Stress Fractures

Cory Keller, DOAssociate Professor

Temple Orthopaedics and Sports Medicine

Disclosures NONE

Objectives Identify the etiology of stress fractures

Compare and contrast high risk vs low risk stress fractures

Identify treatment strategies for stress fractures

Stress Fracture Overuse injury

NOT an acute injury

Occurs when muscles fatigue and cannot absorb added shock Overload of stress gets transferred to the bone,

leading to a tiny crack in the bone

Stress Fractures 0.7-20% of All Sports-related Injuries

Highest Incidence in Sports Track and Field athletes

High prevalence: Gymnastics

Dancing

Most Common Stress Fx’s• Tibia 23.6%• Tarsal Navicular 17.6%• Metatarsal 16.2%• Fibula 15.5%• Femur 6.6 %• Pelvis 1.6 %

LOCATION SPORT

Metatarsals Football, basketball, gymnastics, ballet

Sesamoids of the foot Running, ballet, basketball, skating

Navicular Basketball, football, running

Talus Pole Vaulting

Fibula Running, aerobics, ballet

Tibia Running, sports, dancing, ballet

Patella Running, hurdling

Femoral Neck Distance running

Pubic Rami Distance Running

Pars Articularis Gymnastics, ballet, cricket, volleyball, diving, football

Chest, ribs Swimming, golf, rowing

Ulna Racquet sports, volleyball

Olecrenon Baseball, throwing sports

Bone HealthStress on Bone Distribution of force results in increased stress at focal

points in bone Action of muscle pulling on bone

Osteoblastic vs Osteoclastic Bone stress leads to imbalance Bone Marrow Edema Eventually results in full cortical break

Risk Factors Change in load on the bone Changes in volume or intensity

Changes in surface

Energy imbalance Calories IN vs Calories OUT

Risk Factors

Intrinsic• Female

• Amenorrhea

• Low BMD

• Genu Valgus

• Leg length discrepancy

• Poor aerobic fitness at onset of exercise

Extrinsic• Rapid progression of

training• Poor surface• Running and

Jumping sports• Poor footwear• Smoking• Poor nutrition

Risk Factors

Intrinsic• Pes Planus

• Pes Cavus

• Stiff Joints

• Ligamentous Laxity

• Low Testosterone (males)

Extrinsic• Inadequate rest

periods• >10 alcoholic

beverages per week

Female Athlete Triad Low energy availability with or without disordered

eating

Menstrual dysfunction

Low bone mineral density

Mary Jane De Souza et al. Br J Sports Med 2014;48:289

Clinical Presentation Localized bony pain during or after exercise

Typically increases with continued activity

Physical Exam – tenderness to palpation Hop test

Fulcrum test

Imaging (X-ray) Typically negative

Positive Finding Periosteal reaction

Cortical Defect(Dreaded Black Line)

MRI Very sensitive for detecting stress injury to bone Sensitivity similar to that of bone scan

MRI more sensitive better to define exact anatomic injury

MRI – no radiation exposure

MRI – takes less time to complete study

Risk of Delayed UnionHigh Risk Low Risk

Anterior tibial diaphysis Posteromedial Tibia

Lateral Femoral Neck Metatarsals

Patella Calcaneous

Medial Malleolus Cuboid

Navicular Cuneiform

Fifth Metatarsal Fibula

Proximal Second Metatarsal Medial Femoral Neck

Sesamoids Femoral Shaft

Talus Pelvis

Femoral Head

Behrens et al. Stress fractures of the pelvis and legs in the athlete: a review . Sports Health 2013 Vol 5(2) 165-174

Femoral Neck Stress Fx’s

Stress Fractures of the Tibia

Differential Dx Medial Tibial Stress Syndrome (MTSS)

Exertional Compartment Syndrome (ECS)

Anterior Cortex vs Medial Cortex Anterior Poor blood supply

Area under tension (bowing tibia)

Often takes 12 months of recovery (+/- bone stim/surgery)

Medial – NWB/rest 6-8 weeks

Treatment Rest from aggravating activity (4-12 weeks)

Possibly NWB, cross-train accordingly to maintain CV fitness

Immobilize when necessary

Treatment of underlying issue (nutrition, etc) Calcium 1000-1200 mg/d Vit D 600IU/d Female Athlete Triad Coalition Panel recommended Vit D levels 32-50

Pain (Tylenol vs NSAIDs)

Bone Stimulator

Orthotics

Prevention Screen for Female Athlete Triad

Modify training

Core/hip strengthening and symmetry

Orthotics

Biomechanical evaluation

Nutrition (Vit D, Calcium)

Pain free exercise

References

Behrens et al. Stress fractures of the pelvis and legs in the athlete: a review . Sports Health 2013 Vol 5(2) 165-174

Henning P, The running athlete. Stress fractures, osteitis pubis, and snapping hips. Sports Health 2014 Vol 6(2) 122-127

Mary Jan De Souza et al. Br J Sports Med 2014;48:289

Patel, D et al. Stress fractures: Diagnosis, Treatment, and Prevention. American Family Physician Vol 83(1), Jan 2011.