Course

Stress Fractures

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12 Lessons

Stress fractures represent the failure of the bony skeleton to absorb repetitive loads. This results in structural fatigue of the bone, causing pain, performance impairment and potentially a complete fracture. Loading can be intrinsic through transmission of impact forces within the bone and/or extrinsic via the application of tension across bone from the muscles and connective tissue. As a result, a footballer with a stress fracture may suffer prolonged periods out of the game and require further medical interventions including surgery.

Bone strain can be described in a continuum from bone strain (mild) to stress reaction to stress fracture (severe) and, ultimately, fracture.

The management of stress fractures generally involves a reduction of the inciting load to restore the normal bone physiology. In some cases, however, stress fractures may require special consideration and treatment. Prevention and early recognition of stress fractures is required to reduce the impact on the player.

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Learning outcomes

By the end of this topic, you should:

  • be aware of the basic science relating to stress fractures, including the epidemiology of these injuries in football,
  • be able to diagnose bone stress injuries by taking an appropriate history, examination and order appropriate investigation (where needed),
  • understand and be able to implement an appropriate conservative treatment and rehabilitation programme to treat common stress fractures in football players,
  • understand the indications for surgical treatment and be able to initiate an appropriate referral,
  • understand the potential sequelae following cervical injuries and their treatment,
  • have an understanding regarding the effectiveness and implementation of injury prevention programmes.

Tasks

  • Review the provided text and media content
  • Read the provided articles
  • Complete the case-based assessment task

Suggested reading

Brukner and Khan’s
Clinical Sports Medicine – 4th edition
Chapter 5, pages 25-38

References

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  2. Bennell K., Matheson G., Meeuwisse W., Brukner P. Risk factors for stress fractures. Sports Med. 1999;28(2):91-122.
  3. Popp K.L., Hughes J.M., Smock A.J., et al. Bone geometry, strength, and muscle size in runners with a history of stress fracture. Med Sci Sports Exerc. 2009;41(12):2145-2150.
  4. Ekstrand J., Torstveit M.K. Stress fractures in elite male football players. Scand J Med Sci Sports. 2012;22(3):341-346.
  5. Warden S.J., Creaby M.W., Bryant A..L, Crossley K.M. Stress fracture risk factors in female football players and their clinical implications. Br J Sports Med. 2007;41 Suppl 1:i38-43.
  6. Sundgot-Borgen J., Torstveit M.K. The female football player, disordered eating, menstrual function and bone health. Br J Sports Med. 2007;41 Suppl 1:i68-72.
  7. Patel D.S., Roth M., Kapil N. Stress fractures: Diagnosis, treatment, and prevention. Am Fam Physician. 2011;83(1):39-46.
  8. Liong S.Y., Whitehouse R.W. Lower extremity and pelvic stress fractures in athletes. Br J Radiol. 2012;85(1016):1148-1156.
  9. De Souza M.J., Nattiv A., Joy E., et al. 2014 female athlete triad coalition consensus statement on treatment and return to play of the female athlete triad: 1st international conference held in San Francisco, California, May 2012 and 2nd international conference held in Indianapolis, Indiana, May 2013. Br J Sports Med. 2014;48(4):289-2013-093218.
  10. Friedl K.E., Evans R.K., Moran D.S. Stress fracture and military medical readiness: Bridging basic and applied research. Med Sci Sports Exerc. 2008;40(11 Suppl):S609-22.
  11. Cobb K.L., Bachrach L.K., Sowers M. et al. The effect of oral contraceptives on bone mass and stress fractures in female runners. Med Sci Sports Exerc. 2007;39(9):1464-1473.
  12. Bashardoust Tajali S., Houghton P., MacDermid J.C., Grewal R. Effects of low-intensity pulsed ultrasound therapy on fracture healing: A systematic review and meta-analysis. Am J Phys Med Rehabil. 2012;91(4):349-367.
  13. Swenson E.J. Jr, DeHaven K.E., Sebastianelli W.J., Hanks G., Kalenak A., Lynch J.M. The effect of a pneumatic leg brace on return to play in athletes with tibial stress fractures. Am J Sports Med. 1997;25(3):322-328.
  14. Khan K.M., Fuller P.J., Brukner P.D., Kearney C., Burry H.C. Outcome of conservative and surgical management of navicular stress fracture in athletes. Eighty-six cases proven with computerized tomography. Am J Sports Med. 1992;20(6):657-666.
  15. 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(2):96-103.
  16. Mallee W.H., Weel H., van Dijk C.N., van Tulder M.W., Kerkhoffs G.M., Lin C.W. 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(6):370-376.
  17. Ekstrand J., van Dijk C.N. Fifth metatarsal fractures among male professional footballers: A potential career-ending disease. Br J Sports Med. 2013;47(12):754-758.
  18. Lee K.T., Park Y.U., Jegal H., Kim K.C., Young K.W., Kim J.S. Factors associated with recurrent fifth metatarsal stress fracture. Foot Ankle Int. 2013;34(12):1645-1653.
  19. Torg J.S., Balduini F.C., Zelko R.R., Pavlov H., Peff T.C, 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(2):209-214.
  20. Gregory P.L., Batt M.E., Kerslake R.W. Comparing spondylolysis in cricketers and soccer players. Br J Sports Med. 2004;38(6):737-742.
  21. Standaert C., Herring S. Spondylolysis: A critical review. Br J Sports Med. 2000;34(6):415-422.
  22. Batt M.E., Kemp S., Kerslake R. Delayed union stress fractures of the anterior tibia: Conservative management. Br J Sports Med. 2001;35(1):74-77.
  23. Cruz A.S., de Hollanda J.P., Duarte A. Jr, Hungria Neto J.S. Anterior tibial stress fractures treated with anterior tension band plating in high-performance athletes. Knee Surg Sports Traumatol Arthrosc. 2013;21(6):1447-1450.
  24. Boden B.P., Speer K.P. Femoral stress fractures. Clin Sports Med. 1997;16(2):307-317.
  25. Johnson A.W., Weiss C.B. Jr, Wheeler D.L. Stress fractures of the femoral shaft in athletes–more common than expected. A new clinical test. Am J Sports Med. 1994;22(2):248-256.
  26. Jowett A.J., Birks C.L., Blackney M.C. Medial malleolar stress fracture secondary to chronic ankle impingement. Foot Ankle Int. 2008;29(7):716-721.
  27. Schils J.P., Andrish J.T., Piraino D.W, Belhobek G.H., Richmond B.J., Bergfeld J.A. Medial malleolar stress fractures in seven patients: Review of the clinical and imaging features. Radiology. 1992;185(1):219-221.
  28. Shelbourne K.D., Fisher D.A., Rettig A.C., McCarroll J.R. Stress fractures of the medial malleolus. Am J Sports Med. 1988;16(1):60-63.
  29. Orava S., Karpakka J., Taimela S., Hulkko A., Permi J., Kujala U. Stress fracture of the medial malleolus. J Bone Joint Surg Am. 1995;77(3):362-365.