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Semin Musculoskelet Radiol 2024; 28(02): 130-138
DOI: 10.1055/s-0043-1778030
Review Article

Osseous Stress Injuries: Treatment Algorithms and Return to Play

Alessandra J. Sax 
1   The Warren Alpert Medical School of Brown University/Rhode Island Hospital, Providence, Rhode Island
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Abstract

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.

Keywords

osseous stress - overuse injuries - return to play - return to sport


Publication History

Article published online:
14 March 2024

© 2024. Thieme. All rights reserved.

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  • References

  • 1 Fredericson M, Jennings F, Beaulieu C, Matheson GO. Stress fractures in athletes. Top Magn Reson Imaging 2006; 17 (05) 309-325
    CrossrefPubMedGoogle Scholar
  • 2 Hoenig T, Ackerman KE, Beck BR. et al. Bone stress injuries. Nat Rev Dis Primers 2022; 8 (01) 26
    CrossrefPubMedGoogle Scholar
  • 3 Hoenig T, Tenforde AS, Strahl A, Rolvien T, Hollander K. Does magnetic resonance imaging grading correlate with return to sports after bone stress injuries? A systematic review and meta-analysis. Am J Sports Med 2022; 50 (03) 834-844
    CrossrefPubMedGoogle Scholar
  • 4 Daffner RH, Pavlov H. Stress fractures: current concepts. AJR Am J Roentgenol 1992; 159 (02) 245-252
    CrossrefPubMedGoogle Scholar
  • 5 Orava S, Hulkko A, Koskinen S, Taimela S. Stress fractures in athletes and military recruits. An overview [in German]. Orthopade 1995; 24 (05) 457-466
    PubMedGoogle Scholar
  • 6 Behrens SB, Deren ME, Matson A, Fadale PD, Monchik KO. Stress fractures of the pelvis and legs in athletes: a review. Sports Health 2013; 5 (02) 165-174
    CrossrefPubMedGoogle Scholar
  • 7 Bennell KL, Malcolm SA, Thomas SA. et al. Risk factors for stress fractures in female track-and-field athletes: a retrospective analysis. Clin J Sport Med 1995; 5 (04) 229-235
    CrossrefPubMedGoogle Scholar
  • 8 Bennell KL, Malcolm SA, Thomas SA. et al. Risk factors for stress fractures in track and field athletes. A twelve-month prospective study. Am J Sports Med 1996; 24 (06) 810-818
    CrossrefPubMedGoogle Scholar
  • 9 Kelsey JL, Bachrach LK, Procter-Gray E. et al. Risk factors for stress fracture among young female cross-country runners. Med Sci Sports Exerc 2007; 39 (09) 1457-1463
    CrossrefPubMedGoogle Scholar
  • 10 Warden S. History and evaluation. In: Tenforde A, Fredericson M, eds. Bone Stress Injuries in Athletes: Diagnosis, Treatment, and Prevention. New York, NY:: Springer;; 2022: 3-12
    Google Scholar
  • 11 Changstrom BG, Brou L, Khodaee M, Braund C, Comstock RD. Epidemiology of stress fracture injuries among US high school athletes, 2005–2006 through 2012–2013. Am J Sports Med 2015; 43 (01) 26-33
    CrossrefPubMedGoogle Scholar
  • 12 Rizzone KH, Ackerman KE, Roos KG, Dompier TP, Kerr ZY. The epidemiology of stress fractures in collegiate student-athletes, 2004–2005 through 2013–2014 academic years. J Athl Train 2017; 52 (10) 966-975
    CrossrefPubMedGoogle Scholar
  • 13 Bergman AG, Fredericson M, Ho C, Matheson GO. Asymptomatic tibial stress reactions: MRI detection and clinical follow-up in distance runners. AJR Am J Roentgenol 2004; 183 (03) 635-638
    CrossrefPubMedGoogle Scholar
  • 14 Boden BP, Osbahr DC. High-risk stress fractures: evaluation and treatment. J Am Acad Orthop Surg 2000; 8 (06) 344-353
    CrossrefPubMedGoogle Scholar
  • 15 Boden BP, Osbahr DC, Jimenez C. Low-risk stress fractures. Am J Sports Med 2001; 29 (01) 100-111
    CrossrefPubMedGoogle Scholar
  • 16 Robertson GA, Wood AM. Lower limb stress fractures in sport: optimising their management and outcome. World J Orthop 2017; 8 (03) 242-255
    CrossrefPubMedGoogle Scholar
  • 17 Fredericson M, Bergman AG, Hoffman KL, Dillingham MS. Tibial stress reaction in runners. Correlation of clinical symptoms and scintigraphy with a new magnetic resonance imaging grading system. Am J Sports Med 1995; 23 (04) 472-481
    CrossrefPubMedGoogle Scholar
  • 18 Sommer HM, Vallentyne SW. Effect of foot posture on the incidence of medial tibial stress syndrome. Med Sci Sports Exerc 1995; 27 (06) 800-804
    CrossrefPubMedGoogle Scholar
  • 19 Becker J, Nakajima M, Wu WFW. Factors contributing to medial tibial stress syndrome in runners: a prospective study. Med Sci Sports Exerc 2018; 50 (10) 2092-2100
    CrossrefPubMedGoogle Scholar
  • 20 Becker J, Nakajima M, Wu W. A prospective study on medial tibial stress syndrome in runners. Med Sci Sports Exerc 2017; 49 (05) 141
    CrossrefPubMedGoogle Scholar
  • 21 Milner CE, Foch E, Gonzales JM, Petersen D. Biomechanics associated with tibial stress fracture in runners: a systematic review and meta-analysis. J Sport Health Sci 2023; 12 (03) 333-342
    CrossrefPubMedGoogle Scholar
  • 22 Milner CE, Hamill J, Davis IS. Distinct hip and rearfoot kinematics in female runners with a history of tibial stress fracture. J Orthop Sports Phys Ther 2010; 40 (02) 59-66
    CrossrefPubMedGoogle Scholar
  • 23 Nunns M, House C, Rice H. et al. Four biomechanical and anthropometric measures predict tibial stress fracture: a prospective study of 1065 Royal Marines. Br J Sports Med 2016; 50 (19) 1206-1210
    CrossrefPubMedGoogle Scholar
  • 24 Robertson GA, Wood AM. Return to sports after stress fractures of the tibial diaphysis: a systematic review. Br Med Bull 2015; 114 (01) 95-111
    CrossrefPubMedGoogle Scholar
  • 25 Ekenman I, Milgrom C, Finestone A. et al. The role of biomechanical shoe orthoses in tibial stress fracture prevention. Am J Sports Med 2002; 30 (06) 866-870
    CrossrefPubMedGoogle Scholar
  • 26 Swenson Jr EJ, DeHaven KE, Sebastianelli WJ, Hanks G, Kalenak A, Lynch JM. The effect of a pneumatic leg brace on return to play in athletes with tibial stress fractures. Am J Sports Med 1997; 25 (03) 322-328
    CrossrefPubMedGoogle Scholar
  • 27 Kidd LJ, Cowling NR, Wu AC, Kelly WL, Forwood MR. Selective and non-selective cyclooxygenase inhibitors delay stress fracture healing in the rat ulna. J Orthop Res 2013; 31 (02) 235-242
    CrossrefPubMedGoogle Scholar
  • 28 Kaeding CC, Yu JR, Wright R, Amendola A, Spindler KP. Management and return to play of stress fractures. Clin J Sport Med 2005; 15 (06) 442-447
    CrossrefPubMedGoogle Scholar
  • 29 McInnis KC, Ramey LN. High-risk stress fractures: diagnosis and management. PMR 2016; 8 (3, Suppl): S113-S124
    PubMedGoogle Scholar
  • 30 Fredericson M, Un Jang K, Bergman AG, Gold GE. Femoral diaphyseal stress fractures: results of a systematic bone scan and magnetic resonance imaging evaluation in 25 runners. Phys Ther Sport 2004; 5: 188-193
    CrossrefPubMedGoogle Scholar
  • 31 Bernstein EM, Kelsey TJ, Cochran GK, Deafenbaugh BK, Kuhn KM. Femoral neck stress fractures: an updated review. J Am Acad Orthop Surg 2022; 30 (07) 302-311
    CrossrefPubMedGoogle Scholar
  • 32 Hwang B, Fredericson M, Chung CB, Beaulieu CF, Gold GE. MRI findings of femoral diaphyseal stress injuries in athletes. AJR Am J Roentgenol 2005; 185 (01) 166-173
    CrossrefPubMedGoogle Scholar
  • 33 Brukner PD, Bennell KL. Stress fractures in runners. J Back Musculoskeletal Rehabil 1995; 5 (04) 341-351
    CrossrefPubMedGoogle Scholar
  • 34 Ramey LN, McInnis KC, Palmer WE. Femoral neck stress fracture: can MRI grade help predict return-to-running time?. Am J Sports Med 2016; 44 (08) 2122-2129
    CrossrefPubMedGoogle Scholar
  • 35 Polacek M, Småbrekke A. Displaced stress fracture of the femoral neck in young active adults. BMJ Case Rep 2010; 2010: bcr0220102749
    CrossrefPubMedGoogle Scholar
  • 36 Mayer SW, Joyner PW, Almekinders LC, Parekh SG. Stress fractures of the foot and ankle in athletes. Sports Health 2014; 6 (06) 481-491 Published correction appears in Sports Health 2015;7(6):557
    CrossrefPubMedGoogle Scholar
  • 37 Kaiser PB, Guss D, DiGiovanni CW. Republication of “Stress Fractures of the Foot and Ankle in Athletes. ” Foot Ankle Orthop 2023; 8 (03) 24 730114231195045
    CrossrefPubMedGoogle Scholar
  • 38 Irion V, Miller TL, Kaeding CC. The treatment and outcomes of medial malleolar stress fractures: a systematic review of the literature. Sports Health 2014; 6 (06) 527-530
    CrossrefPubMedGoogle Scholar
  • 39 Patel KA, Christopher ZK, Drakos MC, O'Malley MJ. Navicular stress fractures. J Am Acad Orthop Surg 2021; 29 (04) 148-157
    CrossrefPubMedGoogle Scholar
  • 40 Saxena A, Fullem B, Hannaford D. Results of treatment of 22 navicular stress fractures and a new proposed radiographic classification system. J Foot Ankle Surg 2000; 39 (02) 96-103
    CrossrefPubMedGoogle Scholar
  • 41 Saxena A, Fullem B. Navicular stress fractures: a prospective study on athletes. Foot Ankle Int 2006; 27 (11) 917-921
    CrossrefPubMedGoogle Scholar
  • 42 Attia AK, Mahmoud K, Bariteau J, Labib SA, DiGiovanni CW, D'Hooghe P. Return to sport following navicular stress fracture: a systematic review and meta-analysis of three hundred and fifteen fractures. Int Orthop 2021; 45 (10) 2699-2710
    CrossrefPubMedGoogle Scholar
  • 43 Ekstrand J, van Dijk CN. Fifth metatarsal fractures among male professional footballers: a potential career-ending disease. Br J Sports Med 2013; 47 (12) 754-758
    CrossrefPubMedGoogle Scholar
  • 44 Mallee WH, Weel H, van Dijk CN, van Tulder MW, Kerkhoffs GM, Lin CW. Surgical versus conservative treatment for high-risk stress fractures of the lower leg (anterior tibial cortex, navicular and fifth metatarsal base): a systematic review. Br J Sports Med 2015; 49 (06) 370-376
    CrossrefPubMedGoogle Scholar
  • 45 Torg JS, Balduini FC, Zelko RR, Pavlov H, Peff TC, Das M. Fractures of the base of the fifth metatarsal distal to the tuberosity. Classification and guidelines for non-surgical and surgical management. J Bone Joint Surg Am 1984; 66 (02) 209-214
    CrossrefPubMedGoogle Scholar
  • 46 Kriz P, Rafferty J, Evangelista P, Van Valkenburg S, DiGiovanni C. Stress fracture of the second metatarsal and sprain of Lisfranc joint in a pre-professional ballet dancer. J Dance Med Sci 2015; 19 (02) 80-85
    CrossrefPubMedGoogle Scholar
  • 47 Cain Jr EL, Dugas JR, Wolf RS, Andrews JR. Elbow injuries in throwing athletes: a current concepts review. Am J Sports Med 2003; 31 (04) 621-635
    CrossrefPubMedGoogle Scholar
  • 48 Lin KM, Ellenbecker TS, Safran MR. Rehabilitation and return to sport following elbow injuries. Arthrosc Sports Med Rehabil 2022; 4 (03) e1245-e1251
    CrossrefPubMedGoogle Scholar
  • 49 Eygendaal D, Safran MR. Postero-medial elbow problems in the adult athlete. Br J Sports Med 2006; 40 (05) 430-434 ; discussion 434
    CrossrefPubMedGoogle Scholar
  • 50 Furushima K, Itoh Y, Iwabu S, Yamamoto Y, Koga R, Shimizu M. Classification of olecranon stress fractures in baseball players. Am J Sports Med 2014; 42 (06) 1343-1351
    CrossrefPubMedGoogle Scholar
  • 51 Schickendantz MS, Ho CP, Koh J. Stress injury of the proximal ulna in professional baseball players. Am J Sports Med 2002; 30 (05) 737-741
    CrossrefPubMedGoogle Scholar
  • 52 Smith SR, Patel NK, White AE, Hadley CJ, Dodson CC. Stress fractures of the elbow in the throwing athlete: a systematic review. Orthop J Sports Med 2018;6(10):2325967118799262
    PubMedGoogle Scholar
  • 53 Andrews JR, Timmerman LA. Outcome of elbow surgery in professional baseball players. Am J Sports Med 1995; 23 (04) 407-413 DOI: 10.1177/036354659502300406.
    CrossrefPubMedGoogle Scholar
  • 54 Park JY, Yoo HY, Chung SW. et al. Valgus extension overload syndrome in adolescent baseball players: clinical characteristics and surgical outcomes. J Shoulder Elbow Surg 2016; 25 (12) 2048-2056
    CrossrefPubMedGoogle Scholar
  • 55 Paci JM, Dugas JR, Guy JA. et al. Cannulated screw fixation of refractory olecranon stress fractures with and without associated injuries allows a return to baseball. Am J Sports Med 2013; 41 (02) 306-312
    CrossrefPubMedGoogle Scholar
  • 56 Hy C, Eygendaal D, The B. Elbow arthroscopy – indications and technique. J Clin Orthop Trauma 2021; 19: 147-153
    CrossrefPubMedGoogle Scholar
  • 57 Rahusen FT, Brinkman JM, Eygendaal D. Results of arthroscopic debridement for osteochondritis dissecans of the elbow. Br J Sports Med 2006; 40 (12) 966-969
    CrossrefPubMedGoogle Scholar
  • 58 Benjamin HJ, Engel SC, Chudzik D. Wrist pain in gymnasts: a review of common overuse wrist pathology in the gymnastics athlete. Curr Sports Med Rep 2017; 16 (05) 322-329
    CrossrefPubMedGoogle Scholar
  • 59 Wolf MR, Avery D, Wolf JM. Upper extremity injuries in gymnasts. Hand Clin 2017; 33 (01) 187-197
    CrossrefPubMedGoogle Scholar
  • 60 Heyworth BE, Kramer DE, Martin DJ, Micheli LJ, Kocher MS, Bae DS. Trends in the presentation, management, and outcomes of Little League shoulder. Am J Sports Med 2016; 44 (06) 1431-1438
    CrossrefPubMedGoogle Scholar
  • 61 Bednar ED, Kay J, Memon M, Simunovic N, Purcell L, Ayeni OR. Diagnosis and management of Little League shoulder: a systematic review. Orthop J Sports Med 2021; 9 (07) 23 259671211017563
    CrossrefPubMedGoogle Scholar