A J Sports Med 3(3):14–18
Ekenman I, Tsai-Fellander L, Johansson C, O’Brien M (1995) The plantar flexor muscle attachments on the tibia. A cadaver study. Scand J Med Sci Sports 5(3):160–164
Finestone AS, Lavon HW (2006) Israel medical corps. Command. Instruction no. 09:01
Finestone AS, Milgrom C (2012) Diagnosis and treatment of stress fractures. In: Doral MN, Tandoğan RN, Mann G, Verdonk R (eds) Sports injuries, prevention, diagnosis, treatment and rehabilitation. Springer, Heidelberg/New York, pp 775–785
Finestone AS, Milgrom C, Moran DS (2008) Summary of the state of science stress fracture research conference, Columbia (Ft. Jackson), South Carolina. J Isr Milit Med 5:41–44
Flinn SD (2002) Changes in stress fracture distribution and current treatment. Curr Sports Med Rep 1(5):272–277
Fredericson M, Bergman AG, Hoffman KL, Dillingham MS (1995) Tibial stress reaction in runners. Correlation of clinical symptoms and scintigraphy with a new magnetic resonance imaging grading system. Am J Sports Med 23(4):472–481
Fricker P, Purdam C (1995) Stress fractures of the femoral shaft in athletes- more common than expected. Am J Sports Med 23(3):372
Fullerton LR Jr, Snowdy HA (1988) Femoral neck stress fractures. Am J Sports Med 16(4):365–377
Furia JP, Rompe JD, Cacchio A, Maffulli N (2010) Shock wave therapy as a treatment of nonunions, avascular necrosis, and delayed healing of stress fractures. Foot Ankle Clin 15(4):651–662
Giladi M, Ziv Y, Aharonson Z, Nili E, Danon YL (1984) Comparison between radiography, bone scan and ultrasound in the diagnosis of stress fractures. Mil Med 149:459–461
Goodman PH, Heaslet MW, Pagliano JW, Rubin BD (1985) Stress fracture diagnosis by computer-assisted thermography. Phys Sportsmed 13:114–132
Griffin XL, Smith N, Parsons N, Costa ML (2012) Ultrasound and shockwave therapy for acute fractures in adults. Cochrane Database Syst Rev 2, CD008579. doi:10.1002/14651858.CD008579.pub2
Ha KI, Hahn SH, Chung M, Yang BK, Yi SR (1991) A clinical study if stress fractures in sports activities. Orthopedics 14:41
Halperin N, Copeliovitch L, Schachner E (1983) Radiating leg pain and positive straight leg raising in spondylolysis in children. J Pediatr Orthop 3(4):486–490
Hetsroni I, Mann G (2012) Various modalities to hasten stress fracture healing. In: Doral MN, Tandoğan RN, Mann G, Verdonk R (eds) Sports injuries, prevention, diagnosis, treatment and rehabilitation. Springer, Heidelberg/New York, pp 859–861
Horev G, Korenreich L, Ziv N, Grunebaum M (1990) The enigma of stress fracture in the pediatric age clarification of confusion through the new imaging modalities. Pediatr Radiol 20:469
Hulkko A (1988) Stress fractures in athletes – a clinical study of 368 cases. Thesis, University of OULU
Hung CY, Chang KV (2012) Is therapeutic ultrasound a reliable tool for the diagnosis of bone stress injuries? Letter to the editor. Am J Sports Med 40(9):NP25
Keatig JF, Beggs I, Thorpe GW (1995) Three cases of longitudinal stress fracture of the tibia. Acta Orthop Scand 66(1):41–42
Keene J, Lash E (1992) Negative bone scan in a femural neck stress fracture. A case report. Am J Sports Med 20(2):234–236
Knap TP, Garrett WE Jr (1997) Stress fractures: general concepts. Clin Sports Med 16:339–356
Krauss MD, Van Meter CD (1994) A longitudinal tibial stress fracture. Orthop Rev 23(2):163–166
Krestan CR, Nemec U, Nemec S (2011) Imaging of insufficiency fractures. Semin Musculoskelet Radiol 15(3):198–207
Krischak GD, Augat P, Blakytny R, Claes L, Kinzl L, Beck A (2007) The non-steroidal anti-inflammatory drug diclofenac reduces appearance of osteoblasts in bone defect healing in rats. Arch Orthop Trauma Surg 127:453–458
Lassus J, Tulikoura I, Konttinen YT, Salo J, Santavirta S (2002) Bone stress injuries of the lower extremity: a review. Acta Orthop Scand 73(3):359–368
Lee JK, Yao L (1988) Stress fracture: MR imaging. Radiology 169:217
Lysens RJJ et al (1987) A one-year prospective study of the intrinsic risk factors of sports injuries in young adults. In: Mann G (ed) Sports injuries: proceedings of the third Jerusalem symposium, Freund Publishing House Ltd., London
Mann G (1987) Sports injuries: proceedings of the third Jerusalem symposium. Freund Publishing House, London
Mann G, Matan Y, Nyska M, Lau Y, Peretz M, Siderer M, Barak Y, Hakimi I, Godschmidt R, Ziv B, Borovsky A (2001) The effect of personal factors of the fighter, a custom-made insole and a new boot on the occurrence of over-use injuries and stress fractures in border police recruits in an infantry course. The State of Israel, The Ministry of Internal Security, Chief Scientist Office, Hebrew
Martin J, Brandser EA, Shin MJ, Buckwalter JA (1995) Fatigue fracture of the sacrum in a child. Can Assoc Radiol J 46(6):468–470
Martinez de Albornoz P, Khanna A, Longo UG, Forriol F, Maffulli N (2011) The evidence of low-intensity pulsed ultrasound for in vitro, animal and human fracture healing. Br Med Bull 100:39–57
Matheson GO, Clement DB, McKenzie DC, Taunton JE, Lloyd-Smith DR, MacIntyre JG (1987) Scintigraphic uptake of 99mTc at non-painful sites in athletes with stress fractures. The concept of bone strain. Sports Med 4:65–75
McBryde AM Jr (1985) Stress fractures in runners. Clin Sports Med 4:737–752
McBryde AM Jr, Jackson DW, James CM (1985) Injuries in runners and joggers. In: Schneider RC, Kennedy JC, Plant ML (eds) Sports injuries. Williams & Wilkins, Baltimore, pp 395–416
Miller C, Major N, Toth A (2003) Pelvic stress injuries in the athlete: management and prevention. Sports Med 33(13):1003–1012
Moss A, Mowart AG (1983) Ultrasonic assessment of stress fractures. Br Med J 286:1479–1480
Nachtrab O, Cassar-Pullicino VN, Lalam R, Tins B, Tyrrell PN, Singh J (2012) Role of MRI in hip fractures, including stress fractures, occult fractures, avulsion fractures. Eur J Radiol 81(12):3813–3823
Narvaez JA, Narvaez J, De-Lama E, Sanchez A (2003) Spontaneous osteonecrosis of the knee associated with tibial plateau and femoral condyle insufficiency stress fracture. Eur Radiol 13(8):1843–1848
Newberg AH, Wetzner SM (1994) Bone bruises: their patterns and significance. Semin Ultrasound CT MR 15(5):396–409
Nielens H, Devogalaer JP, Malghem J (1994) Occurrence of a painful stress fracture of the femoral neck simultaneously with six other asymptomatic localizations in a runner. J Sports Med Phys Fitness 34(1):79–82
Orava S, Hulkko A (1987) Treatment of delayed and non unions of stress fractures in athletes. In: Mann G (ed) Sports injuries: proceedings of the third Jerusalem symposium. Freund Publishing House, London
Orava S, Karpakka J, Taimela S, Hulkko A, Permi J, Kujala U (1995) Stress fractures of the medial malleolus. J Bone Joint Surg Am 77(3):362–365
Papalada A, Malliaropoulos N, Tsitas K, Kiritsi O, Padhiar N, Del Buono A, Maffulli N (2012) Ultrasound as a primary evaluation tool of bone stress injuries in elite track and field athletes. Am J Sports Med 40(4):915–919
Pirker H (1934) Bruch der Oberschenkeldiaphyse durch Muskelzug. Arch Klin Chir 175:155–168
Read MT (1994) Single photon emission computed tomography (SPECT) scanning for adolescent back pain. A sine qua non? Br J Sports Med 28(1):56–57
Sahi T et al (1987) Epidemiology, etiology and prevention of stress fractures in the Finnish defense forces and the frontier guard. In: Mann G (ed) Sports injuries: proceedings of the third Jerusalem symposium. Freund Publishing House, London
Saifuddin A, Chalmers AG, Butt WP (1994) Longitudinal stress fractures of the tibia: MRI features in two cases. Clin Radiol 49(7):490–495
Santi M, Sartoris DJ, Resnick D (1988) Magnetic resonance imaging in the diagnosis of metatarsal stress fracture. J Foot Surg 27(2):172
Schlezinger LC, Smith JA (2001) Diagnostic imaging of stress fracture. Position paper submitted to the FIMS Scientific committee
Schneiders AG, Sullivan SJ, Hendrick PA, Hones BD, McMaster AR, Sugden BA, Tomlinson C (2012) The ability of clinical tests to diagnose stress fractures: a systematic review and meta-analysis. J Orthop Sports Phys Ther 42(9):760–771
Schubert F, Carter S (1994) Longitudinal stress fracture in the femoral diaphysis. Australas Radiol 38(4):336–338
Shah MK, Stewart GW (2002) Sacral stress fractures: an unusual cause of low back pain in an athlete. Spine 27(4):E104–E108
Shindle MK, Endo Y, Warren RF, Lane JM, Helfet DL, Schwartz EN, Ellis SJ (2012) Stress fractures about the tibia, foot, and ankle. J Am Acad Orthop Surg 20(3):167–176
Song WS, Yoo JJ, Koo KH, Yoon KS, Kim YM, Kim HJ (2004) Subchondral fatigue fracture of the femoral head in military recruits. J Bone Joint Surg Am 86-A(9):1917–1924
Sormaala MJ, Ruohola JP, Mattila VM, Koskinen SK, Pihlajamäki HK (2011) Comparison of 1.5 T and 3 T MRI scanners in evaluation of acute bone stress in the foot. BMC Musculoskelet Disord 12:128
Soubrier M, Dubost JJ, Rami S, Ristori JM, Bussiere JL (1995) Longitudinal insufficiency fractures of the femoral shaft. Rev Rhum Engl Ed 62(1):48–52
Spitz DJ, Newberg AH (2002) Imaging of stress fractures in the athlete. Radiol Clin N Am 40(2):313–331
Steinbronn DJ, Bennett GL, Kay DB (1994) The use of magnetic resonance imaging in the diagnosis of stress fractures of the foot and ankle: four case reports. Foot Ankle Int 15(2):80–83
Stivitz SD, Arendt EA (2004) NSAIDs should not be used in treatment of stress fractures. Am Fam Physician 70(8):1452–1454
Taun K, Wu S, Sennett B (2004) Stress fractures in athletes: risk factors, diagnosis, and management. Orthopedics 27:583–592
Tuite MJ, De-Smet AA, Gaynon PS (1995) Tibial stress fracture mimicking neuroblastoma metastasis in two young children. Skeletal Radiol 24(4):287–290
Tyrrell PN, Davies AM (1994) Magnetic resonance imaging appearances of fatigue fractures of the long bone of the lower limb. Br J Radiol 67(796):332–338
Umans HR, Kaye JJ (1996) Longitudinal stress fractures of the tibia: diagnosis by magnetic resonance imaging. Skeletal Radiol 25(4):319–324
Wheeler P, Batt ME (2005) Do non-steroidal anti-inflammatory drugs adversely affect stress fracture healing? A short review. Br J Sports Med 39:65–69
Wilson ES Jr, Katz FN (1969) Stress fractures. An analysis of 250 consecutive cases. Radiology 92(3):481–486
Zwas ST, Elkanovitch R, Frank G (1987) Interpretation and classification of bone scintigraphic findings in stress fractures. Nucl Med 28:452
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Mann, G. et al. (2015). Stress Fractures: Diagnosis, Differential Diagnosis, and Treatment. In: Doral, M.N., Karlsson, J. (eds) Sports Injuries. Springer, Berlin, Heidelberg. https://doi.org/10.1007/978-3-642-36569-0_294
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