Skip to main content
SpringerLink
Log in
Book cover

ESSKA Instructional Course Lecture Book pp 53–64Cite as

Stress Fractures in Sport (ICL 5)

  • Chapter
  • First Online:

  • 1001 Accesses

Abstract

Stress fractures arise from the inability of bone to tolerate repeated mechanical loading and are characterized by damage to the bone’s micro-architecture. Repeated mechanical loading can cause an uncoupling of osteoblast bone formation and osteoclast bone resorption [1]. This can lead to bone loss and subsequent micro-damage that can result in localized bone weakening, resulting in stress fracture development. The etiology of stress fractures is multifactorial. The rate of occurrence depends on the bone composition, vascular supply, surrounding muscle attachments, systemic factors, and type of athletic activity. From a biomechanical standpoint, stress fractures may be the result of muscle fatigue, which leads to the transmission of excessive forces to the underlying bone. Muscles may also contribute to stress injuries by concentrating forces across a localized area of bone, thus causing mechanical insults that exceed the stress-bearing capacity of the bone (Table 5.1) [2, 3].

This is a preview of subscription content, log in via an institution.

Chapter
USD   29.95
Price excludes VAT (USA)
  • Available as PDF
  • Read on any device
  • Instant download
  • Own it forever
eBook
USD   79.99
Price excludes VAT (USA)
  • Available as EPUB and PDF
  • Read on any device
  • Instant download
  • Own it forever
Softcover Book
USD   99.99
Price excludes VAT (USA)
  • Compact, lightweight edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info
Hardcover Book
USD   109.99
Price excludes VAT (USA)
  • Durable hardcover edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info

Tax calculation will be finalised at checkout

Purchases are for personal use only

Learn about institutional subscriptions

References

  1. Warden SJ, Burr DB, Brukner PD. Stress fractures: pathophysiology, epidemiology, and risk factors. Curr Osteoporos Rep. 2006;4:103–9.

    Article  PubMed  Google Scholar 

  2. Boden BP, Osbahr DC. High-risk stress fractures: evaluation and treatment. J Am Acad Orthop Surg. 2000;8(6):344–53.

    Article  CAS  PubMed  Google Scholar 

  3. Bennell K, Matheson G, Meeuwisse W, Brukner P. Risk factors for stress fractures. Sports Med. 1999;28:91–122.

    Article  CAS  PubMed  Google Scholar 

  4. Tenforde AS, Sayres LC, McCurdy ML, Sainani KL, Fredericson M. Identifying sex specific risk factors for stress fractures in adolescent runners. Med Sci Sports Exerc. 2013;45:1843–51.

    Article  CAS  PubMed  Google Scholar 

  5. Milner CE, Ferber R, Pollard CD. Biomechanical factors associated with tibial stress fracture in female runners. Med Sci Sports Exerc. 2006;38:323–8.

    Article  PubMed  Google Scholar 

  6. Matheson GO, Clement DB, McKenzie DC, et al. Stress fractures in athletes: a study of 320 cases. Am J Sports Med. 1987;03:46–58.

    Article  Google Scholar 

  7. Bennell KL. Epidemiology and site specificity of stress fractures. Clin Sports Med. 1997;16:179–96.

    Article  CAS  PubMed  Google Scholar 

  8. Boden BP, Osbahr DC, Jimenez C. Low-risk stress fractures. Am J Sports Med. 2001;29:100–11.

    CAS  PubMed  Google Scholar 

  9. Sonoda N, Chosa E, Totoribe K, Tajima N. Biomechanical analysis stress fractures of the anterior middle third of the tibia in athletes: nonlinear analysis using a three-dimensional finite elemento method. J Orthop Sci. 2003;8(4):505–13.

    Article  PubMed  Google Scholar 

  10. Korpelainen R, Orava S, Karpakka J, Siira P, Hulkko A. Risk factors for recurrent stress fractures in athletes. Am J Sports Med. 2001;29(3):304–10.

    CAS  PubMed  Google Scholar 

  11. Monteleone GP. Stress fractures in the athletes. Orthop Clin N Am. 1995;26(3):423–32.

    Google Scholar 

  12. Hulkho A, Orava S. Stress fractures in athletes. Int J Sports Med. 1987;8:221–6.

    Article  Google Scholar 

  13. Popovic N, Jalali A, Georis P, et al. Proximal fifth metatarsal diaphyseal stress fracture in football players. Foot Ankle Surg. 2005;11:135–41.

    Article  Google Scholar 

  14. Pearce CJ, Brooks JH, Kemp SP, Calder JD. The epidemiology of foot injuries in professional rugby union players. Foot Ankle Surg. 2011;17(3):113–8.

    Article  PubMed  Google Scholar 

  15. Raikin SM, Slenker N, Ratigan B. The association of a varus hindfoot and fracture of the fifth metatarsal metaphyseal-diaphyseal junction: the Jones fracture. Am J Sports Med. 2008;36:1367–72.

    Article  PubMed  Google Scholar 

  16. Cain LE, Nicholson LL, Adams RD, Burns J. Foot morphology and foot/ ankle injury in indoor football. J Sci Med Sport. 2007;10(5):311–9.

    Article  PubMed  Google Scholar 

  17. Van Meensel AS, Peers K. Navicular stress fracture in high-performing twin brothers: a case report. Acta Orthop Belg. 2010;76:407–12.

    PubMed  Google Scholar 

  18. Lambros G, Alder D. Multiple stress fractures of the tibia in a healthy adult. Am J Orthop. 1997;26:687–8.

    CAS  PubMed  Google Scholar 

  19. Loud KJ, Micheli LJ, Bristol S, Austin SB, Gordon CM. Family history predicts stress fracture in active female adolescents. Pediatrics. 2007;120:e364–72.

    Article  PubMed  PubMed Central  Google Scholar 

  20. Varley I, Hughes DC, Greeves JP, Stellingwerff T, Ranson C, Fraser WD, Sale C. RANK/RANKL/OPG pathway: genetic associations with stress fracture period prevalence in elite athletes. Bone. 2015;71:131–6.

    Article  CAS  PubMed  Google Scholar 

  21. Hosey RG, Fernandez MF, Johnson DL. Evaluation and management of stress fractures of the pelvis and sacrum. Orthopedics. 2015;71:131–6. doi: 10.1016/j.bone.2014.10.004.Epub 2014 Oct 29

  22. Pepper M, Akuthota V, McCarty EC. The pathophysiology of stress fractures. Clin Sports Med. 2006;25(1):1–16.

    Article  PubMed  Google Scholar 

  23. Lee CH, Huang GS, Chao KH, Jean JL, Wu SS. Surgical treatment of displaced stress fractures of the femoral neck in military recruits: a report of 42 cases. Arch Orthop Trauma Surg. 2003;123(10):527–33.

    Article  PubMed  Google Scholar 

  24. Lin JT, Lane JM. Sacral stress fractures. J Womens Health (Larchmt). 2003;12(9):879–88. Bono CM. Low-back pain in athletes. J Bone Jt Surg Am. 2004;86(2):382–96.

    Google Scholar 

  25. Kelly EW, Jonson SR, Cohen ME, Shaffer R. Stress fractures of the pelvis in female navy recruits: an analysis of possible mechanisms of injury. Mil Med. 2000;165(2):142–6.

    CAS  PubMed  Google Scholar 

  26. Shaffer RA, Rauh MJ, Brodine SK, Trone DW, Macera CA. Predictors of stress fracture susceptibility in young female recruits. Am J Sports Med. 2006;34(1):108–15.

    Article  PubMed  Google Scholar 

  27. Bennell KL, Malcolm SA, Thomas SA, Wark JD, Brukner PD. The incidence and distribution of stress fractures in competitive track and field athletes. A twelve month prospective study. Am J Sports Med. 1996;24(2):211–7.

    Article  CAS  PubMed  Google Scholar 

  28. Yeager KK, Agostini R, Nattiv A, Drinkwater B. The female athlete triad: disordered eating, amenorrhea, osteoporosis. Med Sci Sports Exerc. 1993;25(7):775–7.

    Article  CAS  PubMed  Google Scholar 

  29. Kelsey JL, Bachrach LK, Procter-Gray E, et al. Risk factor for stress fracture among young female cross-country runners. Med Sci Sports Exerc. 2007;29(9):1457–63.

    Article  Google Scholar 

  30. Beck TJ, Ruff CB, Mourtada FA, et al. Dual-energy X-ray absorptiometry derived structural geometry for stress fracture prediction in male U.S. Marine Corps recruits. J Bone Miner Res. 1996;11(5):645–53.

    Article  CAS  PubMed  Google Scholar 

  31. Egol KA, Koval KJ, Kummer F, Frankel VH. Stress fractures of the femoral neck. Clin Orthop Relat Res. 1998;348:72–8.

    Article  PubMed  Google Scholar 

  32. Jones BH, Harris JM, Vinh TN, Rubin C. Exercise-induced stress fractures and stress reactions of bone: epidemiology, etiology, and classification. Exerc Sport Sci Rev. 1989;17(1):379–422.

    CAS  PubMed  Google Scholar 

  33. Pavlov H, Nelson TL, Warren RF, Torg JS, Burstein AH. Stress fractures of the pubic ramus. A report of twelve cases. J Bone Joint Surg Am. 1982;64(7):1020–5.

    CAS  PubMed  Google Scholar 

  34. Major NM, Helms CA. Pelvic stress injuries: the relationship between osteitis pubis (symphysis pubis stress injury) and sacroiliac abnormalities in athletes. Skelet Radiol. 1997;26(12):711–7.

    Article  CAS  Google Scholar 

  35. Miller C, Major N, Toth A. Pelvic stress injuries in the athlete. Management and prevention. Sports Med. 2003;33(13):1003–12.

    Article  PubMed  Google Scholar 

  36. Fricker PA, Taunton JE, Ammann W. Osteitis pubis in athletes: infection, inflammation or injury? Sports Med. 1991;12(4):266–79.

    Article  CAS  PubMed  Google Scholar 

  37. Johnson AW, Weiss Jr CB, Stento K, Wheeler DL. Stress fractures of the sacrum. An atypical cause of low back pain in the female athlete. Am J Sports Med. 2001;29(4):498–508.

    CAS  PubMed  Google Scholar 

  38. Sofka CM. Imaging of stress fractures. Clin Sports Med. 2006;25:53–62.

    Article  PubMed  Google Scholar 

  39. Fredericson M, Moore W, Biswal S. Sacral stress fractures: magnetic resonance imaging not always definitive for early stage injuries: a report of 2 cases. Am J Sports Med. 2007;35(5):835–9.

    Article  PubMed  Google Scholar 

  40. Weistroffer JK, Muldoon MP, Duncan DD, Fletcher EH, Padgett DE. Femoral neck stress fractures: outcome analysis at minimum five-year follow-up. J Orthop Trauma. 2003;17(5):334–7.

    Article  PubMed  Google Scholar 

  41. Carpintero P, Leon F, Zafra M, et al. Stress fractures of the femoral neck and coxa vara. Arch Orthop Trauma Surg. 2003;123(6):273–7.

    Article  CAS  PubMed  Google Scholar 

  42. Armstrong 3rd DW, Rue JP, Wilckens JH, Frassica FJ. Stress fracture injury in young military men and women. Bone. 2004;35(3):806–16.

    Article  PubMed  Google Scholar 

  43. Raasch WG, Hergan DJ. Treatment of stress fractures: the fundamentals. Clin Sports Med. 2006;25(1):29–36.

    Article  PubMed  Google Scholar 

  44. Darabos N, Vlahović I. Surgical treatment of a femoral neck stress fracture without endocrinal comorbidity in an amateur sportswoman. Acta Chir Croat. 2015;12:37–41.

    Google Scholar 

  45. Iwamoto J, Takeda T. Stress fractures in athletes: review of 196 cases. J Orthop Sci. 2003;8:273–8.

    Article  PubMed  Google Scholar 

  46. Tuan K, Wu S, Sennett B. Stress fractures in athletes: risk factors, diagnosis and management. Orthopaedics. 2004;27:583–91.

    Google Scholar 

  47. Knapp T, Garrett W. Stress fractures: general concepts. Clin Sports Med. 1997;16:339–56.

    Article  CAS  PubMed  Google Scholar 

  48. Deutch A, Coel M, Mink J. Imaging of stress injuries to bone. Clin Sports Med. 1996;16:275–90.

    Article  Google Scholar 

  49. Batt ME, Kemp S, Kerslake R. Delayed union stress fractures of anterior tibia conservative management. Br J Sports Med. 2001;35(1):74–7.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  50. Chang PS, Hariss RM. Intramedullary nailing for chronic tibial stress fracture. Am J Sports Med. 1996;24(5):688–92.

    Article  CAS  PubMed  Google Scholar 

  51. Maffulli N, Longo UG, Gougoulias N, Caine D, Denaro V. Sport injuries: a review of outcomes. Br Med Bull. 2011;97:47–80.

    Article  PubMed  Google Scholar 

  52. Gehrmann RM, Renard RL. Current concepts review: stress fractures of the foot. Foot Ankle Int. 2006;27:750–7.

    PubMed  Google Scholar 

  53. Maitra RS, Johnson DL. Stress fractures clinical history and physical examination. Clin Sports Med. 1997;16:260–74.

    Article  Google Scholar 

  54. Maffulli N, Longo UG, Spiezia F, Denaro V. Aetiology and prevention of injuries in elite young athletes. Med Sport Sci. 2011;56:187–200.

    Article  PubMed  Google Scholar 

  55. Beck BR, Matheson GO, Bergman G, et al. Do capacitively coupled electric fields accelerate tibial stress fracture healing? A randomized controlled trial. Am J Sports Med. 2008;36:545–53.

    Article  PubMed  Google Scholar 

  56. Benazzo F, Mosconi M, Beccarisi G, Galli U. Use of capacitative coupled electric fields in stress fractures in athletes. Clin Orthop Relat Res. 1995;310:145–9.

    PubMed  Google Scholar 

  57. Busse JW, Kaur J, Mollon B, et al. Low intensity pulsed ultrasonography for fractures: systematic review of randomized controlled trials. BMJ. 2009;27:338–51.

    Google Scholar 

  58. Khan Y, Laurencin CT. Fracture repair with ultrasound: clinical and cell based evaluation. J Bone Joint Surg Am. 2008;90 suppl 1:S138–44.

    Article  Google Scholar 

  59. Li J, Waugh LJ, Hui SL, Warden SJ. Low-intensity pulsed ultrasound and nonsteroidal anti-inflammatory drugs have opposing effects during stress fracture repair. J Orthop Res. 2007;25:1559–67.

    Article  CAS  PubMed  Google Scholar 

  60. Rue JP, Armstrong III DW, Frassica FJ, Deafenbaugh M, Wilckens JH. The effect of pulsed ultrasound in the treatment of tibial stress fractures. Orthopedics. 2004;27:1192–5.

    PubMed  Google Scholar 

  61. Barrett JG, Sample SJ, McCarthy J, Kalsheur VL, Muir P, Prokuski L. Effect of short-term treatment with alendronate on ulnar bone adaptation to cyclic fatigue loading in rats. J Orthop Res. 2007;25:1070–7.

    Article  CAS  PubMed  Google Scholar 

  62. Finestone A, Milgrom C. How stress fracture incidence was lowered in the Israeli army: a 25-year struggle. Med Sci Sports Exerc. 2008;40 suppl 11:S630–5.

    Article  PubMed  Google Scholar 

  63. Voss LA, Fadale PD, Hulstyn MJ. Exercise-induced loss of bone density in athletes. J Am Acad Orthop Surg. 1998;6:349–57.

    Article  CAS  PubMed  Google Scholar 

  64. Nieves JW, Melsop K, Curtis M, et al. Nutritional factors that influence change in bone density and stress fracture risk among young female crosscountry runners. PM R. 2010;2:740–50.

    Article  PubMed  Google Scholar 

  65. Ruffing JA, Cosman F, Zion M, et al. Determinants of bone mass and bone size in a large cohort of physically active young adult men. Nutr Metab (Lond). 2006;15:3–14.

    Google Scholar 

  66. McCormick JJ, Bray CC, Davis WH, Cohen BE, Jones CP, Anderson RB. Clinical and computed tomography evaluation of surgical outcomes in tarsal navicular stress fractures. Am J Sports Med. 2011;39:1741–8.

    Article  PubMed  Google Scholar 

  67. Maffulli N, Longo UG, Spiezia F, Denaro V. Sports injuries in young athletes: long-term outcome and prevention strategies. Phys Sports Med. 2010;38(2):29–34.

    Article  Google Scholar 

  68. Maffulli N, Longo UG, Gougoulias N, Loppini M, Denaro V. Long-term health outcomes of youth sports injuries. Br J Sports Med. 2010;44(1):21–5.

    Article  CAS  PubMed  Google Scholar 

  69. Saxena A, Krisdakumtorn T. Return to activity after sesamoidectomy in athletically active individuals. Foot Ankle Int. 2003;24:415–9.

    PubMed  Google Scholar 

  70. Biedert R, Hintermann B. Stress fractures of the medial great toe sesamoids in athletes. Foot Ankle Int. 2003;24:137–41.

    PubMed  Google Scholar 

  71. Blundell CM, Nicholson P, Blackney MW. Percutaneous screw fixation for fractures of the sesamoid bones of the hallux. J Bone Joint Surg (Br). 2002;84:1138–41.

    Article  CAS  Google Scholar 

  72. Anderson RB, McBryde Jr AM. Autogenous bone grafting of hallux sesamoid nonunions. Foot Ankle Int. 1997;18:293–6.

    Article  CAS  PubMed  Google Scholar 

  73. Darabos N, Obrovac K, et al. Combined surgical therapy and orthotic management of stress and tuberosity avulsion fracture of the fifth metatarsal bone. JAPMA. 2009;99(6):529–35.

    Google Scholar 

Download references

Author information

Authors and Affiliations

  1. General, Orthopaedic and Traumatology Surgeon, Department of Sports Traumatology, Clinic for Traumatology, Clinical Hospital Center Sisters of Charity Medical School, University of Zagreb, Draskoviceva 19, 10000, Zagreb, Croatia

    Nikica Darabos MD, PhD

  2. Consultant Orthopaedic Surgeon, Knee and Hip Specialist, Sports Surgery Clinic, Santry, Dublin 9, Ireland

    Mihai Vioreanu MD, MCh, FRCSI (Tr&Orth)

  3. Orthopaedic Surgeon, Faculty of Medicine, University of Belgrade, Dr Subotica 6a, Belgrade, Serbia

    Vladan Stevanovic MD

  4. Institute for Orthopedic Surgery “Banjica”, Mihajla Avramovica 28, Belgrade, Serbia

    Vladan Stevanovic MD

  5. Orthopaedic Surgeon, Department of Orthopaedic Surgery, Ljubljana University Medical Centre, Zaloška Cesta 9, 1000, Ljubljana, Slovenia

    Oskar Zupanc MD, PhD

  6. Department of Trauma and Orthopaedic Surgery, University Campus Bio-Medico of Rome, Via Álvaro Del Portillo, 200, 00128, Roma, Italy

    Umile Giusepe Longo MD, MSc, PhD

Authors
  1. Nikica Darabos MD, PhD
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Mihai Vioreanu MD, MCh, FRCSI (Tr&Orth)
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Vladan Stevanovic MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Oskar Zupanc MD, PhD
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Umile Giusepe Longo MD, MSc, PhD
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Nikica Darabos MD, PhD .

Editor information

Editors and Affiliations

  1. Med.Dir.Uni.Hosp.Brande."The.Fon.Med.Sch, Dept.ofOrtho.&Traumato.Cen.of Jt.Replac., Brandenburg, Brandenburg, Germany

    Roland Becker

  2. Academic Medical Center, Orthopaedic Surgery, AZ Amsterdam, The Netherlands

    Gino M.M.J. Kerkhoffs

  3. Universitat Autònoma de Barcelona, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain

    Pablo E. Gelber

  4. Istituto Clinico Humanitas, Monza, Italy

    Matteo Denti

  5. Centre Hospitalier de Luxembourg, Clinique d'Eich, Luxembourg, Luxembourg

    Romain Seil

Rights and permissions

Reprints and permissions

Copyright information

© 2016 ESSKA

About this chapter

Cite this chapter

Darabos, N., Vioreanu, M., Stevanovic, V., Zupanc, O., Longo, U.G. (2016). Stress Fractures in Sport (ICL 5). In: Becker, R., Kerkhoffs, G., E. Gelber, P., Denti, M., Seil, R. (eds) ESSKA Instructional Course Lecture Book . Springer, Berlin, Heidelberg. https://doi.org/10.1007/978-3-662-49114-0_5

Download citation

  • DOI: https://doi.org/10.1007/978-3-662-49114-0_5

  • Published:

  • Publisher Name: Springer, Berlin, Heidelberg

  • Print ISBN: 978-3-662-49113-3

  • Online ISBN: 978-3-662-49114-0

  • eBook Packages: MedicineMedicine (R0)

Publish with us

Policies and ethics

Search

Navigation