Stress Fractures in Athletes (eBook)

Timothy L. Miller, MD, Assistant Professor, Department of Orthopedics, Physician Lead, Endurance Medicine, Sports Medicine Center, Team Physician, Department of Athletics, The Ohio State University, Columbus, OH, USA. Christopher C. Kaeding, MD, Judson Wilson Professor, Department of Orthopedics, Executive Director, Sports Medicine Center, Head Team Physician, Department of Athletics, The Ohio State University, Columbus, OH, USA.

Dedication 6
Preface 8
Contents 10
Contributors 12
Abbreviations 16
Part I: Presentation and Diagnosis of Stress Fractures 17
1: Pathophysiology and Epidemiology of Stress Fractures 18
Stress Fracture Pathophysiology 18
Bone Biology 18
Bone Pathophysiology in Stress Fractures 19
Host Risk Factors for the Development of Bone Stress Injury 20
Bone Mineral Density and Bone Thickness 20
Genetics 21
Nutritional Factors 21
Menstrual Irregularity 21
Summary 22
Stress Fracture Epidemiology 22
Stress Fracture Epidemiology: Military 22
Stress Fracture Epidemiology: Running 23
Stress Fracture Epidemiology: Tennis 24
Stress Fracture Epidemiology: Pediatric/Adolescent Athletes 24
Stress Fracture Epidemiology: Other Sports 24
Summary 24
References 25
2: General Treatment Concepts for Stress Fractures 27
Basic Principles 27
Initial Evaluation 28
Extrinsic Factors 29
Intrinsic Variables 30
Treatment Modalities 31
Activity Modification 31
Pharmacologic Therapies 32
Vitamins 32
NSAIDs 33
Bisphosphonates 33
Forteo (Teriparatide) 34
Adjunctive Therapies 36
Low-Intensity Pulsed Ultrasound 36
Extracorporeal Shock-Wave Therapy 37
Electrical Stimulation 38
Hyperbaric Oxygen 38
Surgical Decision Making 38
Summary 41
References 41
3: Biomechanics and Gait Analysis for Stress Fractures 46
Introduction 46
Overview of Running Biomechanics 46
Static Biomechanical Assessment 48
Foot Type Classification 48
Other Structural Links to Stress Fracture 49
Running Gait Analysis 49
Observational Gait Analysis 49
Motion Analysis 50
Running Biomechanical Assessment 51
Sagittal Plane Mechanics 51
Foot Position and Strike Pattern 52
Hip and Knee 54
Stride Characteristics 55
Frontal and Transverse Plane Mechanics 55
Trunk, Pelvis, and Hip 56
Knee and Lower Leg 57
Foot and Ankle 57
General Treatment and Gait Retraining 60
Summary 60
References 60
4: Classification of Stress Fractures 64
Defining a Stress Fracture 64
Features of a Quality Classification System 65
High-Risk vs. Low-Risk Stress Fractures 65
Current and Historical Classification Systems 67
Kaeding–Miller Classification System [22] 68
Summary 72
References 73
5: Imaging of Stress Fractures 75
Introduction 75
Evolution of Imaging 76
Imaging Techniques 77
Radiography 77
Radionuclide Scintigraphy 80
Ultrasound 82
Computed Tomography 82
Magnetic Resonance Imaging 85
Summary 89
References 89
Part II: Management of Stress Fractures 92
6: Stress Fractures of the Lumbar Spine 93
Introduction 93
Epidemiology 94
Athletes 94
Anatomy, Biomechanics, and Pathogenesis 94
History and Physical Exam 95
Diagnostic Imaging 97
Radiographs 97
Bone Scintigraphy 98
Computed Tomography (CT) and Staging 98
Magnetic Resonance Imaging (MRI) 99
Reasonable Imaging Algorithm 100
Treatment 101
Bracing 101
Activity Modification and Rest from Sports 103
Rehabilitation Stages 103
Outcomes 104
Recurrent Pain After Returning to Sport 105
Associated Injury and Other Lumbar Stress Fractures 105
Summary 106
References 106
7: Stress Fractures of the Pelvis 110
Introduction 110
Sacral Stress Fractures 110
Presentation and Physical Examination 111
Diagnostic Imaging 111
Pubic Rami Stress Fractures 111
Presentation and Physical Examination 112
Diagnostic Imaging 112
Iliac Wing Stress Fractures 113
Apophyseal Avulsion Fractures 113
Presentation and Physical Examination 115
Diagnostic Imaging 115
Management 115
The Role of Nutrition 117
Summary 117
References 117
8: Stress Fractures of the Femur 120
Introduction 120
Epidemiology and Risk Factors 120
Pathophysiology and Classification 122
Diagnosis 125
Imaging 127
Management 129
Return to Sports 131
Summary 132
References 132
9: Stress Fractures of the Patella 134
Introduction 134
Definition 134
Incidence 137
Biomechanics of Injury 138
Diagnosis 140
Management 141
References 143
10: Stress Fractures of the Tibia 145
Introduction 145
Relevant Anatomy and Biomechanics 145
Definition and Classification 146
Risk Factors 147
History 147
Pain Localization 148
Exacerbating and Relieving Factors 148
Other Findings 149
Physical Examination 149
Tibia-Specific Physical Examination 149
Inspection 150
Palpation 150
Motion, Strength, and Special Testing 151
Imaging 151
Treatment 152
Critical Points 153
References 154
11: Stress Fractures of the Fifth Metatarsal 156
Introduction 156
Anatomy 156
Pathophysiology 157
Classification 159
Diagnosis 159
Imaging 160
Radiographs 160
CT Scan 160
MRI and Bone Scintigraphy 160
Treatment 160
Nonoperative 160
Operative 161
Clinical Cases 162
Case 1 162
Case 2 162
Case 3 163
Outcomes 165
Return to Sports Decision-Making 165
Summary 165
References 165
12: Stress Fractures of the Ankle 167
Introduction 167
Stress Fractures of the Lateral Malleolus 167
Incidence, Pathophysiology, and Risk Factors 167
Presentation 168
Physical Examination 168
Imaging 168
Treatment 169
Nonoperative Treatment 169
Operative Treatment 170
Stress Fractures of the Medial Malleolus 170
Incidence, Pathophysiology, and Risk Factors 170
Presentation 170
Physical Examination 171
Imaging 171
Treatment 172
Nonoperative 172
Operative 173
Summary 174
References 175
13: Stress Fractures of the Calcaneus, Sesamoids, and Metatarsals 176
Calcaneus 176
Signs and Symptoms 176
Imaging 177
Treatment 178
Special Circumstances 178
Sesamoids 179
Clinical Presentation 180
Treatment 181
Excision 182
Bone Grafting 182
Percutaneous Screw Fixation 182
First Through Fourth Metatarsals 183
First Metatarsal 183
Second, Third, and Fourth Metatarsals 183
Background 183
Pathophysiology 183
Clinical Presentation 184
Imaging 185
Treatment 185
Prevention 186
Fifth Metatarsal 186
Classification/Grading 186
Pathophysiology 187
Clinical Presentation 188
Imaging 189
Treatment 189
Prevention 191
References 192
14: Stress Fractures of the Ribs and Girdle 197
Introduction 197
Risk Factors 198
Clinical Presentation 198
Physical Examination 198
Differential Diagnosis 198
Causative Activities 199
Stress Fracture of the Ribs 200
First Rib 200
Second Through 12th Ribs 200
Sternum 201
Scapula 201
Clavicle 202
Proximal Humerus 203
Little League Shoulder 203
Diagnostic Imaging 204
X-Ray 204
CT 204
Bone Scan 204
MRI 204
Classification 205
General Treatment Principles 205
Return to Sports Participation 206
Prevention of Rib and Shoulder Girdle Stress Fractures 206
Summary 206
References 207
15: Upper Extremity Stress Fractures 209
Introduction 209
Humerus 209
Spiral Stress Fractures 209
Mechanism: Throwing Athletes 209
Mechanism: Racquet Athletes 210
Presentation 210
Diagnosis 211
Treatment 211
Prognosis 211
Transverse Stress Fractures 212
Mechanism 212
Presentation 212
Diagnosis 212
Treatment 212
Prognosis 212
Olecranon 213
Presentation 213
Diagnosis 213
Proximal-Third (Tip) Fractures 213
Mechanism 213
Diagnosis 213
Treatment 213
Prognosis 214
Middle-Third (Oblique) Fractures 214
Mechanism 214
Diagnosis 214
Treatment 215
Prognosis 215
Physeal (Transverse) Fractures and Osteochondroses 215
Mechanism: Transverse Fractures 215
Mechanism: Osteochondroses 215
Presentation and Diagnosis 215
Treatment 215
Prognosis 216
Ulna 216
Mechanism 216
Presentation 217
Diagnosis 217
Treatment and Prognosis 217
Radius 217
Mechanism 217
Presentation 218
Diagnosis 218
Treatment 218
Prognosis 220
Scaphoid 220
Mechanism 220
Presentation 220
Diagnosis 220
Treatment and Prognosis 221
Metacarpals 221
Mechanism 221
Presentation 221
Diagnosis 221
Treatment and Prognosis 222
Phalanges 222
Mechanism 222
Presentation 222
Diagnosis 222
Treatment and Prognosis 223
Conclusion 223
References 223
16: Insufficiency Fractures 227
Causes of Insufficiency Fractures 227
Osteopenia and Osteoporosis 227
The Female Athlete Triad and Decreased Bone Mineral Density 229
Osteomalacia/Rickets 230
Paget’s Disease of Bone 231
Radiation-Induced Fractures 231
Presentation of Insufficiency Fractures 232
Imaging of Insufficiency Fractures 232
Radiography 232
Multidetector CT Scanning 232
Magnetic Resonance Imaging 232
Bone Scintigraphy 232
Specific Sites of Insufficiency Fractures and Management 233
Pelvis 233
Sacrum 233
Spine 234
Hip and Femur 234
Tibia 236
Foot 237
Upper Extremity 238
Summary 238
References 239
Index 242