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Malliaropoulos N, Bikos G, Tsifountoudis I, Alaseirlis D, Christodoulou D, Padhiar N, Maffulli N. Therapeutic ultrasound related pain threshold in elite track & field athletes with tibial bone stress injuries. Surgeon 2023; 21:225-229. [PMID: 35927163 DOI: 10.1016/j.surge.2022.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Revised: 06/15/2022] [Accepted: 06/23/2022] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Tibial stress injuries are challenging in terms of early diagnosis, management strategy, and safe return-to-play. In the present study, pain production associated with the application of therapeutic ultrasound (TUS) was used as a primary diagnostic tool to assess tibial bone stress injuries, and the sensitivity of this procedure was compared with Magnetic Resonance Imaging (MRI). SUBJECT AND METHODS The study was designed as a retrospective analysis of prospectively collected data on tibial bone stress injuries in elite Track and field athletes attending the National Track and Field Athletics Centre in Thessaloniki, Greece, in the period 1995-2007. All patients underwent evaluation by TUS, and the sensitivity of the procedure was compared with MRI. RESULTS Four of 29 athletes showed a positive TUS examination for stress injury while MRI showed normal findings. Additionally, 5 athletes evidenced MRI findings typical of a tibial bone stress injury, while TUS evaluation was negative. Using MRI as the standard, TUS displayed a sensitivity of 79.2%. CONCLUSION Therapeutic ultrasound is a reproducible modality with satisfactory reliability and sensitivity related to MRI, and could represent a useful tool for clinicians to primarily assess suspected tibial bone stress injuries in high qualification Track and Field athletes.
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Affiliation(s)
- Nikolaos Malliaropoulos
- Sports and Exercise Medicine Clinic, Asklipiou, Thessaloniki, Greece; Sports Clinic, Rheumatology Department, Barts Health NHS Trust, London, UK; Centre for Sports and Exercise Medicine, Queen Mary, University of London, London, UK.
| | - Georgios Bikos
- Euromedica-Arogi Rehabilitation Clinic, Pylaia, Thessaloniki, Greece.
| | | | - Dimosthenis Alaseirlis
- General Clinic-Euromedica, Thessaloniki, Greece; First Department of Orthopaedic Surgery, Aristotle University of Thessaloniki, Greece.
| | | | - Nat Padhiar
- Centre for Sports and Exercise Medicine, Queen Mary, University of London, London, UK; London Sports Care, BMI London Independent Hospital, London, UK.
| | - Nicola Maffulli
- Centre for Sports and Exercise Medicine, Queen Mary, University of London, London, UK; First Department of Orthopaedic Surgery, Aristotle University of Thessaloniki, Greece; Department of Orthopaedics, School of Medicine, Surgery and Dentistry, Salerno, Italy; Institute of Science and Technology in Medicine, Keele University School of Medicine, Stoke on Trent, United Kingdom.
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2
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Kaiser PB, Guss D, DiGiovanni CW. Republication of "Stress Fractures of the Foot and Ankle in Athletes". FOOT & ANKLE ORTHOPAEDICS 2023; 8:24730114231195045. [PMID: 37590306 PMCID: PMC10426306 DOI: 10.1177/24730114231195045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/19/2023] Open
Abstract
Stress fractures of the foot and ankle are common injuries in athletes. Management differs considerably based on fracture location and predisposing factors. Repetitive loading of the foot and ankle in athletes should result in physiologic bone remodeling in accordance with Wolff's law. However, when there is not sufficient time for complete healing to occur before additional loads are incurred, this process can instead lead to stress fracture. Assessment of the athlete's training regimen and overall bone health is paramount to both the discovery and treatment of these injuries, although diagnosis is often delayed in the setting of normal-appearing initial radiographs. While most stress fractures of the foot or ankle can usually be treated nonoperatively with a period of activity modification, fractures in certain locations are considered "high risk" due to poor intrinsic healing and may warrant more proactive operative management.
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Affiliation(s)
- Philip B Kaiser
- Harvard Combined Orthopaedic Surgery Residency Program, Boston, MA, USA
| | - Daniel Guss
- Harvard Combined Orthopaedic Surgery Residency Program, Boston, MA, USA
- Massachusetts General Hospital, Boston, MA, USA
- Newton-Wellesley Hospital, Newton, MA, USA
| | - Christopher W DiGiovanni
- Harvard Combined Orthopaedic Surgery Residency Program, Boston, MA, USA
- Massachusetts General Hospital, Boston, MA, USA
- Newton-Wellesley Hospital, Newton, MA, USA
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3
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Schowalter S, Le B, Creps J, McInnis KC. Rib Fractures in Professional Baseball Pitchers: Mechanics, Epidemiology, and Management. Open Access J Sports Med 2022; 13:89-105. [PMID: 36248020 PMCID: PMC9563740 DOI: 10.2147/oajsm.s288882] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Accepted: 09/14/2022] [Indexed: 11/21/2022] Open
Abstract
Pitching is a complex kinetic chain activity requiring the transfer of energy from the lower body, through the core and trunk, and finally through the arm to generate explosive acceleration of the baseball. As a result, large forces are generated in the trunk musculature and rib attachments from the late cocking phase of pitching through deceleration. The repetitive cumulative load and high pitch velocities put professional pitchers at risk of rib stress fracture. Given the potential for a prolonged recovery course and high rate of recurrence, early recognition of rib bone stress injury is critical to optimize care. Identifying torso strength imbalances, suboptimal pitching biomechanics (such as late or inadequate pelvic rotation), as well as metabolic deficiencies that may adversely affect bone health are essential to expedite safe return to play and prevent future injury. In this review, we discuss risk factors, mechanism of injury, typical clinical presentation, diagnostic imaging findings, and propose treatment and prevention strategies for rib stress fractures in overhand pitchers.
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Affiliation(s)
- Sean Schowalter
- Department of Physical Medicine and Rehabilitation, Harvard Medical School, Spaulding Rehabilitation Hospital, Charlestown, MA, USA,Correspondence: Sean Schowalter, Department of Physical Medicine and Rehabilitation, Harvard Medical School, Spaulding Rehabilitation Hospital, 300 1st Avenue, Charlestown, MA, 02129, USA, Tel +1 617 952 5000, Email
| | - Bryan Le
- Department of Physical Medicine and Rehabilitation, Harvard Medical School, Spaulding Rehabilitation Hospital, Charlestown, MA, USA
| | - James Creps
- Sports Medicine Service, Boston Red Sox, Boston, MA, USA
| | - Kelly C McInnis
- Department of Physical Medicine and Rehabilitation, Harvard Medical School, Spaulding Rehabilitation Hospital, Charlestown, MA, USA,Division of Sports Medicine, Massachusetts General Hospital, Boston, MA, USA
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Rosenthal MD, Rauh MJ, Cowan JE. Prospective Assessment of Clinical Tests Used to Evaluate Tibial Stress Fracture. Orthop J Sports Med 2022; 10:23259671221122356. [PMID: 36147792 PMCID: PMC9486277 DOI: 10.1177/23259671221122356] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2022] [Accepted: 06/09/2022] [Indexed: 12/04/2022] Open
Abstract
Background: Tibial stress fracture (SFx) is the most common SFx of the lower extremity.
Presently, diagnostic accuracy of clinical examination techniques for tibial
SFx remains suboptimal. Purpose: To assess the diagnostic effectiveness of 5 clinical tests for tibial SFx
individually versus a test item cluster. Study Design: Cohort study (diagnosis); Level of evidence, 3. Methods: A total of 50 patients with tibial pain (17 with bilateral symptoms) were
assessed with 5 clinical examination tests (tibial fulcrum test, focal
tenderness to palpation, heel percussion test, therapeutic ultrasound test,
and 128-Hz tuning fork test) before they underwent diagnostic imaging
(radionuclide bone scan). The application of the clinical tests was
counterbalanced to minimize the likelihood of carryover effects. Patients
provided a pain rating immediately before and after the application of each
clinical test. Results: The prevalence of tibial SFx among the study participants was 52.2%. High
levels of specificity were produced by the therapeutic ultrasound test
(93.8%), tuning fork test (90.6%), and percussion test (90.6%). The fulcrum
test had moderate to high specificity (84.4%). All tests demonstrated low
levels of sensitivity, with the highest levels found for focal tenderness to
palpation (48.6%) and fulcrum (45.7%). The fulcrum test provided the highest
positive likelihood ratio (2.93), followed by the therapeutic ultrasound
test (2.30). The fulcrum test had the lowest negative likelihood ratio
(0.64), with the focal tenderness to palpation and tuning fork tests having
negative likelihood ratios >1.0. Combinations of these clinical tests did
not improve the prediction of tibial SFx above that observed among the
individual tests. Conclusion: The clinical tests evaluated were generally highly specific, but all had low
sensitivity. The fulcrum test provided the highest level of diagnostic
accuracy; however, it was inadequate for definitive clinical management.
Combining tests did not improve the diagnostic accuracy of tibial SFx.
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Affiliation(s)
| | | | - James E Cowan
- US Army-Baylor University, Fort Sam Houston, San Antonio, Texas, USA
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5
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Hoenig T, Ackerman KE, Beck BR, Bouxsein ML, Burr DB, Hollander K, Popp KL, Rolvien T, Tenforde AS, Warden SJ. Bone stress injuries. Nat Rev Dis Primers 2022; 8:26. [PMID: 35484131 DOI: 10.1038/s41572-022-00352-y] [Citation(s) in RCA: 43] [Impact Index Per Article: 21.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/11/2022] [Indexed: 01/11/2023]
Abstract
Bone stress injuries, including stress fractures, are overuse injuries that lead to substantial morbidity in active individuals. These injuries occur when excessive repetitive loads are introduced to a generally normal skeleton. Although the precise mechanisms for bone stress injuries are not completely understood, the prevailing theory is that an imbalance in bone metabolism favours microdamage accumulation over its removal and replacement with new bone via targeted remodelling. Diagnosis is achieved by a combination of patient history and physical examination, with imaging used for confirmation. Management of bone stress injuries is guided by their location and consequent risk of healing complications. Bone stress injuries at low-risk sites typically heal with activity modification followed by progressive loading and return to activity. Additional treatment approaches include non-weight-bearing immobilization, medications or surgery, but these approaches are usually limited to managing bone stress injuries that occur at high-risk sites. A comprehensive strategy that integrates anatomical, biomechanical and biological risk factors has the potential to improve the understanding of these injuries and aid in their prevention and management.
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Affiliation(s)
- Tim Hoenig
- Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
| | - Kathryn E Ackerman
- Wu Tsai Female Athlete Program, Boston Children's Hospital, Boston, MA, USA.,Endocrine Unit, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Belinda R Beck
- School of Health Sciences & Social Work, Griffith University, Gold Coast, Queensland, Australia.,Menzies Health Institute Queensland, Gold Coast, Queensland, Australia.,The Bone Clinic, Brisbane, Queensland, Australia
| | - Mary L Bouxsein
- Endocrine Unit, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.,Department of Orthopedic Surgery, Harvard Medical School and Center for Advanced Orthopedic Studies, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - David B Burr
- Department of Anatomy, Cell Biology, and Physiology, Indiana University School of Medicine, Indiana University, Indianapolis, IN, USA.,Indiana Center for Musculoskeletal Health, Indiana University School of Medicine, Indiana University, Indianapolis, IN, USA
| | - Karsten Hollander
- Institute of Interdisciplinary Exercise Science and Sports Medicine, MSH Medical School Hamburg, Hamburg, Germany
| | - Kristin L Popp
- Endocrine Unit, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.,U.S. Army Research Institute of Environmental Medicine, Natick, MA, USA
| | - Tim Rolvien
- Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Adam S Tenforde
- Spaulding Rehabilitation Hospital, Department of Physical Medicine and Rehabilitation, Harvard Medical School, Charlestown, MA, USA.
| | - Stuart J Warden
- Indiana Center for Musculoskeletal Health, Indiana University School of Medicine, Indiana University, Indianapolis, IN, USA. .,Department of Physical Therapy, School of Health & Human Sciences, Indiana University, Indianapolis, IN, USA. .,La Trobe Sport and Exercise Medicine Research Centre, La Trobe University, Bundoora, Victoria, Australia.
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6
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Schaper M, Harcus J. Preliminary image findings of lower limb stress fractures to aid ultrasonographic diagnoses: A systematic review and narrative synthesis. ULTRASOUND (LEEDS, ENGLAND) 2021; 29:208-217. [PMID: 34777541 PMCID: PMC8579372 DOI: 10.1177/1742271x21995523] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Accepted: 01/21/2021] [Indexed: 11/15/2022]
Abstract
INTRODUCTION This systematic review investigates which image appearances are most common when diagnosing lower limb stress fractures using ultrasound imaging, with the aim of outlining an image critique guideline for operators to support confident diagnoses. METHOD A comprehensive literature search of medical databases and handsearching was undertaken to identify relevant studies. All studies were critically examined for quality using the CASP critical appraisal tool. Results from eight studies were combined and interpreted using a narrative synthesis. FINDINGS A clear outline of common stress fracture appearances using ultrasound were identified in a combined total of 119 participants. Each finding was ranked according to its popularity. Periosteal thickening (78/119) and cortical disruption/irregularity (83/119) were noted in all eight studies. Hypervascularity of the periosteum visualised by colour Doppler imaging (66/119) was reported in six of the eight studies. Soft tissue hypervascularity (13/119), bony callus formation (5/119) and cortical break (22/119) were seen in three studies. CONCLUSIONS Based on the findings, we offer a guideline of the most significant preliminary image findings to be utilised by operators when examining athletes suspected of having lower limb stress fractures. The results show a gap in research for evaluating changes in appearance depending on the injury severity. Further research into distinguishing stress fractures from pathological involvement may in future reduce reliance on plain film radiography.
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Affiliation(s)
| | - James Harcus
- Leeds Institute of Cardiovascular and Metabolic Medicine,
University of Leeds, Leeds, UK
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Nussbaum ED, Gatt CJ, Bjornarra J, Yang C. Evaluating the Clinical Tests for Adolescent Tibial Bone Stress Injuries. Sports Health 2021; 13:502-510. [PMID: 33576312 DOI: 10.1177/1941738120988691] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Tibial bone stress injuries are common among the athletic adolescent population. A thorough patient history and clinical examination are essential to identify the location and extent of injury. However, there has been little description or any validation of clinical tests to help guide clinicians. Consequently, a formal diagnosis is usually dependent on results from proper imaging. HYPOTHESIS Clinical examinations will be both highly sensitive and specific determining the incidence, grade, and location of tibial bone stress injury as compared with magnetic resonance imaging (MRI). STUDY DESIGN Case-control. LEVEL OF EVIDENCE Level 2. METHODS A total of 80 consecutive athletic adolescents, from various sports, with greater than 1-week history of shin pain were enrolled in this institutional review board-approved study. Exclusion criteria were age >19 years and history of traumatic injury. Patients underwent a standardized clinical examination, which included a fulcrum test (FT), tap/percussion test (TT), vibration test (VT) utilizing a 128-Hz tuning fork, weight bearing lunge test (WBLT) to determine degree of dorsiflexion range of motion (ROM), and vertical single leg hop test (VSLHT) for height, landing, and pain. Bilateral lower extremity MRI was completed on the same day as clinical evaluation and served as the injury reference. Sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) were calculated to evaluate each clinical examination for its ability to identify a bone stress injury. RESULTS A total of 159 tibiae in 80 patients were evaluated. No single test or combination of tests was both highly sensitive and specific. Individual clinical tests demonstrated sensitivity ranging from 0.11 to 0.72 and specificity ranging from 0.37 to 0.93. The VSLHT noting an increase in pain was the most sensitive test (0.72; 95% CI, 0.62-0.78); however, its specificity was only 0.37 (95% CI, 0.19-0.55), with a PPV of 0.84 (95% CI, 0.78-0.91) and NPV of 0.20 (95% CI, 0.089-0.31). The WBLT demonstrated a mean ROM of 8 cm, with side-to-side differences (range 0-4 cm) not influencing incidence of injury. Combinations of tests demonstrated low sensitivity (0.03-0.40), with better specificity (0.63-1.0). When considering ability to identify higher grades of injury (grade III/IV), all tests had a high NPV indicating that if clinical tests were negative, there was a high likelihood that the patient did not have a grade III or IV injury. CONCLUSION No single test or combination of tests was both highly sensitive and specific. Clinicians cannot solely rely on clinical examination for determining extent or severity of bone stress injury in the athletic adolescent population, but when combinations of tests are negative, there is likely not a high-grade bone stress injury. CLINICAL RELEVANCE Clinical tests utilized in the evaluation of adolescent tibial bone stress injury may help indicate the presence or absence of higher grade tibial bone stress injury.
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Affiliation(s)
- Eric D Nussbaum
- Department of Orthopaedic Surgery, Rutgers, Robert Wood Johnson Medical School, Somerset, New Jersey
| | - Charles J Gatt
- Department of Orthopaedic Surgery, Rutgers, Robert Wood Johnson Medical School, New Brunswick, New Jersey
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8
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Kim HJ, Park YH, Kim JY, Choi GW. Role of Ultrasound in Early Diagnosis of Stress Fracture: A Case Report of Bilateral Distal Fibular Stress Fracture in a Female Recreational Badminton Player. J Am Podiatr Med Assoc 2021; 111:462615. [PMID: 33690809 DOI: 10.7547/19-146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
A 34-year-old female recreational badminton player presented with left ankle pain 1 week after a recreational badminton game. She reported experiencing a similar pattern of pain in her right ankle 4 months before that had persisted for 3 months. On plain radiography, callus formation was evident on the right distal fibula, and a subtle lesion was observed on the left side. Ultrasound was performed with the clinical suspicion of bilateral, nonsimultaneous, distal fibular stress fracture. Focal hyperechoic thickening of the periosteum with irregularity and hypoechoic periosteal edema over the left distal fibula were identified. These findings were consistent with stress fracture, and an early phase of distal fibular stress fracture was diagnosed. This case report highlights that ultrasound can be an alternative modality to magnetic resonance imaging or bone scan scintigraphy for the early diagnosis of stress fracture.
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Abstract
The assessment of bone mainly relies on standard radiographs, CT, MRI, and bone scintigraphy depending on the anatomic region complexity and clinical scenario. Ultrasound (US), due to different acoustic impedance between soft tissues and the bone cortex, only allows the evaluation of the bone surfaces. Nevertheless, US can be useful in the evaluation of several bone disorders affecting the limbs as a result of its tomographic capabilities and high definition. This pictorial review article summarises our clinical experience in adults and reviews the literature on US bone examination. We first present the US appearance of normal bone and the main congenital anatomic variations, after which we illustrate the US findings of a variety of bone disorders. Although US has limits in bone assessment, its analysis must be a part of every musculoskeletal US examination.
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Affiliation(s)
- Stefano Bianchi
- CIM SA Cabinet Imagerie Médicale, 40a route de Malagnou, 1208, Geneva, Switzerland.
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10
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Nussbaum ED, Gatt CJ, Epstein R, Bechler JR, Swan KG, Tyler D, Bjornaraa J. Validation of the Shin Pain Scoring System: A Novel Approach for Determining Tibial Bone Stress Injuries. Orthop J Sports Med 2019; 7:2325967119877803. [PMID: 31696132 PMCID: PMC6822191 DOI: 10.1177/2325967119877803] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
Background The incidence of adolescent overuse injuries, including bone stress injuries (BSIs), is on the rise. The identification of a BSI in the early stages is key to successful treatment. The Shin Pain Scoring System (SPSS) was developed to aid clinicians in identifying patients with a BSI. Hypothesis The SPSS will correlate with magnetic resonance imaging (MRI) grading of a BSI in an adolescent population. Study Design Cohort study (diagnosis); Level of evidence, 2. Methods Enrolled in this study were 80 adolescent high school athletes between the ages of 13 and 18 years participating in a variety of sports with more than 1 week of atraumatic shin pain. The SPSS questionnaire was completed for each participant, and physical examination findings were recorded. Each question and physical examination item was allotted a point value, which totaled 29 points. Radiographs and MRI scans of both lower legs were obtained for each participant. The SPSS score was statistically analyzed using logistic regression, a classification matrix, and a 2 × 2 contingency table to evaluate validity and predictability. Results Logistic regression analysis of our data determined that 3 categories of SPSS scores provided the highest diagnostic value when compared with MRI grading based on the Fredericson classification (0-4). The SPSS correctly identified 43.5% of injuries for category 1 (MRI grades 0-1), 62.5% for category 2 (MRI grade 2), and 50.0% for category 3 (MRI grades 3-4). Overall, the SPSS correctly identified the degree of BSI in 54.4% of all tibias studied. Binary analysis for validity demonstrated a sensitivity of 96%, specificity of 26%, positive predictive value of 76%, and negative predictive value of 71% for the SPSS relative to the "gold standard" MRI results. Conclusion The SPSS is a potentially valid method to identify tibial BSIs, given the sensitivity and negative and positive predictive values. It also provides helpful categorization to alert clinicians to the presence of a BSI and direct further diagnostics and/or interventions. The SPSS should be considered as an additional tool to use when evaluating adolescents with atraumatic tibial BSIs.
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Affiliation(s)
- Eric D Nussbaum
- Department of Orthopaedic Surgery, Robert Wood Johnson Medical School, Rutgers University, New Brunswick, New Jersey, USA.,University Orthopaedic Associates, Somerset, New Jersey, USA
| | - Charles J Gatt
- Department of Orthopaedic Surgery, Robert Wood Johnson Medical School, Rutgers University, New Brunswick, New Jersey, USA
| | - Robert Epstein
- Department of Radiology, Robert Wood Johnson Medical School, Rutgers University, New Brunswick, New Jersey, USA.,University Radiology, New Brunswick, New Jersey, USA
| | - Jeffrey R Bechler
- Department of Orthopaedic Surgery, Robert Wood Johnson Medical School, Rutgers University, New Brunswick, New Jersey, USA.,University Orthopaedic Associates, Somerset, New Jersey, USA
| | - Kenneth G Swan
- Department of Orthopaedic Surgery, Robert Wood Johnson Medical School, Rutgers University, New Brunswick, New Jersey, USA.,University Orthopaedic Associates, Somerset, New Jersey, USA
| | - David Tyler
- Department of Statistics and Biostatistics, Rutgers University, New Brunswick, New Jersey, USA
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Lohrer H, Malliaropoulos N, Korakakis V, Padhiar N. Exercise-induced leg pain in athletes: diagnostic, assessment, and management strategies. PHYSICIAN SPORTSMED 2019; 47:47-59. [PMID: 30345867 DOI: 10.1080/00913847.2018.1537861] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
The purpose of this review is to describe and critically evaluate current knowledge regarding diagnosis, assessment, and management of chronic overload leg injuries which are often non-specific and misleadingly referred to as 'shin splints'. We aimed to review clinical entities that come under the umbrella term 'Exercise-induced leg pain' (EILP) based on current literature and systematically searched the literature. Specifically, systematic reviews were included. Our analyses demonstrated that current knowledge on EILP is based on a low level of evidence. EILP has to be subdivided into those with pain from bone stress injuries, pain of osteo-fascial origin, pain of muscular origin, pain due to nerve compression and pain due to a temporary vascular compromise. The history is most important. Questions include the onset of symptoms, whether worse with activity, at rest or at night? What exacerbates it and what relieves it? Is the sleep disturbed? Investigations merely confirm the clinical diagnosis and/or differential diagnosis; they should not be solely relied upon. The mainstay of diagnosing bone stress injury is MRI scan. Treatment is based on unloading strategies. A standard for confirming chronic exertional compartment syndrome (CECS) is the dynamic intra-compartmental pressure study performed with specific exercises that provoke the symptoms. Surgery provides the best outcome. Medial tibial stress syndrome (MTSS) presents a challenge in both diagnosis and treatment especially where there is a substantial overlap of symptoms with deep posterior CECS. Conservative therapy should initially aim to correct functional, gait, and biomechanical overload factors. Surgery should be considered in recalcitrant cases. MRI and MR angiography are the primary investigative tools for functional popliteal artery entrapment syndrome and when confirmed, surgery provides the most satisfactory outcome. Nerve compression is induced by various factors, e.g., localized fascial entrapment, unstable proximal tibiofibular joint (intrinsic) or secondary by external compromise of the nerve, e.g., tight hosiery (extrinsic). Conservative is the treatment of choice. The localized fasciotomy is reserved for recalcitrant cases.
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Affiliation(s)
- Heinz Lohrer
- a European SportsCare Network (ESN) - Zentrum für Sportorthopädie , Wiesbaden-Nordenstadt , Germany
| | | | - Vasileios Korakakis
- c Department of Rehabilitation , Aspetar, Orthopaedic and Sports Medicine Hospital , Doha , Qatar
| | - Nat Padhiar
- d William Harvey Research Institute, Centre for Sports & Exercise Medicine , Queen Mary University of London , London , UK
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12
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Champagne N, Eadie L, Regan L, Wilson P. The effectiveness of ultrasound in the detection of fractures in adults with suspected upper or lower limb injury: a systematic review and subgroup meta-analysis. BMC Emerg Med 2019; 19:17. [PMID: 30691395 PMCID: PMC6350304 DOI: 10.1186/s12873-019-0226-5] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2018] [Accepted: 01/10/2019] [Indexed: 01/20/2023] Open
Abstract
Background The aim of the present review is to assess the effectiveness of ultrasound (US) in the detection of upper and lower limb bone fractures in adults compared to a diagnostic gold standard available in secondary and tertiary care centres (e.g. radiography, CT scan or MRI). Methods The review followed PRISMA guidelines and used a database-specific search strategy with Medline, EMBASE and The Cochrane Library plus secondary sources (see supplementary material for completed PRISMA checklist). Diagnostic performance of ultrasound was assessed with a qualitative synthesis and a meta-analysis of two data subgroups. Results Twenty-six studies were included (n = 2360; fracture prevalence =5.3 % to 75.0%); data were organised into anatomical subgroups, two of which were subjected to meta-analysis. Sensitivity and specificity ranged from 42.11 − 100% and 65.0 − 100%, with the highest diagnostic accuracy in fractures of the foot and ankle. The pooled sensitivity and specificity of US was 0.93 and 0.92 for upper limb fractures (I2 = 54.7 % ; 66.3%), and 0.83 and 0.93 for lower limb fractures (I2 = 90.1 % ; 83.5%). Conclusion Ultrasonography demonstrates good diagnostic accuracy in the detection of upper and lower limb bone fractures in adults, especially in fractures of the foot and ankle. This is supported by pooled analysis of upper and lower limb fracture subgroups. Further research in larger populations is necessary to validate and strengthen the quality of the available evidence prior to recommending US as a first-line imaging modality for prehospital use. Trial registration The protocol is registered with the PROSPERO International register of systematic reviews: ID = CRD42017053640. Electronic supplementary material The online version of this article (10.1186/s12873-019-0226-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
| | - Leila Eadie
- Centre for Rural Health, University of Aberdeen, Inverness, Scotland, UK
| | - Luke Regan
- NHS Highland, Raigmore Hospital, Inverness, Scotland, UK
| | - Philip Wilson
- Centre for Rural Health, University of Aberdeen, Inverness, Scotland, UK
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13
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Nussbaum ED, Bjornaraa J, Gatt CJ. Identifying Factors That Contribute to Adolescent Bony Stress Injury in Secondary School Athletes: A Comparative Analysis With a Healthy Athletic Control Group. Sports Health 2019; 11:375-379. [PMID: 30645183 DOI: 10.1177/1941738118824293] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Bony stress injuries (BSIs) are common among adolescents involved in high school sports. A better understanding of factors that contribute to adolescent BSI is needed to target preventative measures. HYPOTHESIS Individuals who suffer a BSI will demonstrate significant differences in training methods, sleep, diet, and history of injury compared with a healthy, noninjured control group. STUDY DESIGN Descriptive epidemiologic study. METHODS Data from the National High School Stress Fracture Registry (NHSSFR), an internet-based adolescent BSI survey, were used to identify variables reported with adolescent (13-18 years of age) BSI. These findings were compared with a survey of 100 (50 males, 50 females) healthy athletic controls to identify significant differences between healthy adolescents and those with BSI. RESULTS A total of 346 stress fractures were reported in 314 (206 females, 108 males) athletes within the NHSSFR. Comparison with healthy control participants demonstrated multiple significant findings. In particular, body mass index was significantly lower for patients with BSI injury compared with controls (P < 0.001). Patients slept significantly less than the control group (7.2 vs 7.95 hours; F = 34.41; P < 0.001). Females also slept significantly less hours than males (7.2 vs 7.63 hours; F = 11.02; P < 0.001). Fifty-eight percent of those who reported a BSI did not engage in any weight training. Those with a BSI had significantly higher average stress ratings than control participants (1.67 vs 1.42; P < 0.001), and females also rated their stress levels significantly higher than males (1.8 vs 1.38; P < 0.001). A significant difference between patients with any BSI and control participants existed for history of "shin splints" (Pearson χ2 = 28.31; P < 0.001), and females also expressed having shin pain lasting for longer than 4 weeks (Pearson χ2 = 8.12; P < 0.001) and more often (Pearson χ2 = 5.84; P = 0.02) than males. There was also a significant difference between patients with BSI and control subjects regarding dairy intake (2.25 vs 2.69; F = 6.43; P = 0.01). CONCLUSION Findings revealed significant differences between those who reported a BSI relative to healthy athletic adolescents. These differences included body mass index, prior history of shin splints, involvement in weight training, amount of sleep, daily stress, and dairy intake. Preventive measures should be developed to address these areas to reduce the incidence of BSIs in the adolescent population.
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Affiliation(s)
- Eric D Nussbaum
- Department of Orthopaedic Surgery, Robert Wood Johnson Medical School, Rutgers, Somerset, New Jersey
| | - Jaynie Bjornaraa
- Doctor of Physical Therapy Program, St Catherine University, Minneapolis, Minnesota
| | - Charles J Gatt
- Department of Orthopaedic Surgery, Robert Wood Johnson Medical School, Rutgers, Somerset, New Jersey
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Kaiser PB, Guss D, DiGiovanni CW. Stress Fractures of the Foot and Ankle in Athletes. FOOT & ANKLE ORTHOPAEDICS 2018. [DOI: 10.1177/2473011418790078] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Stress fractures of the foot and ankle are common injuries in athletes. Management differs considerably based on fracture location and predisposing factors. Repetitive loading of the foot and ankle in athletes should result in physiologic bone remodeling in accordance with Wolff’s law. However, when there is not sufficient time for complete healing to occur before additional loads are incurred, this process can instead lead to stress fracture. Assessment of the athlete’s training regimen and overall bone health is paramount to both the discovery and treatment of these injuries, although diagnosis is often delayed in the setting of normal-appearing initial radiographs. While most stress fractures of the foot or ankle can usually be treated nonoperatively with a period of activity modification, fractures in certain locations are considered “high risk” due to poor intrinsic healing and may warrant more proactive operative management.
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Affiliation(s)
- Philip B. Kaiser
- Harvard Combined Orthopaedic Surgery Residency Program, Boston, MA, USA
| | - Daniel Guss
- Harvard Combined Orthopaedic Surgery Residency Program, Boston, MA, USA
- Massachusetts General Hospital, Boston, MA, USA
- Newton-Wellesley Hospital, Newton, MA, USA
| | - Christopher W. DiGiovanni
- Harvard Combined Orthopaedic Surgery Residency Program, Boston, MA, USA
- Massachusetts General Hospital, Boston, MA, USA
- Newton-Wellesley Hospital, Newton, MA, USA
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Abstract
OBJECTIVE To ascertain whether therapeutic ultrasound (TUS) can be used to assess the progression of conservative management in navicular stress injuries. DESIGN This is a prospective, clinical case series. Level of evidence IV. SETTING All participants were examined and followed up in a private Sports Injury Clinic. PARTICIPANTS Ten elite track and field athletes with severe dorsal midfoot pain over the navicular bone participated in this study. INTERVENTIONS All patients underwent both TUS and magnetic resonance imaging (MRI) evaluation. The painful threshold of TUS on initial evaluation was a mean of 0.707 ± 149 W/cm, and MRI detected a navicular stress injury in all patients. The athletes received conservative treatment and underwent sequential TUS evaluations at 4, 8, 12 and 16 weeks. MAIN OUTCOME MEASURES Therapeutic ultrasound pain threshold values were recorded, and the patients were additionally asked to grade local tenderness on a Visual Analogue Scale. Time to return to play was also recorded. RESULTS The level of pain produced by the application of TUS on a navicular stress fracture seemed to correlate well with Visual Analogue Scale scores and the grade of fracture demonstrated on MRI. The initial low TUS painful mean value increased to a normal mean value of 1.97 ± 0.067 W/cm by 16 weeks. When clinical and TUS findings had returned to normal, the patients were allowed to return to sports activities, with no recurrences experienced during the study period. CONCLUSIONS The production of pain associated with the application of TUS on a navicular stress fracture is a safe and reproducible method of monitoring the resolution of these fractures. We have used it successfully in making return-to-play decisions for elite level track and field athletes.
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Amoako A, Abid A, Shadiack A, Monaco R. Ultrasound-Diagnosed Tibia Stress Fracture: A Case Report. CLINICAL MEDICINE INSIGHTS-ARTHRITIS AND MUSCULOSKELETAL DISORDERS 2017; 10:1179544117702866. [PMID: 28469488 PMCID: PMC5390922 DOI: 10.1177/1179544117702866] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/13/2016] [Accepted: 02/28/2017] [Indexed: 12/28/2022]
Abstract
Stress fractures are a frequent cause of lower extremity pain in athletes, and especially in runners. Plain imaging has a low sensitivity. Magnetic resonance imaging (MRI) or bone scan scintigraphy is the criterion standard, but expensive. We present the case of a young female distance runner with left shin pain. Plain radiography was unremarkable. Ultrasound showed focal hyperechoic elevation of the periosteum with irregularity over the distal tibia and increased flow on Doppler. These findings were consistent with a distal tibia stress fracture and confirmed by MRI. Examination of our case will highlight the utility of considering an ultrasound for diagnosis of tibial stress fracture.
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Affiliation(s)
- Adae Amoako
- Departments of Acute Care and Physical Medicine and Rehabilitation, Mid-Atlantic Permanente Medical Group, Upper Marlboro, MD, USA
| | - Ayesha Abid
- Department of Family and Community Medicine, Penn State Milton S. Hershey Medical Center, Hershey, PA, USA
| | - Anthony Shadiack
- Department of Family Medicine, Ocala Health Family Medicine, Ocala, FL, USA
| | - Robert Monaco
- Department of Sports Medicine, The State University of New Jersey, New Brunswick, NJ, USA
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Roston AT, Wilkinson M, Forster BB. Imaging of rib stress fractures in elite rowers: the promise of ultrasound? Br J Sports Med 2017; 51:1093-1097. [DOI: 10.1136/bjsports-2016-096989] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/03/2017] [Indexed: 11/03/2022]
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18
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High-Risk Stress Fractures: Diagnosis and Management. PM R 2017; 8:S113-24. [PMID: 26972260 DOI: 10.1016/j.pmrj.2015.09.019] [Citation(s) in RCA: 59] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2015] [Revised: 09/22/2015] [Accepted: 09/25/2015] [Indexed: 12/11/2022]
Abstract
Stress fractures are common overuse injuries in athletes. They occur during periods of increased training without adequate rest, disrupting normal bone reparative mechanisms. There are a host of intrinsic and extrinsic factors, including biochemical and biomechanical, that put athletes at risk. In most stress fractures, the diagnosis is primarily clinical, with imaging indicated at times, and management focused on symptom-free relative rest with advancement of activity as tolerated. Overall, stress fractures in athletes have an excellent prognosis for return to sport, with little risk of complication. There is a subset of injuries that have a greater risk of fracture progression, delayed healing, and nonunion and are generally more challenging to treat with nonoperative care. Specific locations of high-risk stress fracture include the femoral neck (tension side), patella, anterior tibia, medial malleolus, talus, tarsal navicular, proximal fifth metatarsal, and great toe sesamoids. These sites share a characteristic region of high tensile load and low blood flow. High-risk stress fractures require a more aggressive approach to evaluation, with imaging often necessary, to confirm early and accurate diagnosis and initiate immediate treatment. Treatment consists of nonweight-bearing immobilization, often with a prolonged period away from sport, and a more methodic and careful reintroduction to athletic activity. These stress fractures may require surgical intervention. A high index of suspicion is essential to avoid delayed diagnosis and optimize outcomes in this subset of stress fractures.
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Smoliga JM, Wright AA, Hegedus EJ. Diagnostic Accuracy of Various Imaging Modalities for Suspected Lower Extremity Stress Fractures: Response. Am J Sports Med 2016; 44:NP33-4. [PMID: 27371676 DOI: 10.1177/0363546516655120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
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20
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Shemjaz AM. Diagnostic Accuracy of Various Imaging Modalities for Suspected Lower Extremity Stress Fractures: Letter to the Editor. Am J Sports Med 2016; 44:NP32-3. [PMID: 27371675 DOI: 10.1177/0363546516655118] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
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21
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Wright AA, Hegedus EJ, Lenchik L, Kuhn KJ, Santiago L, Smoliga JM. Diagnostic Accuracy of Various Imaging Modalities for Suspected Lower Extremity Stress Fractures: A Systematic Review With Evidence-Based Recommendations for Clinical Practice. Am J Sports Med 2016; 44:255-63. [PMID: 25805712 DOI: 10.1177/0363546515574066] [Citation(s) in RCA: 75] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND The literature is filled with conflicting findings regarding diagnostic accuracy and protocols for imaging suspected lower extremity stress fractures. The absence of systematic reviews on this topic has limited the development of evidence-based recommendations for appropriate imaging protocols in cases of suspected lower extremity stress fractures. PURPOSE To determine the diagnostic accuracy statistics of imaging modalities used to diagnose lower extremity stress fractures and to synthesize evidence-based recommendations for clinical practice. STUDY DESIGN Systematic review. METHODS A generic search strategy for published studies was performed using multiple databases. A study was eligible for inclusion if it met all of the following criteria: (1) at least 1 diagnostic imaging modality was studied, (2) at least 1 radiological reference standard was used, (3) the study reported or allowed computation of diagnostic accuracy statistics (sensitivity, specificity, positive likelihood ratio, negative likelihood ratio), (4) a full-text version was available, (5) the article was written in English, and (6) the study included lower extremity stress fractures. Studies that examined asymptomatic individuals or patients with fractures due to disease or pharmacologic intervention were excluded. RESULTS Reported sensitivity and specificity (95% CI) were as follows: For conventional radiography, sensitivity ranged from 12% (0%-29%) to 56% (39%-72%) and specificity ranged from 88% (55%-100%) to 96% (87%-100%). For nuclear scintigraphy (NS), sensitivity ranged from 50% (23%-77%) to 97% (90%-100%) and specificity from 33% (12%-53%) to 98% (93%-100%). For magnetic resonance imaging (MRI), sensitivity ranged from 68% (45%-90%) to 99% (95%-100%) and specificity from 4% (0%-11%) to 97% (88%-100%). For computed tomography, sensitivity ranged from 32% (8%-57%) to 38% (16%-59%) and specificity from 88% (55%-100%) to 98% (91%-100%). For ultrasound, sensitivity ranged from 43% (26%-61%) to 99% (95%-100%) and specificity from 13% (0%-45%) to 79% (61%-96%). CONCLUSION MRI was identified as the most sensitive and specific imaging test for diagnosing stress fractures of the lower extremity. When MRI is available, NS is not recommended because of its low specificity, high dosage of ionizing radiation, and other limitations. Conventional radiographs are likely to result in false negatives upon initial presentation, particularly in the early stages of stress fracture, and in some cases may not reveal an existing stress fracture at any time. A diagnostic imaging algorithm was developed with specific recommendations for cost-efficient imaging of low-risk and high-risk suspected stress fractures.
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Affiliation(s)
- Alexis A Wright
- Department of Physical Therapy, High Point University, High Point, North Carolina, USA
| | - Eric J Hegedus
- Department of Physical Therapy, High Point University, High Point, North Carolina, USA
| | - Leon Lenchik
- Department of Radiology, Wake Forest School of Medicine, Medical Center Boulevard, Winston-Salem, North Carolina, USA
| | - Karin J Kuhn
- Internal Medicine Department, Oakland Medical Center-Kaiser Permanente, Oakland, California, USA
| | - Laura Santiago
- Department of Exercise Science, High Point University, High Point, North Carolina, USA
| | - James M Smoliga
- Department of Physical Therapy, High Point University, High Point, North Carolina, USA
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23
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Cheyne I, Roy E, Forster BB. Ultrasonographic assessment of fractures: a break in tradition? Br J Sports Med 2015; 49:143. [PMID: 25738206 DOI: 10.1136/bjsports-2014-094472] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- Ian Cheyne
- Department of Radiology, UBC Hospital, Vancouver, British Columbia, Canada
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24
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Abstract
Context: Stress fractures of the foot and ankle are a common problem encountered by athletes of all levels and ages. These injuries can be difficult to diagnose and may be initially evaluated by all levels of medical personnel. Clinical suspicion should be raised with certain history and physical examination findings. Evidence Acquisition: Scientific and review articles were searched through PubMed (1930-2012) with search terms including stress fractures and 1 of the following: foot ankle, medial malleolus, lateral malleolus, calcaneus, talus, metatarsal, cuboid, cuneiform, sesamoid, or athlete. Study Design: Clinical review. Level of Evidence: Level 5. Results: Stress fractures of the foot and ankle can be divided into low and high risk based upon their propensity to heal without complication. A wide variety of nonoperative strategies are employed based on the duration of symptoms, type of fracture, and patient factors, such as activity type, desire to return to sport, and compliance. Operative management has proven superior in several high-risk types of stress fractures. Evidence on pharmacotherapy and physiologic therapy such as bone stimulators is evolving. Conclusion: A high index of suspicion for stress fractures is appropriate in many high-risk groups of athletes with lower extremity pain. Proper and timely work-up and treatment is successful in returning these athletes to sport in many cases. Low-risk stress fracture generally requires only activity modification while high-risk stress fracture necessitates more aggressive intervention. The specific treatment of these injuries varies with the location of the stress fracture and the goals of the patient.
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Pegrum J, Dixit V, Padhiar N, Nugent I. The pathophysiology, diagnosis, and management of foot stress fractures. PHYSICIAN SPORTSMED 2014; 42:87-99. [PMID: 25419892 DOI: 10.3810/psm.2014.11.2095] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
INTRODUCTION There is an increasing prevalence of osteoporosis, and with it a rise in the diagnosis of stress fractures. Postmenopausal women are particularly at risk of stress fractures. This review article describes the pathophysiology of foot stress fractures and the latest diagnostic and treatment strategies for these common injuries. DISCUSSION There are numerous risk factors for stress fractures that have been identified in the literature. Reduced bone mineral density is an independent risk factor for delayed union. Prevention of stress fractures with training periodization and nutritional assessment is essential, especially in females. Diagnosis of stress fractures of the foot is based on history and diagnostic imaging, which include radiographs, ultrasound, therapeutic ultrasound, computed tomography, and bone scans; however, magnetic resonance imaging is still the gold standard. Treatment depends on the bone involved and the risk of nonunion, with high-risk fractures requiring immobilization or surgical intervention. Patients presenting with underlying bone mineral deficiency treated without surgery require a longer period of activity modification. Training rehabilitation protocols are described for those with low-risk stress fractures. RESULTS A useful algorithm is presented to guide the clinician in the diagnosis and management of such injuries.
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Affiliation(s)
- James Pegrum
- Oxford John Radcliffe Hospitals Orthopaedic Trauma Rotation, Stoke Mandeville Hospital, Aylesbury, Buckinghamshire, England.
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26
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Nattiv A, Kennedy G, Barrack MT, Abdelkerim A, Goolsby MA, Arends JC, Seeger LL. Correlation of MRI grading of bone stress injuries with clinical risk factors and return to play: a 5-year prospective study in collegiate track and field athletes. Am J Sports Med 2013; 41:1930-41. [PMID: 23825184 PMCID: PMC4367232 DOI: 10.1177/0363546513490645] [Citation(s) in RCA: 164] [Impact Index Per Article: 14.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Bone stress injuries are common in track and field athletes. Knowledge of risk factors and correlation of these to magnetic resonance imaging (MRI) grading could be helpful in determining recovery time. PURPOSE To examine the relationships between MRI grading of bone stress injuries with clinical risk factors and time to return to sport in collegiate track and field athletes. STUDY DESIGN Cohort study (prognosis); Level of evidence, 2. METHODS A total of 211 male and female collegiate track and field and cross-country athletes were followed prospectively through their competitive seasons. All athletes had preparticipation history, physical examination, and anthropometric measurements obtained annually. An additional questionnaire was completed regarding nutritional behaviors, menstrual patterns, and prior injuries, as well as a 3-day diet record. Dual-energy X-ray absorptiometry was performed at baseline and each year of participation in the study. Athletes with clinical evidence of bone stress injuries had plain radiographs. If radiograph findings were negative, MRI was performed. Bone stress injuries were evaluated by 2 independent radiologists utilizing an MRI grading system. The MRI grading and risk factors were evaluated to identify predictors of time to return to sport. RESULTS Thirty-four of the athletes (12 men, 22 women) sustained 61 bone stress injuries during the 5-year study period. The mean prospective assessment for participants was 2.7 years. In the multiple regression model, MRI grade and total-body bone mineral density (BMD) emerged as significant and independent predictors of time to return to sport. Specifically, the higher the MRI grade (P = .004) and lower the BMD (P = .030), the longer the recovery time. Location of the bone injury at predominantly trabecular sites of the femoral neck, pubic bone, and sacrum was also associated with a prolonged time to return to sport. Female athletes with oligomenorrhea and amenorrhea had bone stress injuries of higher MRI grades compared with eumenorrheic athletes (P = .009). CONCLUSION Higher MRI grade, lower BMD, and skeletal sites of predominant trabecular bone structures were associated with a delayed recovery of bone stress injuries in track and field athletes. Knowledge of these risk factors, as well as nutritional and menstrual factors, can be clinically useful in determining injury severity and time to return to sport.
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Affiliation(s)
- Aurelia Nattiv
- Department of Family Medicine, Division of Sports Medicine, Department of Orthopaedic Surgery, David Geffen School of Medicine at UCLA, University of California, Los Angeles, Los Angeles, California
| | - Gannon Kennedy
- New York Medical College, Valhalla, New York. Department of Human Nutrition/Dietetics and Food Science, California State University, Northridge, Northridge, California
| | - Michelle T. Barrack
- Department of Emergency Medicine, Harbor–UCLA Medical Center, Torrance, California. Centinela Hospital, Inglewood, California
| | - Ashraf Abdelkerim
- Department of Medicine, Hospital for Special Surgery, New York, New York
| | - Marci A. Goolsby
- Fresno State Student Health Center, California State University, Fresno, Fresno, California
| | | | - Leanne L. Seeger
- Department of Radiology, David Geffen School of Medicine at UCLA, University of California, Los Angeles, Los Angeles, California
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Chen YT, Tenforde AS, Fredericson M. Update on stress fractures in female athletes: epidemiology, treatment, and prevention. Curr Rev Musculoskelet Med 2013; 6:173-81. [PMID: 23536179 PMCID: PMC3702771 DOI: 10.1007/s12178-013-9167-x] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Stress fractures are a common type of overuse injury in athletes. Females have unique risk factors such as the female athlete triad that contribute to stress fracture injuries. We review the current literature on risk factors for stress fractures, including the role of sports participation and nutrition factors. Discussion of the management of stress fractures is focused on radiographic criteria and anatomic location and how these contribute to return to play guidelines. We outline the current recommendations for evaluating and treatment of female athlete triad. Technologies that may aid in recovery from a stress fracture including use of anti-gravity treadmills are discussed. Prevention strategies may include early screening of female athlete triad, promoting early participation in activities that improve bone health, nutritional strategies, gait modification, and orthotics.
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Affiliation(s)
- Yin-Ting Chen
- Department of Orthopaedic Surgery, Division of Physical Medicine and Rehabilitation, Stanford University, 450 Broadway Street, Pavilion A, 2nd Floor MC 6120, Redwood City, CA 94063 USA
| | - Adam S. Tenforde
- Department of Orthopaedic Surgery, Division of Physical Medicine and Rehabilitation, Stanford University, 450 Broadway Street, Pavilion A, 2nd Floor MC 6120, Redwood City, CA 94063 USA
| | - Michael Fredericson
- Department of Orthopaedic Surgery, Division of Physical Medicine and Rehabilitation, Stanford University, 450 Broadway Street, Pavilion A, 2nd Floor MC 6120, Redwood City, CA 94063 USA
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Radiographically occult and subtle fractures: a pictorial review. Radiol Res Pract 2013; 2013:370169. [PMID: 23577253 PMCID: PMC3613077 DOI: 10.1155/2013/370169] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2012] [Accepted: 02/20/2013] [Indexed: 11/17/2022] Open
Abstract
Radiographically occult and subtle fractures are a diagnostic challenge. They may be divided into (1) “high energy trauma fracture,” (2) “fatigue fracture” from cyclical and sustained mechanical stress, and (3) “insufficiency fracture” occurring in weakened bone (e.g., in osteoporosis and postradiotherapy). Independently of the cause, the initial radiographic examination can be negative either because the findings seem normal or are too subtle. Early detection of these fractures is crucial to explain the patient's symptoms and prevent further complications. Advanced imaging tools such as computed tomography, magnetic resonance imaging, and scintigraphy are highly valuable in this context. Our aim is to raise the awareness of radiologists and clinicians in these cases by presenting illustrative cases and a discussion of the relevant literature.
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Hung CY, Chang KV. Is therapeutic ultrasound a reliable tool for the diagnosis of bone stress injuries? Letter to the editor. Am J Sports Med 2012; 40:NP25; author reply NP25-6. [PMID: 22941578 DOI: 10.1177/0363546512458500] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
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Pegrum J, Crisp T, Padhiar N, Flynn J. The pathophysiology, diagnosis, and management of stress fractures in postmenopausal women. PHYSICIAN SPORTSMED 2012; 40:32-42. [PMID: 23528619 DOI: 10.3810/psm.2012.09.1978] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
INTRODUCTION Increasing numbers of elderly individuals are now participating in marathons. With increased participation in running, there has been an increase in the diagnosis of stress fractures in the elderly population. Postmenopausal women are particularly at risk due to osteoporosis. DISCUSSION There are numerous risk factors for stress fractures in the literature that need to be addressed to reduce the risk of injury and recurrence in postmenopausal women. Diagnostic tests include plain radiograph, ultrasound, therapeutic ultrasound, computed tomography scan, and isotope bone scans; however, magnetic resonance imaging remains the gold standard. Treatment is based on risk stratification, with high-risk fractures managed aggressively with either non-weightbearing or surgical intervention. Although exercise is prescribed as a well-recognized treatment modality of poor bone density, balance is essential to avoid precipitating stress fractures. CONCLUSION Optimal exercise programs should balance the beneficial effect of increasing bone mineral density through exercise with the detrimental effect of stress fractures. A useful algorithm is presented in this article to guide the clinician in the diagnosis and management of appropriate investigations and management of such injuries. This review article describes the pathophysiology and provides a review of the literature to determine the latest diagnostic and treatment strategies for this unique population.
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Affiliation(s)
- James Pegrum
- Trauma Registrar, Oxford John Radcliffe Hospitals rotation, Milton Keynes Hospital NHS Foundation Trust, Milton Keynes, Buckinghamshire, United Kingdom; Honorary Research Associate, Centre for Sport and Exercise Medicine, Queen Mary, University of London, London, United Kingdom.
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