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Stress Fractures

- 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.

The effect of pretraining sports activity on the incidence of stress fractures among military recruits. A prospective study.

Stress fractures in young athletes.

Stress Fractures around the Knee in Elderly Patients. A Cause of Acute Pain in the Knee.

MRI in stress fracture.   

Stress fractures and stress reactions of the diaphyseal femur in collegiate athletes: an analysis of 25 cases

Epidemiology of metatarsal stress fractures versus tibial and femoral stress fractures during elite training

Upper-extremity Stress Fractures: Distribution and Causative Activities in 70 Patients

The Comprehensive Description of Stress Fractures: A New Classification System