Stress Fractures in Sport

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This entry is adapted from the peer-reviewed paper 10.3390/medicina57030223

The term stress fracture is familiar to many doctors, therapists and athletes. Stress fractures, either partial or complete, are common overuse injuries caused by a repetitive submaximal bone loading. The location of the stress fracture varies from sport to sport, but is most commonly observed in the lower extremities. They are particularly common in the physically active individuals including but not limited to track and field athletes, long distance runners, dancers, and military recruits.

bones metabolism sport sex stress fracture

1. Risk Factors or Risk Situations for a Stress Fracture

The majority of stress fractures occur among persons with normal bones, no acute injury and who are undergoing physical activity to which they are unaccustomed ^[1]^[2]. Both biological and biomechanical risk factors contribute to the onset of stress fractures ^[3]^[4]. Stress fractures have also been shown to frequently occur among persons routinely engaged in vigorous weight-bearing activities such as long-distance running ^[5]^[6]. The underlying pathophysiologic process is believed to be related to repetitive mechanical loading of the bone secondary to physical activity, stimulating an incomplete remodelling response ^[7]^[8]^[9].

There are numerous risk factors for stress fractures that have been identified in the literature ^[10]. 25(OH)D deficiency is, however, only one of these many factors. Well-documented risk factors include female sex, white ethnicity, older age, taller stature, lower aerobic fitness, prior physical inactivity, greater amounts of current physical training, thinner bones, cigarette smoking, 25(OH)D deficiency, iron deficiency, menstrual disturbances, and inadequate intake of 25(OH)D and/or calcium ^[11]^[12]. Table 1 presents the potential risk factors for a stress fracture.

Table 1. Potential risk factors for stress fractures.

Intrinsic Factors
Demographic characteristics	Female sex
	Age, with athletes over 40 and under 18 most at risk
	Race (other than white)
Anatomic factors	High foot arches
	Uneven leg and/or foot alignment
	Flat feet (pes planus)
	Knock-knees
	High quadriceps angles
	Leg length discrepancies
Bonce characteristics	Geometry
	Low density
	Uneven leg and/or foot alignment
Physical fitness	Lower aerobic fitness
	Lower muscle strength
	Lower muscle endurance
	Lower flexibility
	Body composition
	Body stature
Health risk behaviors	Sedentary lifestyle
	Tobacco use
	History of injury, stress fracture
	Low calcium intake
	Low protein intake
	High caffeine intake
	Prolonged intake of certain medicaments or drugs
Extrinsic Factors
Type of activity/sport	Track and field
	Dance
	Soccer
	Basketball
	Military basic training
Physical training	High amount of training
	High duration of training
	High frequency of training
	High intensity of training
Equipment	Shoes
	Boots
	Insoles
	Orthotic inserts
Environment	Road
	Trail
	Track

2. Symptoms of Stress Fractures

An athlete with a stress fracture typically reports localized pain that gradually worsens, most commonly in the lower extremity. Additionally, athletes experiencing a stress fracture have also reported pain that is aggravated by physical activity and relieved by rest. Athletes with a stress fracture usually recount a history of a recent increase in physical activity or the beginning of a new activity or some other change in their routine. They complain about a nagging and aching pain that is felt deep within the foot, toe, ankle, shin, hip, or arm. A pain localized in a particular area, such as the foot, ankle, or hip, appears in the evening and is often associated with a stress fracture, even if the pain is not debilitating during sports activities. Pain that resumes or remains constant despite taking time off to rest and/or using rest, ice, compression and elevation may be due to a stress fracture.

3. Diagnosis of a Stress Fracture

The diagnosis of a stress fracture is based on history and selected diagnostic imaging ^[10]. The early detection of a bone stress injury before it becomes stress fracture is essential ^[4].

The evaluation of a runner with a suspected stress fracture needs to include completing an appropriate history and physical examination ^[3]^[4]. Both the history and the accurate physical examination of the athlete provide the foundation for diagnosing a stress fracture ^[3]^[4].

The affected area to test should be examined for pain, tenderness, and swelling, as well for as any associated risk factors for a stress fracture such as weak muscles and/or bone misalignments ^[13]^[14]. Accurate palpation elicits localized tenderness over a bone. Additionally, localized swelling and erythema may be observed ^[13].

Simple clinical tests can assist in the diagnosis, but more definitive imaging tests will eventually be needed to be conducted when a stress fracture is suspected ^[11]. In case of positive signs during a physical examination, radiographs are indicated for confirmation of diagnosis. When a stress fracture is suspected, a plain radiography should be obtained initially and, if negative, may be repeated after two to three weeks for greater accuracy ^[13]. However, radiologic signs depend on the time from the onset of symptoms and the type of bone affected. Stress fractures often do not show up on X-ray right away. Radiographic findings may include early lucent zones, periosteal new bone formation, focal sclerosis, endosteal callous, or later fractures or cortical cracks ^[15]^[16].

At the onset of symptoms, radiographs may be negative, and radiologic signs, if they become evident, may take several weeks to evolve ^[15]^[16]^[17]^[18]. Continued pain may warrant advanced imaging, such as scintigraphy or magnetic resonance imaging (MRI) ^[19]. While they have clinical specificity, radiographs lack sensitivity. Bone scans, on the other hand, have a superior sensitivity, but they lack specificity ^[20]^[21], and should not be used alone to make the diagnosis of a stress fracture ^[21]. Therefore, other types of diagnostic testing such as MRI, computerized tomography (CT) scans, ultrasound, or Technetium-99 bone scans may be used to confirm a suspected stress fracture diagnosis ^[4]. X-ray can be used to detect older stress fractures that have partially healed, and/or stress fractures that have progressed to a non-union (hairline) or a displaced fracture. If an urgent diagnosis is needed, triple-phase bone scintigraphy or MRI should be considered. Both modalities have a similar sensitivity, but MRI has a greater specificity ^[13].

References

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Song, S.H.; Koo, J.H. Bone stress injuries in runners: A review for raising interest in stress fractures in Korea. J. Korean Med. Sci. 2020, 35, e38.
Kiel, J.; Kaiser, K. Stress Reaction and Fractures; StatPearls Publishing: Treasure Island, FL, USA, 2020.
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Daffner, R.H.; Pavlov, H. Stress fractures: Current concepts. Am. J. Roentgenol. 1992, 159, 245–252.
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Greaney, R.B.; Gerber, F.H.; Laughlin, R.L.; Kmet, J.P.; Metz, C.D.; Kilcheski, T.S.; Rao, B.R.; Silverman, E.D. Distribution and natural history of stress fractures in U.S. Marine recruits. Radiology 1983, 146, 339–346.
Roub, L.W.; Gumerman, L.W.; Hanley, E.N.; Clark, M.W.; Goodman, M.; Herbert, D.L. Bone stress: A radionuclide imaging perspective. Radiology 1979, 132, 431–438.
Jacobs, J.M.; Cameron, K.L.; Bojescul, J.A. Lower extremity stress fractures in the military. Clin. Sports Med. 2014, 33, 591–613.
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1. Risk Factors or Risk Situations for a Stress Fracture

2. Symptoms of Stress Fractures

3. Diagnosis of a Stress Fracture

References