Diagnosis and management of bone stress injuries of the lower limb in athletes (original) (raw)
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Stress and Insufficiency Fractures
Clinical Reviews in Bone and Mineral Metabolism, 2017
Stress fractures are most common in athletes and military recruits but also occur in patients with underlying metabolic bone disease (insufficiency fractures). Stress fractures are most frequent in the lower extremities and more common in women. The female athlete triad is an important risk factor. At the cellular level, the osteocyte may be important in the detection of stress fractures. Further, osteocytes are probably important in the healing of stress fractures. In patients with recurrent stress fractures, a biochemical evaluation for underlying metabolic bone disease should be undertaken. Prevention includes avoidance of sudden increases in the exercise, the use of proper footwear, avoidance of rough and hilly surfaces, and adequate nutrition. In premenopausal women with persistent amenorrhea and hypoestrogenism, estrogen replacement should be considered. Altering the mechanics of running might decrease the risk in some patients. In the patient with a stress fracture, the offending activity must be stopped for the fracture to heal. In some high-risk stress fractures, orthopedic surgery is advised. There is no specific drug therapy. Stress fractures are also associated with several metabolic bone diseases which are highlighted in this review with clinical vignettes. Diagnosis and management of these conditions is critical in the treatment of these patients.
Stress Fractures: Diagnosis, Treatment, and Prevention
S tress fractures are common injuries that begin with repetitive and excessive stress on the bone. This leads to the acceleration of normal bone remodeling, the production of microfractures (caused by insufficient time for the bone to repair), the creation of a bone stress injury (i.e., stress reaction), and, eventually, a stress fracture. 1,2 In contrast, pathological (insufficiency) fractures occur under normal stress in bone weakened by a tumor, infection, or osteoporosis. 1,2
Calcified Tissue International, 1998
Bone remodeling may be involved in the pathogenesis of stress fractures in athletes. We conducted a 12month prospective study to evaluate bone turnover in 46 female and 49 male track and field athletes aged 17-26 years (mean age 20.3; SD 2.0) 20 of whom developed a stress fracture. Baseline levels of bone turnover were evaluated in all athletes and monthly bone turnover levels were evaluated in a subset consisting of the 20 athletes who sustained a stress fracture and a matched comparison group who did not sustain a stress fracture. Bone formation was assessed using serum osteocalcin (OC) measured by human immunoradiometric assay and bone resorption by urinary excretion of pyridinium cross-links (Pyr and D-Pyr); high performance liquid chromatography and N-telopeptides of type 1 collagen (NTx) using ELISA assay. Athletes who developed stress fractures had similar baseline levels of bone turnover compared with their nonstress fracture counterparts (P > 0.10). Results of serial measurements showed no differences in average levels of Pyr, D-Pyr, or OC in those who developed stress fractures (P ס 0.10) compared with the control group. In the athletes with stress fractures, there was also no difference in bone turnover levels prior to or following the onset of bony pain. Our results show that single and multiple measurements of bone turnover are not clinically useful in predicting the likelihood of stress fractures in athletes. Furthermore, there were no consistent temporal changes in bone turnover associated with stress fracture development. However, our results do not negate the possible pathogenetic role of local changes in bone remodeling at stress fracture sites, given the high biological variability of bone turnover markers and the fact that levels of bone turnover reflect the integration of all bone remodeling throughout the skeleton.
Stress fractures in the lower extremity
European Journal of Radiology, 2007
Stress fractures are fatigue injuries of bone usually caused by changes in training regimen in the population of military recruits and both professional and recreational athletes. Raised levels of sporting activity in today's population and refined imaging technologies have caused a rise in reported incidence of stress fractures in the past decades, now making up more than 10% of cases in a typical sports medicine practice.
Stress fractures: concepts and therapeutics
The Journal of Clinical Endocrinology & Metabolism, 2016
Context: Stress fractures are repetitive use injuries in which recurrent strains lead to material fatigue and microarchitectural discontinuities. They account for up to 20% of athletic injuries, more often in women and in the setting of track-and-field events. In women, menstrual disturbances, low body mass index, low energy intake, and sometimes low bone mass, may be contributing factors. There are no standard protocols for evaluation or management of stress fractures. Evidence Acquisition: Available literature published in English was retrieved using the following terms: stress fractures; fractures; osteoporosis, athletes, premenopausal women, and athletic triad; through PubMed. Reviews, original reports, and case reports were all included. Evidence Synthesis: Despite lack of consistency among the publications, a phenotype emerges, namely of individuals whose bone mineral density is reduced along with low intake of dietary calcium and low circulating levels of 25-hydroxy vitamin D. Limited experience suggests that calcium and vitamin D supplementation might be helpful. Bisphosphonates or teriparatide may accelerate fracture healing in special circumstances. Conclusions: Most individuals who experience a stress fracture are young and healthy and do not appear to have an underlying metabolic bone disease. On the other hand, the presence of low bone mass and hormonal disturbances in some afflicted individuals might identify a cohort who needs endocrinological attention. Prospective, well-designed studies of stress fractures are needed to elucidate further underlying pathophysiological elements that predispose such individuals. Guidelines for prevention and treatment may follow from such well-controlled studies.
Current Concepts Review: Stress Fractures of the Foot
Foot & Ankle International
Stress fractures are debilitating injuries that occur in all types of patient populations, ranging from military recruits and athletes to patients with chronic medical conditions, such as rheumatoid arthritis and metabolic bone disease. Because of the repetitive stress of endurance training, stress fractures are more frequent in the athletic population than the general public. The high forces associated with weightbearing help explain why they occur most frequently in the lower extremity of athletes involved in sports such as basketball, track and field, soccer, lacrosse, and ballet. In a review of 320 athletes with stress fractures, Matheson et al.22 found that most (49%) were in the tibia, followed by the tarsals (25.3%); the metatarsals were the least frequently involved (8.8%). A stress fracture is any fracture or microfracture that occurs as the result of repetitive loading to the bone rather than from a single traumatic event. A stress fracture can occur as the result of a marked increase in the load on a normal bone, such as may occur when a military recruit enters “bootcamp” and begins his or her new training regimen. Stress fractures also can occur from normal loading patterns in bone that is abnormally weak because of chronic diseases, such as rheumatoid arthritis or long-term corticoidsteroid use. The location of the stress fracture is dictated by the precipitating activity and the characteristic manner in which the force is absorbed in each person’s foot. The etiology of these injuries is complicated but can be divided into intrinsic and extrinsic factors, which can help explain the pathology and determine subsequent treatment options.14 Intrinsic factors include an excessively high arch, leg-length discrepancies, and excessive forefoot varus position,19 bone