Lower limb stress fractures in sport: Optimising their management and outcome

Osseous Stress Injuries: Treatment Algorithms and Return to Play

Osseous stress injuries are common in athletes. Specifically, lower extremity injuries are prevalent in running athletes and upper extremity injuries are prevalent in throwing athletes. Such injuries are suspected when there is focal bone tenderness and increased pain with the inciting activity. In elite athletes, osseous stress injuries are a relatively common culprit in lost play time. Thus rapid diagnosis and treatment is imperative to expedite return to play (RTP). The radiologist's role in these cases is not only for diagnosis, but also to grade the injury, which has implications in determining a treatment regimen. The high sensitivity and specificity of magnetic resonance imaging is thus the preferred imaging modality. This article discusses common osseous stress injuries, the imaging findings, and how different treatment regimens affect RTP.

Stress Fracture after Arthroscopic Lesser Trochanter Resection: Diagnosis and Therapy

We report on the case of a 52-year-old female who presented with a stress fracture after undergoing an endoscopic resection of the lesser trochanter in ischiofemoral impingement, which was resistant to maximal conservative treatment. To the best of our knowledge, this complication has not been previously described. Non-weight-bearing and intravenous alendronic acid were prescribed for management. No additional surgery was required. The patient was pain free with the ability to perform sports on the same level as before and had no complaints.

Speed and surface steepness affect internal tibial loading during running

BACKGROUND

Internal tibial loading is influenced by modifiable factors with implications for the risk of stress injury. Runners encounter varied surface steepness (gradients) when running outdoors and may adapt their speed according to the gradient. This study aimed to quantify tibial bending moments and stress at the anterior and posterior peripheries when running at different speeds on surfaces of different gradients.

METHODS

Twenty recreational runners ran on a treadmill at 3 different speeds (2.5 m/s, 3.0 m/s, and 3.5 m/s) and gradients (level: 0%; uphill: +5%, +10%, and +15%; downhill: -5%, -10%, and -15%). Force and marker data were collected synchronously throughout. Bending moments were estimated at the distal third centroid of the tibia about the medial-lateral axis by ensuring static equilibrium at each 1% of stance. Stress was derived from bending moments at the anterior and posterior peripheries by modeling the tibia as a hollow ellipse. Two-way repeated-measures analysis of variance were conducted using both functional and discrete statistical analyses.

RESULTS

There were significant main effects for running speed and gradient on peak bending moments and peak anterior and posterior stress. Higher running speeds resulted in greater tibial loading. Running uphill at +10% and +15% resulted in greater tibial loading than level running. Running downhill at -10% and -15% resulted in reduced tibial loading compared to level running. There was no difference between +5% or -5% and level running.

CONCLUSION

Running at faster speeds and uphill on gradients ≥+10% increased internal tibial loading, whereas slower running and downhill running on gradients ≥-10% reduced internal loading. Adapting running speed according to the gradient could be a protective mechanism, providing runners with a strategy to minimize the risk of tibial stress injuries.

Evaluation of Low-Intensity Pulsed Ultrasound on Stress Fractures to Reduce the Time to Return to Sport or Activity in the Physically Active Population: A Systematic Review

Stress fractures are a common and significant source of pain and burden that can require long periods of rest from physical activity to allow adequate healing. Specifically in athletes or those with physically demanding occupations, the prolonged period of rest and the potential for requiring surgical intervention in the case of poor or delayed healing can have devastating impacts on these individuals' careers and socioeconomic well-being. In this population, successful healing, in addition to a quicker healing time and a sooner return to activity, are important outcomes when faced with treating stress fractures. The use of low-intensity pulsed ultrasound (LIPUS) to accelerate bone healing has been a topic of investigation, though little research has explored the use of LIPUS specifically in the physically active population. The purpose of this study was to review the existing literature on the use of LIPUS for stress fracture healing in the physically active population with the outcome of a quicker return to sport or physical duties. The PubMed and Embase databases were screened for relevant articles using defined Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) criteria. Two independent researchers screened articles using PICOS criteria for inclusion in the review. Data were independently extracted regarding study and population characteristics as well as outcome measures, including time to healing of fractures and time to return to sport or physical activity. Five studies were ultimately included in the systematic review. One study investigated the use of LIPUS in pediatric athletes with spondylolysis, while four studies investigated lower extremity stress fractures in adult populations. All reported the outcomes of either rate or time to healing and ability to return to sport or activity. One study found a statistically significant improvement in the rate of bone union in the intervention group undergoing LIPUS compared to the control. Two studies found a statistically significant decrease in the time to resolution of symptoms, allowing an earlier return to sport or physical duties. Two studies found no difference in the time to healing or success rate of healing between the LIPUS group and the control group. This review of the literature suggests that the use of LIPUS for the treatment of stress fractures in the athletic or physically active population has the potential to expedite the resolution of symptoms and return to activity. Due to the heterogeneity of the existing studies, more research is needed to definitively determine the most appropriate clinical application of LIPUS and its most effective ultrasound settings. Further research should be directed toward more controlled studies specifically investigating the athletic and physically active population.

[High-risk stress fractures in competitive athletes]

Bone stress injuries are chronic overload reactions of the bone, which are characterized by the load-dependent occurrence of locally perceived pain and tenderness on palpation at the site of the injury. Structurally normal bone becomes fatigued as a result of repetitive submaximal loading and/or inadequate regeneration. Certain stress fractures of the femoral neck (tension side), patella, anterior tibial cortex, medial malleolus, talus, tarsal navicular bone, proximal fifth metatarsal, and sesamoid bones of the great toe tend to develop complications (complete fractures, delayed union, pseudarthrosis, dislocation, arthrosis). These injuries are classified as high-risk stress fractures. Aggressive diagnostics and treatment are recommended when a high-risk stress fracture is suspected. Treatment is frequently different from low-risk stress fractures, including prolonged non-weight-bearing immobilization. In rare cases, surgery is indicated when conservative treatment fails, when a complete or non-healing fracture develops, or in cases of dislocation. The outcomes of both conservative and operative treatment are described as less successful compared with low-risk stress injuries.

Femoral neck stress fracture return to activity and the effect of metabolic dysfunction on recovery: A systematic review

Background

Femoral neck stress fractures are rare fractures traditionally found in athletes and military personnel. There is limited literature on return to activity.

Objectives

To report return to activity rates and times, and long-term outcomes for femoral neck stress fractures reported in the literature. To examine the effects of bone metabolic dysfunction and surgical management on return to activity following FNSF.

Research design & methods

A systematic literature review of case reports and case series on adults with femoral neck stress fracture that were diagnosed by gross fracture line on X-ray or gold-standard diagnosis with MRI was conducted. Initial search was limited to articles published from January 1997 to Jan 2023 listed in Medline, Embase, and Scopus. Additional articles were manually added via search of retained paper sources. Patient demographics, fracture type, return to activity time, and surgical vs non-surgical treatment modality were collected. In addition, long-term outcomes and metabolic effects, if reported, were abstracted.

Results

A total of 40 case reports or case series were retained. 123 stress fractures of the femoral neck from 103 patients were compiled. Of the 103 patients, data on return to activity at least one year following treatment was available for 53 patients. 71% (37/53) of those with long-term follow-up information returned to full pre-injury activity. 24% (13/53) at long-term follow-up had functional recovery but did not return to pre-injury activity due to residual pain. 4% (3/53) had disabling pain. Metabolic workup information was available for 36 patients.

Conclusion

Long-term follow-up and return to activity information following FNSF treatment are not commonly reported. Based on the available data, outcomes appear benign with most returning to full activity. There is a clear need for standardization of follow-up periods and hip function measure after FNSF treatment. Additionally, a sizable proportion of FNSF occurred in a new population of low-activity individuals with abnormal bone metabolism, which warrants further exploration.

Therapeutic ultrasound related pain threshold in elite track & field athletes with tibial bone stress injuries

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.

Return to sport following toe phalanx fractures: A systematic review

BACKGROUND

Evidence-based guidance on return to sport following toe phalanx fractures is limited.

AIM

To systemically review all studies recording return to sport following toe phalanx fractures (both acute fractures and stress fractures), and to collate information on return rates to sport (RRS) and mean return times (RTS) to the sport.

METHODS

A systematic search of PubMed, MEDLINE, EMBASE, CINAHL, Cochrane Library, Physiotherapy Evidence Database, and Google Scholar was performed in December 2022 using the keywords ‘Toe’, ‘Phalanx’, ‘Fracture’, ‘injury’, ‘athletes’, ‘sports’, ‘non-operative’, ‘conservative’, ‘operative’, ‘return to sport’. All studies which recorded RRS and RTS following toe phalanx fractures were included.

RESULTS

Thirteen studies were included: one retrospective cohort study and twelve case series. Seven studies reported on acute fractures. Six studies reported on stress fractures. For the acute fractures (n = 156), 63 were treated with primary conservative management (PCM), 6 with primary surgical management (PSM) (all displaced intra-articular (physeal) fractures of the great toe base of the proximal phalanx), 1 with secondary surgical management (SSM) and 87 did not specify treatment modality. For the stress fractures (n = 26), 23 were treated with PCM, 3 with PSM, and 6 with SSM. For acute fractures, RRS with PCM ranged from 0 to 100%, and RTS with PCM ranged from 1.2 to 24 wk. For acute fractures, RRS with PSM were all 100%, and RTS with PSM ranged from 12 to 24 wk. One case of an undisplaced intra-articular (physeal) fracture treated conservatively required conversion to SSM on refracture with a return to sport. For stress fractures, RRS with PCM ranged from 0% to 100%, and RTS with PCM ranged from 5 to 10 wk. For stress fractures, RRS with PSM were all 100%, and RTS with surgical management ranged from 10 to 16 wk. Six cases of conservatively-managed stress fractures required conversion to SSM. Two of these cases were associated with a prolonged delay to diagnosis (1 year, 2 years) and four cases with an underlying deformity [hallux valgus (n = 3), claw toe (n = 1)]. All six cases returned to the sport after SSM.

CONCLUSION

The majority of sport-related toe phalanx fractures (acute and stress) are managed conservatively with overall satisfactory RRS and RTS. For acute fractures, surgical management is indicated for displaced, intra-articular (physeal) fractures, which offers satisfactory RRS and RTS. For stress fractures, surgical management is indicated for cases with delayed diagnosis and established non-union at presentation, or with significant underlying deformity: both can expect satisfactory RRS and RTS.

The Role of Footwear, Foot Orthosis, and Training-Related Strategies in the Prevention of Bone Stress Injuries: A Systematic Review and Meta-Analysis

Objective

To evaluate the effectiveness of footwear, foot orthoses and training-related strategies to prevent lower extremity bone stress injury (BSI).

Design

Systematic review and meta-analysis.

Data sources

Four bibliographic databases (from inception until November 2021): Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE and CINAHL.

Eligibility criteria

Randomised controlled trials (RCTs) that assessed the risk of developing a BSI when using particular footwear, foot orthoses or training-related strategies such as muscle strengthening, stretching, and mechanical loading exercises.

Results

Eleven studies were included in this systematic review. When wearing foot orthoses, the risk ratio of developing a BSI on any lower extremity bone is 0.47 (95% CI 0.26 to 0.87; p = 0.02). When doing pre-exercise dynamic stretching, the risk ratio of suffering a tibial BSI is 1.06 (95% CI 0.67 to 1.68; p = 0.79). No meta-analyses could be performed for footwear or training-related strategies. The quality of evidence for all these results is low considering the high risk of bias in each study, the low number of studies and the low number of cases in each study.

Conclusion

This systematic review reveals the lack of high-quality studies in BSI prevention. Based on studies at high risk of bias, foot orthoses could potentially help prevent BSIs in the military setting. It is still unknown whether footwear and training-related strategies have any benefits. It is crucial to further investigate potential BSI prevention strategies in women and athletes. Research is also needed to assess the influence of running shoes and loading management on BSI incidence.

Tarsal Navicular Stress Fractures: A Rare Soccer Injury Twelve-Year Follow-Up of the First Reported Case in a Professional Player and Literature Review

Tarsal navicular stress fractures are rare injuries, mostly occurring in long-distance runners, jumpers, and occasionally affecting athletes in high-contact sports such as rugby or American/Australian football. This condition generally represents a clinical challenge, resulting in considerable diagnostic delays. While the ideal treatment is still controversial, surgical treatment seems to provide good results in recovering function and return to play. Tarsal navicular stress fractures have been extremely rare in soccer players; only seven published cases have been located to date. This article is a paradigmatic report on a professional player with this injury and a successful outcome after a 12-year follow-up.

Stress fractures

Stress fractures (SF) represent 10%-20% of all injuries in sport medicine. An SF occurs when abnormal and repetitive loading is applied on normal bone: The body cannot adapt quickly enough, leading to microdamage and fracture. The etiology is multifactorial with numerous risk factors involved. Diagnosis of SF can be achieved by identifying intrinsic and extrinsic factors, obtaining a good history, performing a physical exam, and ordering laboratory and imaging studies (magnetic resonance imaging is the current gold standard). Relative energy deficiency in sport (RED-S) is a known risk factor. In addition, for women, it is very important know the menstrual status to identify long periods of amenorrhea in the past and the present. Early detection is important to improve the chance of symptom resolution with conservative treatment. Common presentation involves complaints of localized pain, with or without swelling, and tenderness on palpation of bony structures that begins earlier in training and progressively worsens with activity over a 2- to 3-week period. Appropriate classification of SF based on type, location, grading, and low or high risk is critical in guiding treatment strategies and influencing the time to return to sport. Stress injuries at low-risk sites are typically managed conservatively. Studies have suggested that calcium and vitamin D supplementation might be helpful. Moreover, other treatment regimens are not well established. Understanding better the pathophysiology of SFs and the potential utility of current and future bone-active therapeutics may well yield approaches that could treat SFs more effectively.

Comparison of Ultrasonography to MRI in the Diagnosis of Lower Extremity Bone Stress Injuries: A Prospective Cohort Study

OBJECTIVE

To determine the sensitivity and specificity of ultrasound imaging (USI) compared to the reference-standard of MRI in the diagnosis of bone stress injury (BSI).

METHODS

A prospective blinded cohort study was conducted. Thirty seven patients who presented to an academic sports medicine clinic from 2016 to 2020 with suspected lower-extremity BSI on clinical exam underwent both magnetic resonance imaging (MRI) and USI. Participant characteristics were collected including age, gender and sport. Exclusion criteria included contraindication for dedicated MRI, traumatic fracture, or severe tendon or ligamentous injury. The primary outcome measure was BSI diagnosis by USI. An 8-point assessment system was utilized on USI for diagnosis of BSI, and the Fredericson and Nattiv²² criteria were applied to classify MRI findings.

RESULTS

Thirty seven participants who met study criteria were consented to participate. All participants completed baseline measures. Using MRI, there were 30 (81%) athletes with a positive and seven participants with a negative BSI diagnosis. The most common BSIs in the study were in the metatarsal (54%) and tibia (32%). Compared to MRI, USI demonstrated 0.80 sensitivity (95% confidence interval [CI], 0.61-0.92) and 0.71 specificity (95% CI, 0.29-0.96) in detecting BSI, with a positive predictive value of 0.92 (95% CI, 0.75-0.99) and negative predictive value of 0.45 (95% CI, 0.17-0.77).

CONCLUSIONS

USI is a potentially useful point-of-care tool for practicing sports medicine providers to combine with their clinical evaluation in the diagnosis of BSIs. Further research is ongoing to determine the role of USI in follow-up care and return-to-play protocols.

Platelet rich plasma for hallux sesamoid injuries: a case series

OBJECTIVE

Hallux sesamoid injuries are well described and can be debilitating and chronically disabling. The role of orthobiologics such as platelet-rich plasma (PRP) in sesamoid injuries has not been reported. This study describes three cases of recalcitrant hallux sesamoid injuries in teenage athletes who returned to impact activities, pain free, following one treatment of PRP.

METHODS

This is a case-series study describing three teenage athletes presenting to a tertiary level pediatric sports medicine practice with chronic hallux sesamoid injuries.

RESULTS

The three patients (two female, one male) described in this case series were 13-, 16-, and 17-year-old athletes. Their primary sports were ballet, basketball, and Irish step dance, respectively. All three athletes received PRP: two received unilateral treatment (one tibial sesamoid, one fibular sesamoid) and one received treatment to bilateral tibial sesamoids. The average duration of symptoms prior to PRP was 52.5 weeks (14-128 weeks). The average time out of their primary sport was 48.7 weeks (20-78 weeks). Three of the 4 sesamoids treated with PRP were tibial sesamoids. Each site of injury was treated with one treatment of leukocyte-rich PRP. All three athletes were cleared to return to impact activities such as running and jumping at 6-9 weeks following PRP, specifically 9 weeks after the final PRP injection for the patient who underwent bilateral treatments.

CONCLUSION

In the three cases provided of sesamoid injuries treated with PRP, the time to return to impact activities was less than reported for athletes not treated with PRP. Acknowledging that other management factors likely contributed to return to impact activities, this case series sets the groundwork for future research investigating the role of PRP with needle fenestration in the treatment of sesamoid injuries.

Uncommon Bone Injuries in Soccer Players

Soccer is the most common team sport in the world. A significant number of players are associated with a large number of injuries. Injuries occur in a variety of contexts regardless of the age or performance level of players. The vast majority of injuries involve soft tissues. Bone injuries are less common, but usually result in long-term exclusion from the game. Three different types of fractures related to soccer are classified as acute types, stress fractures and avulsion. This manuscript outlines the diagnostic procedures and treatments for stress fractures, avulsion fractures and bone cyst. The common feature of the described injuries includes frequent difficulties associated with the correct diagnosis and treatment direction. In therapeutic treatment, the doctor and the patient often have to choose between conservative treatment and surgical treatment, which in many cases is not simple. We suggest that in the event of injuries to soccer players, surgical treatment should be used, shortening the time to return to full sports activity. A very important element of the therapeutic process is proper rehabilitation, which should be individually tailored to the patient in order to optimize the treatment process. Some of the rehabilitation protocols should be permanently incorporated into the warm-up protocols for training. Such a procedure has a preventive effect.

A Current Update on Pelvifemoral Conditions That Should be in the Differential Diagnosis for Patients With Lower Extremity Radiculopathy

Patients presenting to an outpatient spine clinic frequently report symptoms of low back pain with associated buttock, groin, and lower extremity pain. While many of these individuals suffer from lumbar spine radiculopathy, a number of different orthopedic pathologies can mimic these symptoms. Management depends substantially on a detailed history and physical examination, in addition to working from a broad list of differential diagnoses when evaluating these patients. It is imperative that spine practitioners have a comprehensive understanding of the differential diagnoses that may mimic those originating from the lumbar spine, especially when a patient's symptoms are atypical from classic radicular pain. Misdiagnosis can lead to unnecessary testing and treatment, while delaying an accurate clinical assessment and treatment plan. This review highlights common orthopedic diagnoses that may present similar to lumbar spine pathologies and the evidence-based evaluation of these conditions.

The Use of Percutaneous Screw Fixation Without Fracture Site Preparation in the Treatment of Fifth Metatarsal Base Nonunion

Nonunion after a proximal fifth metatarsal fracture can cause considerable pain, with high morbidity and loss of work. Although many authors advocate early surgical management of zone 3 injuries (Jones fractures), zone 1 and 2 fractures are generally expected to heal with conservative management. Uncommonly, zone 1 and 2 fractures can develop nonunions. The aim of this study was to evaluate the efficacy of closed intramedullary screw fixation for nonunions of the fifth metatarsal base. We performed a prospective study involving all fifth metatarsal base nonunions treated in our department over 2 years. Only minimally displaced adult fractures were considered for this study. The fracture pattern was categorized using the Dameron classification (zone 1, styloid process; zone 2, metadiaphyseal area; zone 3, proximal diaphysis). All nonunions were fixed percutaneously under radiographic guidance, without fracture site preparation. Zone 1 injuries were fixed using a 3-mm headless compression screw, and those of zones 2 and 3, with an intramedullary 4-mm screw. Of 30 patients included in this study, a minimum 6-month clinical follow-up was obtained. The average time from injury to treatment was 5.9 months (range 3 to 36). There were no smokers in this patient cohort. There were 12 zone 1 injuries, 9 zone 2 injuries, and 9 zone 3 injuries. All patients achieved union by 3 months after screw fixation, with 29 of 30 achieving union by 6 weeks. All patients had resolution of symptoms. There were no complications. We conclude that percutaneous fixation of fifth metatarsal base nonunions, without fracture site preparation, achieves excellent results. We believe that the screw alters the strain of the fracture, thus promoting fibrous-to-osseous conversion and therefore union.

Tibial stress during running following a repeated calf-raise protocol

Tibial stress fractures are a problematic injury among runners. Increased loading of the tibia has been observed following prolonged weight-bearing activity and is suggested to be the result of reduced activity of the plantar flexor muscles. The musculature that spans the tibia contributes to bending of the bone and influences the magnitude of stress on the tibia during running. Participant-specific models of the tibia can be used as a non-invasive estimate of tibial stress. This study aimed to quantify tibial stress during running using participant-specific bone geometry and to compare tibial stress before and after a protocol of repeated muscular contractions of the plantar flexor muscle group. Fourteen participants who run recreationally were included in the final analysis of the study. Synchronized force and kinematic data were collected during overground running before and after an exhaustive, weighted calf-raise protocol. Bending moments and stress at the distal third of the tibia were estimated using beam theory combined with inverse dynamics and musculoskeletal modeling. Bone geometry was obtained from magnetic resonance images. There was no difference in stress at the anterior, posterior, medial, or lateral peripheries of the tibia after the calf-raise protocol compared with before. These findings suggest that an exhaustive, repeated calf-raise protocol did not alter tibial stress during running.

Estimating Tibial Stress throughout the Duration of a Treadmill Run

INTRODUCTION

Stress fractures of the tibia are a problematic injury among runners of all levels. Quantifying tibial stress using a modeling approach provides an alternative to invasive assessments that may be used to detect changes in tibial stress during running. This study aimed to assess the repeatability of a tibial stress model and to use this model to quantify changes in tibial stress that occur throughout the course of a 40-min prolonged treadmill run.

METHODS

Synchronized force and kinematic data were collected during prolonged treadmill running from 14 recreational male rearfoot runners on two separate occasions. During each session, participants ran at their preferred speed for two consecutive 20-min runs, separated by a 2-min pause. The tibia was modeled as a hollow ellipse and bending moments and stresses at the distal third of the tibia were estimated using beam theory combined with inverse dynamics and musculoskeletal modeling.

RESULTS

Intraclass correlation coefficients indicated good-to-excellent repeatability for peak stress values between sessions. Peak anterior and posterior stresses increased after 20 min of prolonged treadmill running and were 15% and 12% greater, respectively, after 40 min of running compared with the start of the run.

CONCLUSION

The hollow elliptical tibial model presented is a repeatable tool that can be utilized to assess within-participant changes in peak tibial stress during running. The increased stresses observed during a prolonged treadmill run may have implications for the development of tibial stress fracture.

Bone Stress Injuries in Runners: a Review for Raising Interest in Stress Fractures in Korea

A bone stress injury (BSI) means that the bones cannot tolerate repeated mechanical loads, resulting in structural fatigue and local bone pain. A delay in BSI diagnosis can lead to more serious injuries, such as stress fractures that require longer treatment periods. Therefore, early detection of BSI is an essential part of management. Risk factors for BSI development include biological and biomechanical factors. Medical history and physical examination are the basics for a BSI diagnosis, and magnetic resonance imaging is helpful for confirming and grading. In this paper, the authors review the overall content of BSI and stress fractures which are common in runners. Through this review, we hope that interest in stress fractures will be raised in Korea and that active researches will be conducted.

Part II: presentation, diagnosis, classification, treatment, and prevention of stress fractures in female athletes

Objectives: Stress fractures (SFx) occur as the result of repetitive loads over short periods of time, which leads to micro-damage of the bone through cortical resorption, ultimately leading to fracture. They are a common injury in female athletes and often cause significant morbidity. The goal of this study is to review the presentation, diagnosis, classification, treatment, and prevention of SFx in female athletes.Results: A thorough history, physical exam, and appropriate imaging can facilitate early diagnosis of stress fracture (SFx) and faster resolution of symptoms with more conservative management. The female athlete triad is an especially important factor that contributes to the increased risk of SFx in females. The continuum of stress injuries ranges from mild microfailure to complete fracture, which has resulted in the development of newer grading schemas through MRI and radiographic findings. Stress fractures are also classified as low- or high-risk according to anatomic location, as blood supply and applied forces at different locations affect the likelihood of fracture propagation, displacement, delayed union, or non-union.Conclusions: The ability to screen for at-risk athletes is paramount in preventing SFx. Recognition and prompt treatment of the female athlete triad requires a multidisciplinary approach in order to restore energy balance, correct menstrual irregularities, and improve bone health. This review provides a basis for understanding how to identify and treat stress fractures, which may allow treating physicians to diagnose this condition earlier and minimize any associated morbidity.

Early return to playing professional football following fixation of 5th metatarsal stress fractures may lead to delayed union but does not increase the risk of long-term non-union

PURPOSE

5th metatarsal stress fractures are frequently encountered in professional football. There is concern that early return to play following intra-medullary screw fixation may lead to an increased risk of delayed union. The purpose of the study was to assess whether an early return to play after surgical fixation of 5th metatarsal fractures in professional football players is a risk factor for delayed union and the effect of this on the ultimate clinical outcome.

METHODS

Retrospective review of prospectively collected data of a series of 37 professional football players following intramedullary screw fixation of 5th metatarsal stress fractures. End points included time of return to play and to radiological union of the fracture.

RESULTS

At a minimum follow-up of 24 months the mean return to play was 10.5 weeks and mean time to complete radiological union was 12.7 weeks. Return to play at 8 weeks or less resulted in a higher risk of delayed radiological union (24% at 3 months), but this neither prevented the athlete from continuing to play football nor did it affect the ultimate risk of non-union (3% overall). A re-fracture occurred in 1 patient (3%) at 10 months who previously had complete radiographic union at 9 weeks.

CONCLUSION

Intramedullary screw fixation of 5th metatarsal stress fractures leads to a predictable time of return to play and a low rate of non-union. If players return to play at 8 weeks or less a persistent line may be expected in up to a quarter of patients. However, if asymptomatic this radiological finding does not mean that athletes must avoid playing football as ultimately a good outcome is expected with low rates of non-union and refracture.

LEVEL OF EVIDENCE

Case series, Level IV.

Bilateral femoral neck stress fractures in a high-performance young female runner

A 16-year-old female patient showed up at the orthopaedics unit complaining of intolerable pain on her left hip. While being questioned and her clinical history written down, she shared that as part of her daily exercise routine, she ran 10 miles (16 km) daily at a speed of 9.5-10.5 mph (15-17 km/hour). MRI was consequently ordered, confirming the presence of a stress fracture. Therefore, immediate suspension of physical activity was indicated, followed by the prescription of crutches as well as restricted weight bearing. Gradually, she recovered complete functionality and approximately a month after she had entirely healed. While on a skiing trip, again she abruptly developed an acute pain on her right hip. Another MRI was ordered; its result confirmed a new stress fracture. Her previous treatment has proved so successful, a conservative approach was once again prescribed for her, showing optimum results 6 months later.

[Stress fracture of athletes as a cause of groin pain]

CLINICAL/METHODICAL ISSUE

In this article, suitable imaging of stress reactions and stress fractures in athletes will be examined.

STANDARD RADIOLOGICAL METHODS

Diagnostic procedures include X‑ray, computed tomography (CT), magnetic resonance imaging (MRI), and bone scintigraphy.

METHODICAL INNOVATIONS

MRI represents the gold standard for these types of injuries.

PERFORMANCE

Of all imaging techniques, MRI shows the highest sensitivity in terms of diagnostic and prognostic aspects in stress reactions and stress fractures.

PRACTICAL RECOMMENDATIONS

Early performance of MRI to evaluate the staging, therapy and prognosis of the healing process is recommended.

Exercise-induced leg pain in athletes: diagnostic, assessment, and management strategies

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.

Concurrent Bilateral Anterior Tibial Stress Fractures and Vitamin D Deficiency in an Adolescent Female Athlete: Treatment With Early Surgical Intervention

Case: A 16-year-old African American multi-sport female athlete presents with bilateral worsening activity-related leg pain for 5 months. Multiple bilateral anterior tibial diaphyseal stress fractures and significant vitamin D deficiency were identified. She was treated with a combination of vitamin D supplements and static intramedullary nailing of the bilateral tibias resulting in clinical and radiographic healing and return to sports. Discussion: Vitamin D deficiency and high level of activity in a young athlete may be the etiology to atypical multiple stress fractures. In athletes who may want to return to sport rapidly, early operative intervention and correction of vitamin D deficiency may be treatment options. Level of Evidence: Level V- case report.