- 57 Downloads
The stress fracture is a common injury seen by healthcare professionals caring for athletes. They have been described in numerous areas of the skeletal system and in multiple sports. However, they are most commonly seen in the lower extremities, with running the reported cause in most cases.
Stress fractures result from repetitive, cyclic loading of bone which overwhelms the reparative ability of the skeletal system. Mechanically, three events may lead to stress fractures. First, the applied load can be increased. Secondly, the number of applied stresses can increase. Finally, the surface area over which the load is applied can be decreased.
Diagnosis requires thorough clinical evaluation with a high index of suspicion for stress fractures. History must focus on examining the athletes training regimen, especially any changes in distance, running surface and type of shoe. Physical examination varies depending on the location of the stress fracture. Ultrasound is a possible adjunct to the physical examination.
Initial plain radiological evaluation may be normal, especially early in the course of a stress fracture. Further radiological evaluation may be necessary to make a definitive diagnosis. Repeating plain radiographs, bone scintigraphy, magnetic resonance imaging and computerised tomography are all possible options.
Treatment options begin with rest and cessation of the precipitating activity. This should be ‘active rest’ in which the athlete continues to exercise depending on the site of the fracture. The athlete should be evaluated from a biomechanical point of view and any abnormalities dealt with prior to rehabilitation. Possible adjuncts to treatment include pneumatic braces and electromagnetic field therapy.
There are specific stress fractures that must be considered at-risk for complications of healing. The treatment of these fractures begins with immobilisation and may require surgery pending response to therapy.
Stress fractures occur more frequently in female athletes in relation to their male counterparts. There is a demonstrated relationship to eating disorders, amenorrhea and osteoporosis, or the female athlete triad. Thus, stress fractures in the female athlete requires additional investigation into those areas.
The diagnosis and treatment of stress fractures is a challenge for the physician caring for the athlete. It requires a high index of suspicion combined with a strong knowledge of the at-risk stress fractures and their complications. Accurate and timely diagnosis is required to prevent possible costly and disabling complications.
KeywordsAdis International Limited Stress Fracture Eating Disorder Female Athlete Ballet Dancer
Unable to display preview. Download preview PDF.
- 3.Devas MB. Stress fracture of the tibia in athletes or ‘shin soreness’. J Bone Joint Surg Am 1958; 40B: (227–36)Google Scholar
- 5.Zelko RR, DePalma BF. Stress fractures in athletes: diagnosis and treatment. Postgrad Adv Sports Med 1986; 1–20Google Scholar
- 12.Orava S, Karpakka J, Taimela S, et al. Stress fracture of the medial malleolus. J Bone Joint Surg Am 1995 Mar; 77-A (3): 362–5Google Scholar
- 21.Black KP, Ehlart KJ. A stress fracture of the lateral process of the talus in a runner: a case report. J Bone Joint Surg Am 1994; 76-A(3):441–3Google Scholar
- 28.Bennell KL, Malcolm SA, Thomas SA, et al. The incidence and distribution of stress fractures in competitive track and field athletes. A twelve-month prospective study. Am J Sports Med 1996; 24 (2): (211–7)Google Scholar
- 40.Rockwood CA, Green DP. Fractures in adults. Philadelphia: J.B. Lippincott Co., 1991: 1–8Google Scholar
- 42.Junqueira LC, Carneiro J, Kelley RO. Basic histology. Norwalk (CT): Appleton & Lange, 1992Google Scholar
- 43.Johnson LC. Morphologic analysis in pathology in bone bio-dynamics. In: Frost HM, editor. Bone dynamics. Boston: Little, Brown & Co., 1963:535–49Google Scholar
- 44.McBryde AM. Stress fractures in runners. In: D’Ambrosia R, Drez Jr D, editors. Prevention and treatment of running injuries. Thorofare (NJ): Charles B. Slack Inc., 1982: 21–42Google Scholar
- 46.Devas M. Ultrasonic assessment of stress fractures. BMJ 1983 May; 286(5): 1479–80Google Scholar
- 51.Taunton JE, Clement DB, Webber D. Lower extremity stress fractures in athletes. Physician Sports Med 1981 Jan; 9(1): 77–86Google Scholar
- 59.Stafford SA, Rosenthal D, Gebhardt MC, et al. MRI in stress fracture. Am J Radiol 1986; 147: (553–6)Google Scholar
- 60.Yao L, Lee JL. Occult intraosseus fracture: assessment with MR imaging. Radiology 1987; 164: (763–6)Google Scholar
- 62.Dale PA, Brook JT, Kelly PJ. Fracture healing with elevated venous pressure. 35th Annual Meeting ORS; 1989 Feb 6–9; Las VegasGoogle Scholar
- 65.Bergfeld JA, Khoury M. Stress fractures in sports. Sports Medicine Symposium: 1994 Sep 14–16; Burlington (VT). Vermont: University of Vermont, 1994: 144–65Google Scholar
- 66.Bassett CAL, Mitchell SN, Gaston SR, et al. Treatment of un-united tibial diaphyseal fractures with pulsing electromagnetic fields. J Bone Joint Surg Am 1981; 63A: (511–23)Google Scholar
- 71.Pribis AB, Reeder MT, Dick BD. Anterior tibial stress fracture progressing to complete fracture: a case report [abstract no. 30]. Med Sci Sports Exerc 1996; 28 Suppl.: S5Google Scholar
- 80.Nativ A, Agostini R, Drinkwater B, et al. The female athlete triad: the inter-relatedness of disordered eating, amenorrhea, and osteoporosis. Clin J Sport Med 1994; 13 (2): (405–18)Google Scholar
- 81.Dummer GM, Rosen LW, Heusner WW. Pathogenic weight-control behavior of young competitive swimmers. Physician Sports Med 1987; 15: (75–86)Google Scholar
- 82.Rosen LW, Hough DO. Pathogenic weight control behaviors of female college gymnasts. Physician Sports Med 1988; 16: (141–6)Google Scholar
- 83.Rosen LW, McKeag DB, Hough DO, et al. Pathogenic weight control behaviors of female college athletes. Physician Sports Med 1986; 14: (79–86)Google Scholar
- 86.Johnson MD. Disordered eating in active and athletic women. Clin J Sport Med 1994; 13 (2): (355–69)Google Scholar
- 89.Erdelyi GJ. Effects of exercise on the menstrual cycle. Physician Sports Med 1976; 4: (79–84)Google Scholar
- 90.Speroff L, Redwine DB. Exercise and menstrual function. Physician Sports Med 1980; 8: (42–9)Google Scholar
- 108.Robinson T, Snow-Harter C, Gillis D, et al. Bone mineral density and menstrual cycle status in competitive female runners and gymnasts. Med Sci Sports Exerc 1993; 25 Suppl. 5: S49Google Scholar
- 109.Cann CE, Cavanaugh DJ, Schnurpfiel, et al. Menstrual history is the primary determinant of trabecular bone density in women runners. Med Sci Sports Exerc 1988; 20 Suppl. 2: S59Google Scholar