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Stress fractures and sports

Dr N Muambadzi
Stress fractures (In general) Specific regional injuries
• Epidemiology • Ankle and feet
• Pathophysiology • Leg
• Risk factors • MTSS (Shin splints)
• Presentation • Thigh
• Imaging • Hips and pelvis
• Management • Spondylolysis
• Upper limb
• Military service -closely linked
• The first report was in 1855
• The Prussian Army Physician Briethaupt described the syndrome of a
painful swollen foot associated with marching hence ‘march fracture’
• Bone has a remodelling response to mechanical stress
• Wolff’s Law
• Bone that is subject to a sudden increase in repetitive stress is
vulnerable to stress fracture
• A stress fracture is -type of incomplete fracture in bones
• It is a focal area of increased bone turnover secondary to the
repeated stress
• It could be described as a very small sliver or crack in the bone;
"hairline fracture".
• Osteoblastic response replaces the absorbed bone
• The process of rarefaction is faster than the osteoblastic process and
will progress if the individual continues with stressful activity and
• Complete fracture through the zone of rarefaction may occur
• Stages in development:
1. Crack initiation
2. Crack propagation
3. Rapid failure of bone

Note: Bone can repair itself quickly if strain removed before 3rd stage
Fatigue fractures

• Training regimen
• Training surface
• Bone anatomy

• Sex
• Nutrition
• Fitness
• Smoking
Clinical features
~ 40% of patients can be asymptomatic
>1 stress fracture can be found in up to 87% of patients
History of unaccustomed & repeated activity
Sequence-pain after exercise, pain during exercise, pain without
Load related pain-early symptom
Focal bone pain with palpation and stressing- Hallmark
pathophysiology basis of nuclear medicine El Gazaar
Specific regional injuries
• Tendonitis, Strains, Myositis,
• Ankle and foot
• Leg
• Thigh
• Sacral stress fracture
• Upper extremity
• Elbow and forearm
• Wrist and hand
Ankle and foot

• Navicular Stress Fracture

Running with abrupt stops and starts
Basketball -directs posterior to anterior force through the navicular
• Calcaneal stress fracture
The foot is imaged for unexplained pain
Focal linear increased tracer accumulation
Located in the superior mid portion of the calcaneus
• Metatarsal Stress Fracture
Most commonly occurring in the 2nd to 4th metatarsals
The uptake is focal and fusiform
Because of differences in management between fractures of the
tuberosity of the fifth metatarsal and of the metatarsal shaft
It is important to locate precisely the site of the fracture
• 5th Metatarsal
Proximal diaphysis of the bone just distal to the tuberosity &
ligamentous structures
Basketball players
Problematic site (prox 1.5cm of the diaphysis) where cortical
hypertrophy usually occurs in athletes, rendering zone avascular
Propensity for delayed union or non union and high risk of refracture
• Os trigonum syndrome
Accessory ossicle located at the posterior aspect of the talus
Posterior ankle pain
Pain increases with flexion of the great toe
Surgical removal often is necessary for relief of pain
• Achilles Tendonitis
The Achilles tendon AKA calcaneal tendon
Inserts into the middle part of the posterior surface of the calcaneus
• Plantar fasciitis
Traumatic inflammation secondary to a strain or rear of the long
plantar ligament/aponeurosis.
More typical pain
• Lisfranc Fracture
Fracture-dislocation of the tarsometatarsal joint
Common injury among cavalry officers and among patients involved in
motor vehicle accidents.
Also sports-related
Occur as a result of combined forced plantar flexion and rotation

• Tibial Stress Fracture

Most commonly detected on delayed bone scans as solitary, focal,
fusiform, longitudinally oriented areas of increased uptake
Involving the posterior medial cortex
• Fibular Stress Fracture
Less common than tibial stress fractures
They occur most often in the lower third of the bone
Secondary to stress resulting from powerful contraction of the flexor
muscles of the ankle and foot
• Shin splints/MTSS
Result from periosteal reaction
Caused by microperiosteal tears from abnormal stress
Mediated by Sharpey fibers
Usually do not progress to further trauma to the bone
Cause increased tracer uptake in a bone scan
• Femoral Shaft
Proximal medial shaft of the femur in runners demonstrate focal, fusiform
increased activity on delayed

• Femoral neck
High complication rate
Compression type more common- benign

Tension type-superior cortex

High chance of displacement and progression
Pelvis and hips

• Pubic Symphysitis
Common among runners
Avulsion of the adductor and rectus abdominis muscles
The symptoms often are vague
Pain referred to the lower abdomen or groin, occasionally with perineal
• Sacral stress fracture:
In the sacrum, stress fractures are associated with:
• Osteoporosis
• Prior radiation therapy to the pelvis
• The fractures appear as a hot, geographic lesions confined to the sacrum
• Characteristic "butterfly" or "Honda sign" appearance

Plain film are typically normal

• Spondylolysis
The incidence in the general population 6-7%
Result in the presenting complaint of back pain

Other patients –incidental and asymptomatic

MD, and Nandita Bhattacharjee, MD, MHA; Marshfield Clinic
Department of Radiology.
Elbow and forearm
• Medial epicondylitis (Little League elbow)
• Lateral epicondylitis (Tennis elbow)
• Scaphoid fractures
Most common, accounting for 60-70% of all carpal injuries
The tenuous blood supply through the waist of the bone may cause
Readily visualized within 3 days of trauma -Scintigraphy
Diagnosis & Imaging
• Early diagnosis:
Minimise not only time away from training
Preclude non-union or a catastrophic displaced fracture

• Delay in diagnosis can lead:

To medical discharge from the Services for military personnel
Early retirement from sport

• A thorough history should be established :

risk factors discussed above
• Radiographic findings:
Lucent fracture line or focal sclerosis due to callous formation
The degree of confidence is low
Initial radiographs usually are negative
Even follow-up studies are positive in only 50% of patients

The delay in the appearance of findings can result in false negatives

Can hold up therapy until the diagnosis is made by scintigraphy
. Courtesy of Drs. Mike Handlon, Jennifer Keilp, and Molly
• CT scan
May be performed to diagnose stress fractures

Disruption of the bony cortex and evidence of periostitis

The sensitivity of CT scans is higher than that of plain films

Compared with MRI /bone scanning, the sensitivity is low, resulting in a

high rate of false negatives

Low signal on T1- and T2-weighted images is the classic appearance

Useful in patients with severe osteoporosis
Highly sensitive for the detection of bone marrow changes
Better anatomic resolution
Distinguishing between arthritis, osteomyelitis, and osteonecrosis
…of which potentially can have the same appearance on a bone scan
. Courtesy of Drs. Mike Handlon, Jennifer Keilp, and Molly
Phase bone scan and SPECT/CT
More sensitive
• >80% of stress fractures will not be evident on initial radiographs
Sensitivity ~ 100%
• Features on bone scan:
Solitary / Focal / Fusiform areas of increased tracer activity
Uptake generally lasting for 10 to 12 weeks
Increased flow (for up to 3 to 4 weeks after onset of pain)
Increased blood pool (for 6 to 8 weeks) activity may also be seen
• The most important aspect of management is early diagnosis

• Majority can be successfully treated non-operatively by avoidance of

the stressing activity
• Fundamental principle is REST
• Identifying and correcting predisposing factors
• Hormone replacement therapy
• Training errors-identified and corrected
• Low Risk
A rest period of 1-6 weeks of limited weight bearing
Phase of low impact activities than slowly returning to high impact

• High Risk
Predilection for progressing to complete fracture
More aggressive treatment approach
Due to high complication rate treated as acute fracture
Algorith femoral stress gfractures
• Journal of orthopaedic trauma, stress fractures Mark R Philipson Paul
J Parker
• Abdelhamid H. Elgazzar (Ed.) The Pathophysiologic Basis of Nuclear
Medicine Second Edition
• Nuclear Medicine in clinical diagnosis and treatment PJ ELL and SS
Gambhir, 3rd edition
• Nuclear medicine the requisites, Harvey Ziessman et al 4th edition
• Atlas of clinical nuclear medicine, Fogelman 3rd edition