Stress fractures in runners

An assessment of the diagnosis, treatment, and outcomes of lower extremity stress fractures in pediatric and adolescent populations

OBJECTIVES

To present one of the first descriptive case series of pediatric and adolescent lower extremity stress injuries, their management, and outcomes in athletes and non-athletes.

METHODS

The IRB-approved retrospective study included patients under 18 years at a tertiary children's hospital who were diagnosed with a lower extremity stress fracture/reaction. Demographic data, mechanism of injury, physical exam, radiographic findings, treatment, & outcomes were collected. Descriptive statistical analysis was conducted.

RESULTS

Ninety-seven patients with stress injuries on clinical exams and on radiographs or MRI were included. The average age when diagnosed was 11.7 years (range 1.1-18 years) and the most common injuries were to the tibia (n = 33, 28.4%) and the least common involved were the cuneiforms (n = 4, 3.4%). Patients under the age of 14 were more likely to experience cuboid and calcaneal stress injuries (mean age 5.5 and 8.3 years respectively). Nineteen patients (19.6%) had high-risk stress fractures, with the average age of 14.9 years versus 11.6 for those with low risk (p-value = 0.01) and return to activity time being 15 weeks compared to 10.5 (p-value = 0.027). The most common forms of treatment were controlled ankle motion (CAM), walker boots (58.6%), and physical therapy (PT) (38.1%). The mean Lower Extremity Function Score of the patient population was 73.8, indicating no clinically important difference from full functionality.

CONCLUSION

Lower extremity stress injuries in this cohort were most seen in the tibia, although patients younger than 14 had a high number of cuboid and calcaneal stress injuries. Those with high-risk stress fractures were older and took longer to recover from when compared to low-risk injuries. Treatment is commonly conservative, with CAM boots and PT being the most frequently utilized interventions and serving as a successful approach to treatment, with patients returning to activity at an average of 11.4 weeks, which is comparable to similar studies.

[High-risk stress fractures in competitive athletes]

Bone stress injuries are chronic overload reactions of the bone, which are characterized by the load-dependent occurrence of locally perceived pain and tenderness on palpation at the site of the injury. Structurally normal bone becomes fatigued as a result of repetitive submaximal loading and/or inadequate regeneration. Certain stress fractures of the femoral neck (tension side), patella, anterior tibial cortex, medial malleolus, talus, tarsal navicular bone, proximal fifth metatarsal, and sesamoid bones of the great toe tend to develop complications (complete fractures, delayed union, pseudarthrosis, dislocation, arthrosis). These injuries are classified as high-risk stress fractures. Aggressive diagnostics and treatment are recommended when a high-risk stress fracture is suspected. Treatment is frequently different from low-risk stress fractures, including prolonged non-weight-bearing immobilization. In rare cases, surgery is indicated when conservative treatment fails, when a complete or non-healing fracture develops, or in cases of dislocation. The outcomes of both conservative and operative treatment are described as less successful compared with low-risk stress injuries.

Return to sport following low-risk and high-risk bone stress injuries: a systematic review and meta-analysis

OBJECTIVE

Bone stress injuries (BSIs) are classified in clinical practice as being at low- or high-risk for complication based on the injury location. However, this dichotomous approach has not been sufficiently validated. The purpose of this systematic review was to examine the prognostic role of injury location on return-to-sport (RTS) and treatment complications after BSI of the lower extremity and pelvis.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

PubMed, Web of Science, Cochrane CENTRAL and Google Scholar databases were searched from database inception to December 2021.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Peer-reviewed studies that reported site-specific RTS of BSIs in athletes.

RESULTS

Seventy-six studies reporting on 2974 BSIs were included. Sixteen studies compared multiple injury sites, and most of these studies (n=11) described the anatomical site of injury as being prognostic for RTS or the rate of treatment complication. Pooled data revealed the longest time to RTS for BSIs of the tarsal navicular (127 days; 95% CI 102 to 151 days) and femoral neck (107 days; 95% CI 79 to 135 days) and shortest duration of time for BSIs of the posteromedial tibial shaft (44 days, 95% CI 27 to 61 days) and fibula (56 days; 95% CI 13 to 100 days). Overall, more than 90% of athletes successfully returned to sport. Treatment complication rate was highest in BSIs of the femoral neck, tarsal navicular, anterior tibial shaft and fifth metatarsal; and lowest in the fibula, pubic bone and posteromedial tibial shaft.

CONCLUSION

This systematic review supports that the anatomical site of BSIs influences RTS timelines and the risk of complication. BSIs of the femoral neck, anterior tibial shaft and tarsal navicular are associated with increased rates of complications and more challenging RTS.

PROSPERO REGISTRATION NUMBER

CRD42021232351.

Does Magnetic Resonance Imaging Grading Correlate With Return to Sports After Bone Stress Injuries? A Systematic Review and Meta-analysis

BACKGROUND

While some studies have failed to reveal any significant relationship between magnetic resonance imaging (MRI) grading and return to sports after bone stress injuries, others have reported either a linear or nonlinear relationship.

PURPOSE

To evaluate the prognostic value of MRI grading for time to return to sports and rate of return to sports after bone stress injuries.

STUDY DESIGN

Systematic review and meta-analysis.

METHODS

A systematic search was performed in PubMed, Web of Science, SPORTDiscus, and Google Scholar. Studies reporting return to sports data after bone stress injuries using MRI grading systems were included in this review. The risk of bias was evaluated using the Quality in Prognosis Studies tool. Meta-analyses were performed to summarize the mean time to return to sports. The Pearson correlation was used to determine the relationship between time to return to sports and MRI grade. A meta-analysis of proportions was conducted to determine the percentage of athletes who successfully returned to sports.

RESULTS

A total of 16 studies with 560 bone stress injuries met inclusion criteria. Higher MRI-based grading was associated with an increased time to return to sports (P < .00001). Pooled data revealed that higher MRI-based grading correlated with a longer time to return to sports (r = 0.554; P = .001). Combining all anatomic locations, the mean time to return to sports was 41.7 days (95% CI, 30.6-52.9), 70.1 days (95% CI, 46.9-93.3), 84.3 days (95% CI, 59.6-109.1), and 98.5 days (95% CI, 85.5-112.6) for grade 1, 2, 3, and 4 injuries, respectively. Trabecular-rich sites of injury (eg, pelvis, femoral neck, and calcaneus) took longer to heal than cortical-rich sites of injury (eg, tibia, metatarsal, and other long-bone sites of injury). Overall, more than 90% of all athletes successfully returned to sports.

CONCLUSION

The findings from this systematic review indicate that MRI grading may offer a prognostic value for time to return to sports after the nonsurgical treatment of bone stress injuries. Both MRI grade and location of injury suggest that individually adapted rehabilitation regimens and therapeutic decisions are required to optimize healing and a safe return to sports.

Generalized Uncoupled Bone Remodeling Associated With Delayed Healing of Fatigue Fractures

Fatigue fractures in bones are common injuries with load‐bearing activities, during which the remodeling aimed at removing microdamage has been suggested to play a role in increasing related fracture risk. Much attention has been given to the uncoupling between osteoclastic bone resorption and osteoblastic osteogenesis in fatigue fracture cases; however, the underlying pathophysiologic mechanisms of impaired fracture healing are yet unknown. Here we report multiple fatigue fractures in a physically active woman receiving contraceptive pills for years. Her fracture healing was remarkably slow, although she has been otherwise healthy. The patient underwent bone biopsy of the iliac crest that showed remarkable peritrabecular fibrosis with increased osteoclastic bone resorption combined with relatively low bone formation. Analysis of bone biochemical composition revealed a more complex picture: First, notable declines in bone mineral content–based parameters indicating abnormal mineralization were evident in both cancellous and cortical bone. Second, there was elevation in mineral crystal size, perfection, and collagen maturity in her bone tissues from different anatomical sites. To our knowledge, this is the first report showing generalized uncoupling in bone remodeling, increased peritrabecular fibrosis, and bone compositional changes associated with delayed healing of fatigue fractures. These results may explain delayed healing of fatigue and stress fractures. © 2021 The Authors. JBMR Plus published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research.

Stress fracture of proximal tibia after proximal fibula osteotomy: A case report

Introduction

Proximal fibula osteotomy (PFO) is a new method for treating medial compartment osteoarthritis of the knee, which is based on the theory of differential settlement (nonuniform settlement). This procedure has been widely recognized for its advantages of relative simplicity, low rate of postoperative complications, and low postoperative costs. Stress fracture of the proximal tibia after PFO has not been previously reported.

Case presentation

We report a 62-year-old woman with chronic rheumatoid arthritis (RA) underwent left PFO for chronic knee pain, who developed a stress fracture of the proximal tibia more than 1 year after PFO.

Clinical discussion

In the early stage of proximal tibia stress fracture, due to the concealment of radiography manifestations, doctors from another hospital performed total knee arthroplasty (TKA) for the patient. They ignored the treatment of stress fracture of the proximal tibia, and the stress fracture was further aggravated after surgery. Six months later, the patient underwent open reduction and internal fixation with a plate and screw in the left proximal tibia fracture at our hospital. The patient was followed up at the hospital three months after open reduction, and the proximal tibia stress fracture began to heal.

Conclusion

RA is usually not confined to the medial compartment and its pathogenesis is different from that of osteoarthritis. Therefore, PFO is not an appropriate procedure for this type of patient.

•

Stress fracture of proximal tibia after PFO has not been previously reported.

•

This case is extremely rare of a stress fracture of the proximal tibia more than 1 year after PFO.

•

RA is usually not confined to the medial compartment that PFO is not an appropriate procedure for this type of patient.

Use of Meat-Bone Paste to Develop Calcium-Enriched Liver Pâté

The production technology of meat-bone paste and its effect on chemical, mineral and amino acid compositions of liver pâté were studied. The liver was replaced by meat-bone paste in the concentration of 5, 10, 15, 20, and 25% for the production of experimental samples. The compositional analysis of pâté manufactured with meat-bone paste showed that the reformulation did not influence the content of moisture (~56%), fat (~28%), or protein (~11%) while producing a significant increase of ash and a decrease of carbohydrates in comparison with control pâtés. The higher amounts of minerals of bone-meat paste, including calcium (3080 mg/100 g), magnesium (2120 mg/100 g), phosphorous (2564 mg/100 g), and iron (7.30 mg/100 g), explained the higher amount of both ash and these minerals in the reformulated samples compared to the control samples. The total caloric value (~300 kcal/100 g) was also unaffected by the addition of bone-meat paste. The content of both essential and non-essential amino acids decreased with the inclusion of meat-bone paste, although this decrease was lower in essential (6280 mg/100 g in control vs. 5756 mg/100 g in samples with 25% of meat-bone paste) than in non-essential amino acids (6080 mg/100 g in control vs. 3590 mg/100 g in samples with 25% of meat-bone paste). This fact is due to several essential amino acids not showing differences between control and reformulated samples, while in non-essential amino acids, these differences were greater. The results of this study showed that meat-bone paste addition is a good strategy to produce liver pâté enriched in minerals and with minimum influence on the content of the other important nutrients. Therefore, these results can be used for the design of new liver pâté with an increased nutritional significance by using meat industry by-products. According to the balance of minerals, the use of 15% of meat-bone paste to reformulate liver pâté is the best strategy used in the present research. However, additional studies on the stability (during storage), shelf-life, and sensory acceptability of these reformulated pâtés should be carried out.

Accuracy of the Tuning Fork Test for Determination of Presence and Location of Tibial Stress Fractures in a Military Training Population

INTRODUCTION

Stress fractures or bone stress injuries arise from trauma or overuse, often as a result of rapid increase in training. This rapid increase in training occurs frequently as military recruits begin their entry-level training, as many individuals are not accustomed to the level of activity required during boot camp. Tibial stress fractures are the most common bone stress injuries in the military setting. MRI is the gold standard test for identification of stress fractures, but MRI may not be available in field settings. Although limited evidence has suggested that a vibrating tuning fork may be beneficial in determining the presence of a stress fracture, the tuning fork has become a frequent tool used to detect or diagnose stress fractures.

MATERIALS AND METHODS

Military personnel with suspected unilateral tibial stress fractures were asked to participate in evaluation of tuning forks as a diagnostic tool, in addition to receiving standard diagnostics and treatment. Points of maximal shin tenderness to palpation and vibration, followed by the application of a tuning fork, were evaluated. Each service member also underwent an abbreviated MRI evaluation with a 1.5T magnet consisting of coronal and sagittal STIR (Short Tau Inversion Recovery) and T1 (weighted longitudinal relaxation time) sequences. The results of tuning fork testing were compared to the MRI findings, considering grade 1 changes on MRI to represent a true stress fracture. A two-by-two table was used to determine the performance of tuning fork testing, relative to MRI findings, applying conventional definitions of sensitivity, specificity, positive predictive value, and negative predictive value.

RESULTS

Among 63 male active duty members with suspected tibial stress fractures, 39 had MRI-confirmed stress fractures. Tuning fork testing, relative to MRI, demonstrated overall sensitivity of 61.5%, specificity of 25.0%, positive predictive value of 57.1%, and negative predictive value of 28.6%. A sub-analysis restricting to grade 3 and grade 4 MRI findings did not improve the diagnostic performance of tuning forks.

CONCLUSIONS

The tuning fork is an ineffective tool for diagnosing tibial stress fractures.

Overuse-Related Injuries of the Musculoskeletal System: Systematic Review and Quantitative Synthesis of Injuries, Locations, Risk Factors and Assessment Techniques

Overuse-related musculoskeletal injuries mostly affect athletes, especially if involved in preseason conditioning, and military populations; they may also occur, however, when pathological or biological conditions render the musculoskeletal system inadequate to cope with a mechanical load, even if moderate. Within the MOVIDA (Motor function and Vitamin D: toolkit for risk Assessment and prediction) Project, funded by the Italian Ministry of Defence, a systematic review of the literature was conducted to support the development of a transportable toolkit (instrumentation, protocols and reference/risk thresholds) to help characterize the risk of overuse-related musculoskeletal injury. The PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) approach was used to analyze Review papers indexed in PubMed and published in the period 2010 to 2020. The search focused on stress (overuse) fracture or injuries, and muscle fatigue in the lower limbs in association with functional (biomechanical) or biological biomarkers. A total of 225 Review papers were retrieved: 115 were found eligible for full text analysis and led to another 141 research papers derived from a second-level search. A total of 183 papers were finally chosen for analysis: 74 were classified as introductory to the topics, 109 were analyzed in depth. Qualitative and, wherever possible, quantitative syntheses were carried out with respect to the literature review process and quality, injury epidemiology (type and location of injuries, and investigated populations), risk factors, assessment techniques and assessment protocols.

Synovial Inclusion Cyst Mimicking a Femoral Neck Stress Fracture in an Active Duty Servicemember: A Case Report

CASE

A 19-year-old female servicemember with history of ischiopubic rami stress fractures was referred to orthopaedic surgery for magnetic resonance imaging findings concerning for a tension-sided femoral neck stress fracture. However, her history and symptoms were discordant with the diagnosis of stress fracture. The patient was managed with protected weight-bearing for 6 weeks with gradual return to physical activity.

CONCLUSION

Prophylactic surgical fixation is advocated for the management of tension-sided femoral neck stress fractures. However, surgeons should consider a broader differential diagnosis, to include a synovial inclusion cyst, when the clinical presentation is not consistent with a stress fracture.

High Number of Daily Steps Recorded by Runners Recovering from Bone Stress Injuries

BACKGROUND

Bone stress injuries (BSIs) are common among runners for which activity modification is the primary treatment. The clinical utility of measuring activity during recovery has not been evaluated.

QUESTIONS/PURPOSES

We sought to measure the physical activity of runners recovering from BSIs and determine if activity can be correlated with symptoms.

METHODS

A prospective observational pilot study was performed of runners with a new lower extremity BSI treated non-surgically. For 30 days, activity of runners was measured with a physical activity tracker and daily pain scores were collected.

RESULTS

We enrolled 18 runners (average age, 33 years; 72% female). Twelve had stress fractures and six had stress reactions. The average daily steps of all runners during the observation period was 10,018 ± 3232, and the runner with the highest daily steps averaged 15,976. There were similar average daily steps in those with stress fractures versus reactions, 10,329 versus 9965, respectively. There was no correlation between daily steps or relative change in daily steps with pain or relative change in pain scores.

CONCLUSION

Runners with BSIs averaged over 10,000 steps per day during early recovery. Clinicians may not be aware of the amount of activity runners maintain after being diagnosed with a BSI. Although daily steps and symptoms could not be correlated in this study, objectively measuring activity may assist clinicians in guiding runners recovering from BSIs.

A rs936306 C/T Polymorphism in the CYP19A1 Is Associated With Stress Fractures

Kumagai, H, Miyamoto-Mikami, E, Kikuchi, N, Kamiya, N, Zempo, H, and Fuku, N. A rs936306 C/T polymorphism in the CYP19A1 is associated with stress fractures. J Strength Cond Res XX(X): 000-000, 2020-A stress fracture (SF) is an overuse injury, and low bone mineral density (BMD) is the risk factor for the SF. Estrogen is suggested to have a crucial role in bone metabolism, and estrogen-related genetic polymorphisms are associated with BMD. However, the possible association between SF and estrogen-related genetic polymorphisms has not been clarified yet. Therefore, we aimed to clarify whether estrogen-related genetic polymorphisms are associated with a history of SFs in Japanese athletes. A total of 1,311 (men: n = 868, women: n = 443) top-level Japanese athletes who participated in various sports and at different levels were analyzed. The history of SFs was assessed using a questionnaire, and the cytochrome P450 aromatase gene (CYP19A1) rs936306 C/T and estrogen receptor α gene (ESR1) rs2234693 T/C polymorphisms were analyzed using the TaqMan genotyping assay. The genotype frequency of the CYP19A1 C/T polymorphism was significantly different between the injured group and noninjured group under the C allele additive genetic model (odds ratio = 1.31, 95% confidence interval = 1.01-1.70), especially in men and in women with irregular menstruation. On the other hand, there were no significant differences with the ESR1 T/C polymorphism. This study demonstrated that the C allele in the CYP19A1 rs936306 polymorphism is a risk factor for SFs in top-level Japanese athletes.

Impact-Related Ground Reaction Forces Are More Strongly Associated With Some Running Injuries Than Others

BACKGROUND

Inconsistent associations have been reported for impact-related ground reaction force variables and running injuries when grouping all injuries together. However, previous work has shown more consistent associations when focusing on specific injuries.

PURPOSE

To compare ground reaction force variables between healthy and injured runners as a group and within specific common injuries.

STUDY DESIGN

Controlled laboratory study.

METHODS

A total of 125 runners presenting with patellofemoral pain, tibial bone stress injury, plantar fasciitis, Achilles tendinopathy, or iliotibial band syndrome and 65 healthy controls completed an instrumented treadmill assessment at a self-selected speed. Impact-related ground reaction force variables included vertical average (VALR) and instantaneous (VILR) load rates, posterior and medial/lateral instantaneous load rates, and vertical stiffness at initial loading (VSIL). Mean comparisons were made between the general and specific injury and control groups (α = .05). Cutoff thresholds were established and evaluated using several criteria.

RESULTS

VALR (+17.5%; P < .01), VILR (+15.8%; P < .01), and VSIL (+19.7%; P < .01) were significantly higher in the overall injured versus control groups. For individual injuries, VALR, VILR, and VSIL were significantly higher for patellofemoral pain (+23.4%-26.4%; P < .01) and plantar fasciitis (+17.5%-29.0%; P < .01), as well as VSIL for Achilles tendinopathy (+29.4%; P < .01). Cutoff thresholds showed better diagnostic criteria for individual versus grouped injuries.

CONCLUSION

Impact variables (VALR, VILR, and VSIL) were significantly higher when assessing the injured group as a whole. However, these findings were driven by specific injury groups, highlighting the importance of taking an injury-specific approach to biomechanical risk factors for running injury.

CLINICAL RELEVANCE

These results suggest that practitioners may want to address impact loading in their treatment of injured runners, especially in those with patellofemoral pain and plantar fasciitis.

Stress fractures in uncommon location: Six case reports and review of the literature

BACKGROUND

Individuals’ interest in sports activities has been increasing, contributing to more stress fracture occurrences in uncommon locations on the skeleton. In this study, several cases of stress fractures in atypical locations are presented, and the possibility of combining diagnostic methods to make accurate and quick diagnoses is explored. Additionally, different causes of stress fractures, as well as various modalities of treatment, are highlighted. Other potential factors of stress fractures were identified by a literature review.

CASE SUMMARY

Six cases of stress fractures in the calcaneus, intermediate cuneiform bone, sacrum, tibia (bilateral), navicular bone and femoral neck are presented, with different types of diagnostic imaging and treatments. All of the cases were associated with an aspect of mobility because all of the patients were physically active in various sport disciplines.

CONCLUSION

The type of therapeutic procedure selected should depend on the specific clinical case, i.e., the patient’s condition and level of physical activity.

A Review and Proposed Rationale for the use of Ultrasonography as a Diagnostic Modality in the Identification of Bone Stress Injuries

Bone stress injuries are common in military personnel and athletes. The delayed diagnosis of a bone stress injury can lead to a more severe injury that requires a longer period of treatment. The early detection of bone stress injuries is a central part of management. Currently, the reference standard for detecting bone stress injuries is magnetic resonance imaging. However, the expanding use of point-of-care ultrasonography (US) may enable the early detection of bone stress injuries in the clinical setting. In this article, we review the US detection of bone stress injuries, as well as discuss the rationale for the use of US in the diagnosis of these injuries.

Stress Fracture of Proximal Femur after Hip Resurfacing Treated with Cannulated Screw

Stress fractures of the proximal femur are described in athletes and military personnel. In most cases, they are not treated surgically, except when they are at the top of the femoral neck and with cortical involvement. The return to sports is not recommended in patients with hip replacement, especially for the high rate of revision of implants in the younger patients. One of the major complications of hip resurfacing (HR) is the medial fracture of the femoral neck, which usually occurs within 9 weeks after surgery. The causes have to be attributed to a malposition of the femoral component or to an insufficient bone density. The case reported herein is unique because it describes a stress fracture on patient operated with HR, treated with screw fixation. Two years after surgery, the patient returned to his normal life, practicing sports, without progression of varus angulation of the stem.

ACR Appropriateness Criteria® Stress (Fatigue/Insufficiency) Fracture, Including Sacrum, Excluding Other Vertebrae

Stress fractures, including both fatigue and insufficiency types, are frequently encountered in clinical practice as a source of pain in both athletes and patients with predisposing conditions. Radiography is the imaging modality of choice for baseline diagnosis. MRI has greatly improved our ability to diagnose radiographically occult stress fractures. Tc-99m bone scan and CT may also be useful as diagnostic tools. Although fatigue and insufficiency fractures can be self-limited and go onto healing even without diagnosis, there is usually value in initiating prompt therapeutic measures as incomplete stress fractures have the potential of progressing to completion and requiring more invasive treatment or delay in return to activity. This is particularly important in the setting of stress fractures of the femoral neck. Accuracy in the identification of these injuries is also relevant because the differential diagnosis includes entities that would otherwise be treated significantly different (ie, osteoid osteoma, osteomyelitis, and metastasis). The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer-reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Online pre-race education improves test scores for volunteers at a marathon

OBJECTIVES

This study examined whether an online course would lead to increased knowledge about the medical issues volunteers encounter during a marathon.

MATERIALS AND METHODS

Health care professionals who volunteered to provide medical coverage for an annual marathon were eligible for the study. Demographic information about medical volunteers including profession, specialty, education level and number of marathons they had volunteered for was collected. A 15-question test about the most commonly encountered medical issues was created by the authors and administered before and after the volunteers took the online educational course and compared to a pilot study the previous year.

RESULTS

Seventy-four subjects completed the pre-test. Those who participated in the pilot study last year (N = 15) had pre-test scores that were an average of 2.4 points higher than those who did not (mean ranks: pilot study = 51.6 vs. non-pilot = 33.9, p = 0.004). Of the 74 subjects who completed the pre-test, 54 also completed the post-test. The overall post-pre mean score difference was 3.8 ± 2.7 (t = 10.5 df = 53 p < 0.001). While subjects with all levels of volunteer experience demonstrated improvement, only change among first time marathon volunteers was significantly different from the others. Subjects reporting all degree/certification levels demonstrated improvement, but no difference in improvement was found between degree/certification levels.

CONCLUSION

In this follow-up to the previous year's pilot study, online education demonstrated a long-term (one-year) increase in test scores. Testing also continued to show short-term improvement in post-course test scores, compared to pre-course test scores. In general, marathon medical volunteers who had no volunteer experience demonstrated greater improvement than those who had prior volunteer experience.

High-Risk Stress Fractures: Diagnosis and Management

Stress fractures are common overuse injuries in athletes. They occur during periods of increased training without adequate rest, disrupting normal bone reparative mechanisms. There are a host of intrinsic and extrinsic factors, including biochemical and biomechanical, that put athletes at risk. In most stress fractures, the diagnosis is primarily clinical, with imaging indicated at times, and management focused on symptom-free relative rest with advancement of activity as tolerated. Overall, stress fractures in athletes have an excellent prognosis for return to sport, with little risk of complication. There is a subset of injuries that have a greater risk of fracture progression, delayed healing, and nonunion and are generally more challenging to treat with nonoperative care. Specific locations of high-risk stress fracture include the femoral neck (tension side), patella, anterior tibia, medial malleolus, talus, tarsal navicular, proximal fifth metatarsal, and great toe sesamoids. These sites share a characteristic region of high tensile load and low blood flow. High-risk stress fractures require a more aggressive approach to evaluation, with imaging often necessary, to confirm early and accurate diagnosis and initiate immediate treatment. Treatment consists of nonweight-bearing immobilization, often with a prolonged period away from sport, and a more methodic and careful reintroduction to athletic activity. These stress fractures may require surgical intervention. A high index of suspicion is essential to avoid delayed diagnosis and optimize outcomes in this subset of stress fractures.

Young man with sudden severe hip pain secondary to femoral neck stress fracture

Femoral neck stress fractures have been described in military recruits and athletes. Early recognition and aggressive treatment are important, as femoral neck stress fractures have a high potential for complications and even uncomplicated fractures require an extensive course of rehabilitation. Tension-side (superolateral) stress fractures of the femoral neck are at high risk for complications such as displacement, non-union and avascular necrosis, and need to be treated surgically, while compression-side (inferomedial) fractures can be treated conservatively. We describe a case illustrating a typical presentation of insidious hip pain culminating in sudden onset of severe hip pain in a healthy young man. We perform a literature review of studies showing epidemiology, treatment algorithms and rehabilitation.

Minimally Invasive Screw Fixation of Inferior Pubic Ramus Stress Fracture Nonunion in a Runner: A Case Report

CASE

A fifty-one-year-old female runner developed a stress fracture of the inferior pubic ramus. Nonoperative treatment was initiated, but the symptoms persisted and she was diagnosed with a nonunion. After eleven months of symptoms and ten months of nonoperative treatment, including four months of complete avoidance of running, percutaneous screw fixation was performed, with radiographic and clinical healing of the fracture.

CONCLUSION

While inferior pubic ramus stress fractures are usually successfully treated nonoperatively, instances of nonunion and delayed union have been described. In the present report, we describe the case of a patient in whom an inferior pubic ramus stress fracture nonunion was successfully treated with minimally invasive screw fixation.

Muscle size, quality, and body composition: characteristics of division I cross-country runners

The primary purpose of this study was to identify the relationship between muscle cross-sectional area (mCSA), echo intensity (EI), and body composition of Division I cross-country runners. The secondary purpose was to examine differences in these variables in athletes stratified based on stress-fracture (SFx) history. Thirty-six athletes were stratified based on sex and SFx history. A panoramic scan vastus lateralis was performed using a GE Logiq-e B-mode ultrasound. Echo intensity and mCSA were determined from the scan using a grayscale imaging software (ImageJ). Body composition measures were determined using dual-energy x-ray absorptiometry. For females, mCSA was significantly correlated with left leg lean mass (LM; R = 0.54) and EI (R = -0.57). Lean mass was significantly correlated with bone mineral density (BMD; R = 0.58) and bone mineral content (BMC; R = 0.56), whereas BMC was also correlated with leg LM (R = 0.72). For males, mCSA was significantly correlated with leg LM (R = 0.66), BMD (R = 0.50), and BMC (R = 0.54). Leg LM was significantly correlated with BMD (R = 0.53) and BMC (R = 0.77). Personal best times for males were significantly correlated with fat mass (R = 0.489) and %fat (R = 0.556) for the 10- and 5-km races, respectively. Female and male athletes with a history of SFx were not significantly different across any variables when compared with athletes with no history. These correlations suggest that more muscle mass may associate with higher BMD and BMC for stronger bone structure. Modifications in training strategies to include heavy resistance training and plyometrics may be advantageous for preventing risk factors associated with SFx reoccurrence.

Diagnostic Accuracy of Various Imaging Modalities for Suspected Lower Extremity Stress Fractures: A Systematic Review With Evidence-Based Recommendations for Clinical Practice

BACKGROUND

The literature is filled with conflicting findings regarding diagnostic accuracy and protocols for imaging suspected lower extremity stress fractures. The absence of systematic reviews on this topic has limited the development of evidence-based recommendations for appropriate imaging protocols in cases of suspected lower extremity stress fractures.

PURPOSE

To determine the diagnostic accuracy statistics of imaging modalities used to diagnose lower extremity stress fractures and to synthesize evidence-based recommendations for clinical practice.

STUDY DESIGN

Systematic review.

METHODS

A generic search strategy for published studies was performed using multiple databases. A study was eligible for inclusion if it met all of the following criteria: (1) at least 1 diagnostic imaging modality was studied, (2) at least 1 radiological reference standard was used, (3) the study reported or allowed computation of diagnostic accuracy statistics (sensitivity, specificity, positive likelihood ratio, negative likelihood ratio), (4) a full-text version was available, (5) the article was written in English, and (6) the study included lower extremity stress fractures. Studies that examined asymptomatic individuals or patients with fractures due to disease or pharmacologic intervention were excluded.

RESULTS

Reported sensitivity and specificity (95% CI) were as follows: For conventional radiography, sensitivity ranged from 12% (0%-29%) to 56% (39%-72%) and specificity ranged from 88% (55%-100%) to 96% (87%-100%). For nuclear scintigraphy (NS), sensitivity ranged from 50% (23%-77%) to 97% (90%-100%) and specificity from 33% (12%-53%) to 98% (93%-100%). For magnetic resonance imaging (MRI), sensitivity ranged from 68% (45%-90%) to 99% (95%-100%) and specificity from 4% (0%-11%) to 97% (88%-100%). For computed tomography, sensitivity ranged from 32% (8%-57%) to 38% (16%-59%) and specificity from 88% (55%-100%) to 98% (91%-100%). For ultrasound, sensitivity ranged from 43% (26%-61%) to 99% (95%-100%) and specificity from 13% (0%-45%) to 79% (61%-96%).

CONCLUSION

MRI was identified as the most sensitive and specific imaging test for diagnosing stress fractures of the lower extremity. When MRI is available, NS is not recommended because of its low specificity, high dosage of ionizing radiation, and other limitations. Conventional radiographs are likely to result in false negatives upon initial presentation, particularly in the early stages of stress fracture, and in some cases may not reveal an existing stress fracture at any time. A diagnostic imaging algorithm was developed with specific recommendations for cost-efficient imaging of low-risk and high-risk suspected stress fractures.

CONSUMO ALIMENTAR, PERFIL ANTROPOMÉTRICO E CONHECIMENTOS EM NUTRIÇÃO DE CORREDORES DE RUA

Introdução A nutrição esportiva e a composição corporal são fatores importantes para o desempenho de atividades esportivas. A corrida de rua se popularizou no mundo, especialmente na última década. Os corredores de rua devem consumir uma dieta nutricionalmente adequada e ter conhecimento sobre nutrição para manter um perfil nutricional adequado. Objetivo Avaliar a adequação dietética, o perfil antropométrico e os conhecimentos em nutrição de corredores de rua. Métodos Os corredores adultos de ambos os gêneros (n = 51) foram entrevistados sobre conhecimentos em nutrição, por meio de um questionário padronizado modificado. A avaliação do consumo alimentar foi feita com a aplicação de dois recordatórios de 24 horas em dias não consecutivos e com a análise da adequação de macronutrientes, micronutrientes e fibra alimentar. A avaliação antropométrica foi realizada por meio do índice de massa corporal e percentual de gordura. Resultados A maioria dos corredores de rua do gênero masculino teve um percentual de gordura adequado e foi constatada magreza para cerca de 30% de homens e mulheres. As inadequações dietéticas de ma-cronutrientes caracterizaram-se por consumo insuficiente de carboidratos (59,6% de indivíduos) e ingestão elevada de proteínas (32,7%). Fibra, cálcio, tiamina, riboflavina e niacina foram consumidas abaixo dos níveis recomendados, principalmente entre os homens. O conhecimento em nutrição foi associado à adequação da ingestão de micronutrientes. As mulheres tiveram melhor nível de conhecimento básico em nutrição e maior prevalência de ingestão adequada. Conclusão Apesar dos corredores de rua demonstrarem alto nível de conhecimento básico em nutrição e adequado perfil antropométrico, a maioria teve hábitos alimentares e nutrição inadequados ao desempenho esportivo.

Diagnosis, treatment, and rehabilitation of stress fractures in the lower extremity in runners

Stress fractures account for between 1% and 20% of athletic injuries, with 80% of stress fractures in the lower extremity. Stress fractures of the lower extremity are common injuries among individuals who participate in endurance, high load-bearing activities such as running, military and aerobic exercise and therefore require practitioner expertise in diagnosis and management. Accurate diagnosis for stress fractures is dependent on the anatomical area. Anatomical regions such as the pelvis, sacrum, and metatarsals offer challenges due to difficulty differentiating pathologies with common symptoms. Special tests and treatment regimes, however, are similar among most stress fractures with resolution between 4 weeks to a year. The most difficult aspect of stress fracture treatment entails mitigating internal and external risk factors. Practitioners should address ongoing risk factors to minimize recurrence.

The injured runner

Running is often recommended by physicians to maintain a healthy lifestyle. As more individuals participate in running-related activities, clinicians must be increasingly aware of common injuries. Training errors leading to overuse are the most common underlying factors in most running-related injuries. Clinicians need to keep in mind that the presenting injury is frequently the result of an inability to compensate for a primary dysfunction at another site. Although imaging may be helpful in differentiating among diagnoses with similar clinical presentations, a detailed history and physical examination are essential in making a correct diagnosis.

The running athlete: stress fractures, osteitis pubis, and snapping hips

CONTEXT

Pelvic stress fractures, osteitis pubis, and snapping hip syndrome account for a portion of the overuse injuries that can occur in the running athlete.

EVIDENCE ACQUISITION

PUBMED SEARCHES WERE PERFORMED FOR EACH ENTITY USING THE FOLLOWING KEYWORDS: snapping hip syndrome, coxa sultans, pelvic stress fracture, and osteitis pubis from 2008 to 2013. Topic reviews, case reports, case series, and randomized trials were included for review.

STUDY DESIGN

Clinical review.

LEVEL OF EVIDENCE

Level 4.

RESULTS

Collectively, 188 articles were identified. Of these, 58 were included in this review.

CONCLUSION

Based on the available evidence, the majority of these overuse injuries can be managed non-operatively. Primary treatment should include removal from offending activity, normalizing regional muscle strength/length imbalances and nutritional deficiencies, and mitigating training errors through proper education of the athlete and training staff.

STRENGTH OF RECOMMENDATION TAXONOMY

C.

Evaluation and treatment of biking and running injuries

Exercise is universally recognized as a key feature for maintaining good health. Likewise, lack of physical activity is a major risk factor for chronic disease and disability, an especially important fact considering our rapidly aging population. Biking and running are frequently recommended as forms of exercise. As more individuals participate in running-related and cycling-related activities, physicians must be increasingly aware of the common injuries encountered in these pursuits. This review focuses on the evaluation and management of common running-related and cycling-related injuries.