- Discussion:
- occur as the result of repetitive loading below yeild strength & are most common in lower extremity (metatarsals > calcaneus > tibia);
- Matheson, et al.: 370 athletes with stress fractures tibia (49.1%), tarsals (25.3%), metatarsals (8.8%) and bilateral stress fractures in 16.6% of cases;
- focal structural & muscle weakness & repetitive muscle pull are common;
- common in athletes, esp in white women, with advancing age, and w/ underlying metabolic bone diseases;
- differential dx:
- predisposing factors:
- menstrual irregularity, osteoporosis, diabetic or idiopathic neuropathy, smoking and alcohol intake, hypothyroidism, anorexia nervosa,
Paget's disease, and rheumatoid arthritis;
- progression of stress fractures:
- stage I - crack initiation: areas of stress concentration
- stage II - crack propagation: no repair or more damage than repair
- stage III - final fracture: cracks coalesce, enlarge, ultimate failure
- history:
- 1855 – Breithaupt described foot pain and swelling in military recruits
- 1897 – Stechow recognized “march fracture” on radiographs
- 1921 – Deutschlander reported six cases in civilian women
- 1956 – Devas and Sweetnam noted fibula stress fractures in athletes
- Stress fractures in athletes. A study of 320 cases.
- Work Up:
- endocrine considerations:
- menstrual irregularity
- hyperparathyroidism (need to r/o hypercalcemia);
- bone density study: (dual X-ray absorptiometry);
- Specific Types of Stress Frx:
- sacral stress fractures:
- reference:
- Jogger's fracture and other stress fractures of the lumbo-sacral spine.
- pubic stress frx:
- patients will note groin pain;
- diff dx includes hernia and partial avulsion of the rectus abdominus;
- bone scan may assist in the diagnosis;
- references:
- Stress fractures of the pubic ramus. A report of twelve cases.
- Osteitis pubis in athletes. Infection, inflammation or injury?
- Abdominal musculature abnormalities as a cause of groin pain in athletes.
- Osteitis pubis, Tc 99m MDP, and professional hockey players.
- femoral neck stress frx
- tibial stress frx
- shin splints
- foot and ankle stress frx:
- risk factors: pronated feet, cavus feet, and increased external tibial torsion are common risk factors;
- specific types of frx:
- distal fibular and medial malleolar frx: uncommon but do occur;
- calcaneal fatigue fractures
- forefoot & midfoot stress frx
- navicular stress frx
- metatarsal stress frx
- references:
- Diagnostic dilemmas in foot and ankle injuries.
- Stress fracture of the medial malleolus.
- Fatigue fractures of the foot and ankle in the athlete.
- Insufficiency stress fractures of the foot and ankle in postmenopausal women.
- Epidemiology of metatarsal stress fractures versus tibial and femoral stress fractures during elite training.
Review Article: Stress Fractures: Current Concepts.
The long-term followup of soldiers with stress fractures.
Recurrent stress fractures in military recruits. One-year follow-up of 66 recruits.
External rotation of the hip. A predictor of risk for stress fractures.
Stress fractures in young athletes.
Stress Fractures around the Knee in Elderly Patients. A Cause of Acute Pain in the Knee.
Upper-extremity Stress Fractures: Distribution and Causative Activities in 70 Patients
The Comprehensive Description of Stress Fractures: A New Classification System