|
 
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| REVIEW ARTICLE |
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| Year : 2015 | Volume
: 15
| Issue : 2 | Page : 123-126 |
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Stress fractures in athletes: A literature review
Hazem Al-Khawashki
Department of Orthopedic Surgery, King Saud University, Riyadh, Saudi Arabia
| Date of Web Publication | 6-May-2015 |
Correspondence Address:
Hazem Al-Khawashki
Department of Orthopedic Surgery, King Saud University, Riyadh
Saudi Arabia
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/1319-6308.156341
Stress fractures are commonly seen in athletes. The lower extremities are more frequently involved than the upper extremities. Stress fractures usually occur after a recent increase in activity or repeated activity with limited rest. A high index of suspicion and timely diagnosis are crucial in order to avoid the severe secondary damage that can occur. Although stress fractures are significant for all patients, in athletic individuals they may bring about the end of their sporting careers. Treatment usually is conservative including activity modification and analgesics to relieve pain. Orthopedic surgeon consultation is indicated in patients with recurrent fractures, nonunion, or fractures in high-risk locations. This article reviews the latest scientific literature in reference to stress fractures in athletes. It goes some way to explaining the principles, approach and guidelines for the management. ملخص : تعد الكسور الإجهادية من الإصابات الشائعة لدى الرياضيين ويكون الطرف السفلي أكثر تعرضا من الطرف العلوي. تحدث هذه الكسور بسبب زيادة المجهود الرياضي أو قلة الراحة. يحتل التشخيص المبكر والدقيق أهمية قصوى لتلافي الأضرار المزمنة. بالرغم من الكسر الإجهادي يعد أمرا هاما عند جميع المرضى, إلا أن له أهمية خاصة لدى الرياضيين لأنه قد يؤدي إلى وضع نهاية لمستقبلهم الرياضي. يبقى العلاج التحفظي مناسباً لمعظم الكسورويستدعي بعضها استشارة طبيب جراحة العظام للتدخل الجراحي. يعرض هذا المقال أحدث المقالات العلمية التي تشير إلى الكسور الإجهادية لدى الرياضيين, ويشرح المبادئ وطريقة الوصول إلى التشخيص ومبادئ العلاج. Keywords: Athlete, fracture, stress
How to cite this article:
Al-Khawashki H. Stress fractures in athletes: A literature review. Saudi J Sports Med 2015;15:123-6 |
| Introduction | |  |
Stress fractures were first described in military personnel in 1855 by Breithaupt, a Prussian military surgeon, who observed these injuries "march foot" in military recruits with foot pain and swelling following long marches. [1],[2] By the 1970s, stress fractures in athletes were increasingly reported in the literature. [3],[4],[5]
Stress fracture of the bone is currently a well-recognized cause of suboptimal training and underperformance in athlete. Active, athletic population involved in repetitive, high-impact activities, in particular, long-distance runners, are the most frequently affected. [6],[7],[8] Stress fractures have been reported to account for 2% of total sports injuries in athletes. [9] Stress fractures can affect almost any bone, but the vast majority; up to 95%; affects the lower extremity. Therefore, this article reviews the pathophysiology, risk factors, diagnosis, treatment, and prevention of stress fractures in athletes with special emphasis on lower limb injuries.
| Pathophysiology | | |
Repetitive and excessive stress on the normal bone leads to the acceleration of normal bone remodeling and the production of microfractures caused by insufficient time for the bone to heal. This, subsequently, creates a bone stress injury or reaction that, eventually, results in a stress fracture. In contrast, pathological or insufficiency fractures occur under normal stress in a bone weakened by a pathological condition, such as tumor, infection, or osteoporosis. [10],[11]
The common lower limb locations for stress fractures are the tibia, metatarsal, tarsal navicular, fibula, femur, and pelvis. [6],[12] Tibial shaft stress fractures constitute about half of lower limb stress fractures. [13] Metatarsal stress fractures are the next most common, occurring in about 10-20% of athletes, particularly runners. [14],[15] Femoral fractures constitute 11%, although these injuries may be underdiagnosed. [16] Femoral fractures typically occur in the neck, medial proximal shaft, and distal shaft. [17] Although less common, upper limb stress fractures can occur in athletes who participate in sports involving throwing or other overhead activities. [18]
Poor nutrition and lifestyle habits may increase the risk of stress fracture. Women with the female athlete triad comprising eating disorders, functional hypothalamic amenorrhea, and osteoporosis are at higher-risk of stress fracture. [19] History of low Vitamin D levels, smoking and excessive alcohol drinking are possibly associated with an increased risk of stress fracture. [20] Risk factors for stress fractures in athletes are summarized in Box 1. 
| Diagnosis | | |
Stress fracture should be suspected in athletes with a drastic recent increase in physical activity or repeated excessive activity with limited rest periods. [21],[22],[23],[24] Pain of insidious onset, particularly with mobilization, is the most common presenting symptom (81%). Athletes often do not recollect a specific inciting event or injury to the area. Initially, the pain typically occurs only during the sport activity. If the fracture is not attended to, the athlete will progress to experience pain with routine ambulation or even at rest. It is always important to elicit a history regarding predisposing factors to stress fractures especially a recent change in training patterns. It is important in female athletes in particular to inquire about dietary intake and menstrual dysfunction. Although stress fractures mostly occur in bones of the lower limb, any upper limb pain or rib pain in athletes involved in throwing or other upper limb sports should raise suspicion of stress fracture.
The classic physical examination finding is focal tenderness. Swelling and warmth can also be present at the site of the fracture. However, it is not a requisite for the diagnosis. [22],[23]
Diagnosis of stress fractures can be challenging. Medial tibial stress syndrome; previously called shin splints; is a common condition that should be distinguished from tibial stress fractures. Medial tibial stress syndrome is characterized by diffuse nonlocalized tenderness along the posteromedial, mid-to distal part of the tibia and a lack of edema. [24] Other differential diagnosis may also include 10 dinopathy, compartment syndrome, nerve or artery entrapment syndrome and malignancies, such as osteosarcoma and ewing sarcoma. [10]
| Imaging | | |
Early diagnosis of stress fractures through correct imaging reduces morbidity and avoids unnecessary time out from training or sport participation. If the stress fracture is suspected on the basis of clinical findings, Plain radiographs should be the first imaging modality considered because of its availability and low cost. [25] Plain radiographs often appear initially normal despite clinical symptoms and signs suggestive of stress fracture but is more likely to become positive over time (e.g. initial sensitivity of 10%; sensitivity of 30-70% after 3 weeks). [6],[22],[26] If the fracture is evident on plain radiographs, further imaging is usually not needed except for operative planning of fractures at high-risk of nonunion.
Triple-phase bone scintigraphy is sensitive for stress fractures (74-100%) [22],[27] but not specific because increased uptake of radioisotopes is also found in infection, inflammatory conditions, and cancer. With scintigraphy, nonlocalized increased uptake of radioisotopes is less likely to be caused by stress fracture. [23] Increased uptake, for instance, in the tibia that is spread diffusely along the tibia is more consistent with medial tibial stress syndrome rather than a stress fracture. [22],[24] It is worth remembering when requesting the bone scintigraphy that the radiation dose is 75 times the dose of a normal chest radiograph.
Despite limitations of cost and availability, magnetic resonance imaging (MRI) is more sensitive and specific than bone scintigraphy. [22],[23],[27] For this reason, MRI may be considered next when plain radiography is negative. In addition to not exposing patients to radiation and the ability to detect bone changes (stress response) earlier, MRI also provides information about surrounding soft tissues, which helps to exclude other differential diagnosis. [25],[28]
Computed tomography has limited usefulness in the diagnosis of stress fractures because of lower sensitivity and higher radiation exposure than other imaging modalities. [26],[27] It may be used in patients with displaced fractures for preoperative planning. [29]
Although musculoskeletal ultrasound is becoming more widely available, limited data exist for its use in diagnosing stress fractures. One study investigating its usefulness in the diagnosis of metatarsal stress fractures suggests that it may have a place as an alternative to MRI, but further research is needed. [30] The potential advantages of ultrasound include no radiation exposure and low cost, but additional studies are usually needed. An algorithm for the diagnosis of stress fractures in athletes is depicted on Diagram 1. 
| Treatment | | |
Most stress fractures can be treated conservatively by stopping the stressing activity; the more serious the injury, the longer the time to rest the limb. [31] Stress fractures can be divided into low-risk or high-risk fractures. Low-risk fractures encompass all nondisplaced fractures in regions of good blood supply and along the lines of the compression side of the bone. Therefore, they are at low-risk of nonunion. High-risk fractures carry a high-risk of avascular necrosis, nonunion or delayed union because of their location on the tension side of the bone; as in superolateral femoral neck or anterior tibial shaft fractures; or have a poor blood supply; as in talus and navicular fractures. These often require orthopedic surgeon consultation for possible surgical intervention. Operative treatment aims to obtain fracture union and enhance a timely return to sport. Common locations of high-risk fractures in the athletic population are shown in Box 2. 
| Prevention | | |
Although various methods have been proposed to prevent stress fractures in athletes, few have been validated to justify definitive recommendations. [6],[32],[33],[34] Stress fractures can be reduced by dealing with modifiable risk factors. Optimal nutrition for athletes, particularly female athletes, cannot be overemphasized. Adequate intake of calcium and Vitamin D are equally important. Other adjuncts such as shock-absorbing shoe inserts or other orthotics may play a role. [32]
Modification of training schedules may reduce the incidence of stress fractures, but specific training programs may need individualization. Two randomized trials found that leg muscle stretching during warm-up before exercise had no significant effect on preventing stress fractures. [32] The use of periodization as a training method where a training is increased over a 3 weeks-period, followed by a relative rest week allows subsequent metabolic adaptation to occur and may minimize the risk of developing a stress fracture in athletes. Periodization was first used in the training of military recruits and found to reduce stress fractures risk from 7% to 3.8%, after controlling for other variables. [35]
| Conclusion | | |
Stress fractures are a relatively common entity in athletes, particularly in long-distance runners. Physicians and health care providers should maintain a high index of suspicion for stress fractures in athletes in concert with obtaining sufficient radiological imaging. Early recognition and timely treatment reduce athletic morbidity and allow early return to high-level activity. High-risk stress fractures are associated with an increased risk of complications and should be evaluated by an orthopedic surgeon.
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