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

Biologic therapies in stress fractures: Current concepts

Stress fractures, a common overuse injury in physically active individuals, present a significant challenge for athletes and military personnel. Patients who sustain stress fractures have demanding training regimes where periods of rest and immobilisation have unacceptable negative consequences on sports goals and finances. Aside from being an overuse injury, there are various contributing risk factors that put certain individuals at risk of a stress fracture. The main two being nutritional deficiencies and hormonal variations, which have significant effects on bone metabolism and turnover. Historically, treatment of stress fractures focused on conservative strategies such as rest and immobilisation. Calcium and vitamin D deficiencies have been closely linked to stress fractures and so over time supplementation has also played a role in treatment. With the introduction of biologics into orthopaedics, newer treatment strategies have been applied to accelerate fracture healing and perhaps improve fracture callus quality. If such therapies can reduce time spent away from sport and activity, it would be ideal for treating stress fractures. This article aims to offer insights into the evolving landscape of stress fracture management. It investigates the pre-clinical evidence and available published clinical applications. Though fracture healing is well understood, the role of biologics for fracture healing is still indeterminate. Available literature for the use of biologic therapies in stress fractures are restricted and most reports have used biologics as a supplement to surgical fixation in subjects in studies that lack control groups. Randomised control trials have been proposed and registered by a few groups, with results awaited. Assessing individuals for risk factors, addressing hormonal imbalances and nutritional deficiencies seems like an effective approach to addressing the burden of stress fractures. We await better designed trials and studies to accurately determine the clinical benefit of adding biologics to the management of these injuries.

Consecutive Bilateral Iliac Stress Fracture in an Adult Male Runner

Iliac stress fractures (ISF) are uncommon in sports, particularly among runners, and are attributed to repetitive loading and other predisposing factors. ISF poses diagnostic challenges due to nonspecific symptoms and the limited sensitivity of conventional imaging procedures. The reported case is about a 51-year-old male marathon runner with consecutive bilateral ISF. Initial symptoms included mechanical pain in the right buttock, leading to a diagnosis confirmed via pelvic MRI. Conservative management with eight weeks rest from sport activity was indicated with symptom resolution and return to sport. However, 20 days after returning to sport, the patient developed left-sided symptoms post-resumption of running, with MRI confirming a new ISF. An additional eight weeks of rest was prescribed, allowing the patient to resume sport at preinjury levels. ISF should be considered in runners presenting with gluteal pain, emphasizing the importance of early diagnosis. MRI emerges as a valuable tool for accurate diagnosis, guiding appropriate management strategies. Conservative management focusing on rest is paramount for favorable outcomes and optimizing runners' health and performance.

Stress Fracture after Arthroscopic Lesser Trochanter Resection: Diagnosis and Therapy

We report on the case of a 52-year-old female who presented with a stress fracture after undergoing an endoscopic resection of the lesser trochanter in ischiofemoral impingement, which was resistant to maximal conservative treatment. To the best of our knowledge, this complication has not been previously described. Non-weight-bearing and intravenous alendronic acid were prescribed for management. No additional surgery was required. The patient was pain free with the ability to perform sports on the same level as before and had no complaints.

Epidemiology of bone injuries in elite athletics: A prospective 9-year cohort study

OBJECTIVES

To describe bone injury patterns in elite track and field athletes. To investigate relationships between bone injury and athlete characteristics to inform future injury prevention strategies.

DESIGN

Descriptive epidemiology study.

SETTING

Elite athletics training centres across the United Kingdom and internationally, observed between 2012 and 2020.

PARTICIPANTS

207 Olympic programme senior track and field athletes.

MAIN OUTCOME MEASURES

Injury number, Incidence, Severity, Burden, Time Loss.

RESULTS

There were 78 fractures during the study period. Gradual repetitive bone injuries were the most common type of injury mode. The foot, pelvis and the lumbar spine were the regions with the highest number of bone stress injuries. Stress fractures had a higher burden overall compared to stress reactions. Average return to full training was 67.4 days (±73.1) for stress reactions and 199 (±205.2) days for stress fractures. There was no relationship between bone injury type and age, sex, ethnicity, side dominance or event group.

CONCLUSION

Bone stress injuries in athletics have a high severity and burden warranting continued efforts to prevent their occurrence and optimize management. Age, sex, ethnicity, side dominance and event region do not have any relationship with bone injury occurrence and are therefore unlikely to increase risk in this cohort.

Surgical Treatment for Non-union of the Great Toe Proximal Phalanx Stress Fracture in an Adolescent Jumping Athlete

Stress fractures of the proximal phalanx of the great toe are primarily attributed to repetitive shear forces, with the vertical ground reaction forces exerting several times the body weight. In the initial stages of injury, conservative management anticipates bone healing within approximately five weeks, followed by a gradual return to sports activities over an additional five weeks. Athletes presenting with pain in this region warrant a thorough evaluation for stress fractures to initiate timely conservative care. In instances of delayed healing or non-union, surgical intervention is indicated. However, literature on the management and optimal timing of surgery, particularly in adolescent athletes, remains sparse. This case report, complemented by a literature review, offers insights into management based on the patient's clinical course.

Multifocal stress fractures in a patient with rheumatoid arthritis

Stress fractures are often associated to activities that requires repetitive stress such as running. However, insufficiency-type stress fractures can also occur in patients with risk factors such as rheumatoid arthritis. Diagnosis of stress fracture would require a thorough clinical evaluation along with radiological imaging. However, this may be difficult due to how it mimics other musculoskeletal problems. The case of a woman in her 60s presenting with 2 months of severe ipsilateral right knee and ankle pain is used as an example. Based on initial clinical assessment and plain radiograph, her provisional diagnosis was osteoarthritis or inflammatory arthritis secondary to rheumatoid disease. However, MRI scan revealed that she had multifocal stress fractures in her knee, ankle and foot. Hence, we hope that this case study can allow clinicians to consider multifocal stress fracture as a possible diagnosis in patients with risk factors and to have lower threshold in performing MRI scans.

Ultrasound ability in early diagnosis of metatarsal stress fractures

Stress fractures are common in young and active individuals, associated with aggressive or repetitive physical activity and their early detection is fundamental to optimise patient care, decrease complications and avoid unnecessary exams. Currently, magnetic resonance imaging is the standard of care for detecting these lesions. Recently, ultrasound has been getting an increasing interest for the detection of stress fractures. In this article, we describe a clinical case that involved a second metatarsal stress fracture diagnosed by ultrasound and review the literature regarding the use of ultrasound in the diagnosis of stress fractures, particularly of the metatarsals.

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.

[Stress fractures in the military context]

BACKGROUND

Soldiers, especially as recruits, are exposed to significantly elevated stress patterns of the foot due to occupation-related marching and excessive running. This can lead to military-specific stress fractures of the metatarsals, i.e., marching fractures. The treatment and prevention of stress fractures are of particular importance in the military context due to the impact on operational capability and treatment costs. A uniform classification of these fractures does not yet exist.

OBJECTIVE

Review of stress fractures in the military setting with presentation of the incidence, risk factors, classification, treatment and prevention possibilities.

MATERIAL AND METHODS

A PubMed®-based review of the current literature on stress fractures in the military context was conducted and the results were discussed with a focus on specific military medical treatment options.

RESULTS

There are several possibilities to classify stress fractures, the most well-known being a 4-level magnetic resonance imaging (MRI)-based classification. Prevention and treatment possibilities are multifaceted but so far insufficiently validated.

CONCLUSION

Military-specific stress fractures should be grouped according to a 4-level and MRI-based classification. The treatment options include both conservative and surgical measures and should be implemented taking the patient's individual requirements into account. Preventive measures play a key role in the military context. They include the adaptation of screening tools, training and equipment and require continuous evaluation and development.

Treatment and Rehabilitation Approaches for Stress Fractures in Long-Distance Runners: A Literature Review

Stress fractures (SFs) result from repetitive mechanical stress on bones, leading to an imbalance in osseous tissue adaptation and resulting in cortical fractures. The majority of SFs occur in the lower limb due to excessive mechanical loads. Long-distance runners are highly susceptible to SFs, especially when there is a significant increase in the load or intensity of their activity. Various intrinsic and extrinsic factors contribute to the development of SFs. Common SF locations in long-distance runners include the tibial shaft, femur, metatarsal, and pelvic region. Diagnosis may be delayed due to mild symptoms and unremarkable imaging tests. However, the chronicity and recurrence of misdiagnosed SFs may lead to debilitating complete fractures that are even more challenging to treat. In this review, we present data revealed from published case reports and case series studies obtained through PubMed and Embase databases focusing on the management of SFs in long-distance runners and correlate treatment outcomes with rehabilitation and return to high-level athletic performance.

[Sacral H-shaped fractures between traumatic, insufficiency and fatigue fractures : Similarities, differences and controversies]

In the basic entirety of stress fractures, insufficiency fractures are defined as fractures caused by prolonged normal or physiological loading of a bone with insufficient elastic resistance. This clearly distinguishes it from fatigue fractures, in which excessive loads are continuously applied to a bone with normal elastic resistance. According to Pentecost (1964) both entities of stress fracture result from "the inherent inability of the bone to withstand stress applied without violence in a rhythmical, repeated, subthreshold manner". This distinguishes them from acute traumatic fractures. In the clinical routine these differences are not always so clearly presented. The example of the H‑shaped sacral fracture is used to illustrate the relevance of a clear terminology. In this context, current controversies in the treatment of sacral insufficiency fractures are discussed.

Infrared Thermography-A Novel Tool for Monitoring Fracture Healing: A Critically Appraised Topic With Evidence-Based Recommendations for Clinical Practice

CLINICAL SCENARIO

Stress fractures are one of the most common injuries in athletes. Unfortunately, they are hard to diagnose, require multiple radiology exams and follow-up which leads to more exposure to radiation and an increase in cost. Stress fractures that are mismanaged can lead to serious complications and poorer outcomes for the athlete. During the rehabilitation process, it would be beneficial to be able to monitor the healing of fractures to know when it is safe to gradually allow a patient to a return to sport because the return to activity is not usually objective and based on pain level.

CLINICAL QUESTION

Can infrared thermography (IRT) be a useful tool to measure the pathophysiological state of the fracture healing? The aim of this critically appraised topic is to analyze the current evidence of IRT for measuring the temperature change in fractures to provide recommendations for medical practitioners.

SUMMARY OF KEY FINDINGS

For this critically appraised topic, we examined 3 articles that compared medical imaging and IRT over multiple time points during the follow-up. The 3 articles concluded that a 1 °C asymmetry in temperature followed by a return to normal (less than 0.3 °C) temperature during the healing process of fractures can be monitored using IRT.

CLINICAL BOTTOM LINE

Once the patient has been diagnosed with a fracture, IRT can safely be used to monitor the evolution of a fracture. When the thermogram progresses from a hot thermogram to a cold thermogram, the healing is considered good enough to return to sport.

STRENGTH OF RECOMMENDATION

Grade 2 evidence exists to support IRT being used by clinicians to monitor fracture healing. Due to the limited research and novelty of the technology, the current recommendations are for following the treatment of the fracture once the initial diagnosis is made.

Clinical Presentation and Outcomes of Sacral Stress Fractures in Athletes: A Case Series of 13 Patients

BACKGROUND

Sacral stress fractures are a rare cause of low back pain in athletes. Given the low incidence of these fractures, there is a scarcity of data on symptomatology, risk factors, and clinical outcomes.

HYPOTHESIS

Patients diagnosed with sacral stress fractures would be athletes presenting with low back pain.

STUDY DESIGN

Case series of 13 patients with sacral stress fractures.

LEVEL OF EVIDENCE

Level 4.

METHODS

We conducted a retrospective review of medical records to identify patients diagnosed with sacral stress fractures at a single academic institution. Fractures were diagnosed on noncontrast T2-weighted magnetic resonance imaging scans and categorized using the Bakker classification system. Subjects were administered an electronic survey that asked about (1) the onset, time course, and location of pain and other symptoms; (2) time to treatment and treatment modalities pursued; (3) sports performance and time to return to sport; and (4) risk factors for stress fractures.

RESULTS

Of 18 eligible patients, 13 (72.2%) completed the survey with mean follow-up of 49.6 months (range, 1-144 months). Mean age was 28.0 years (range, 18-52 years); 9 patients (69.2%) were female, of whom 7 (77.8%) were premenopausal. The most common fracture type was Bakker type B (8 patients; 61.5%). Most patients presented with acute lumbosacral back pain in the setting of running/jogging activities. All patients underwent nonoperative treatment for an average of 3.8 months (range, 0-8 months) and three-quarters reported pain resolution at last follow-up. Rate of return to sport was 83.3%, but most patients reported ongoing deficits in running performance.

CONCLUSION

Sacral stress fractures commonly present as acute lumbosacral back pain provoked by running sports. While the pain associated with these fractures prevents most athletes from participating in sports, nonoperative management appears to be an effective treatment modality with a high rate of return to sport.

Tarsal Navicular Bone Stress Injuries: A Multicenter Case Series Investigating Clinical Presentation, Diagnostic Approach, Treatment, and Return to Sport in Adolescent Athletes

BACKGROUND

Tarsal navicular bone stress injuries (BSIs) are considered "high risk" because of prolonged healing times and higher rates of nonunion in adult populations but, to our knowledge, have not been comprehensively examined in adolescent athletes.

PURPOSE

To describe the characteristics of tarsal navicular BSIs in adolescents.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

A retrospective analysis of patients aged 10 to 19 years with a radiographically diagnosed tarsal navicular BSI was performed at 8 academic centers over a 9-year study period. Age, sex, body mass index (BMI), primary sport, physical examination findings, imaging, treatment, surgical technique, return-to-sport time, and complications were analyzed.

RESULTS

Among 110 patients (mean age, 14.7 ± 2.7 years; 65% female), common primary sports were cross-country/track and field (29/92 [32%]) and gymnastics/dance (25/92 [27%]). Grade 4 BSIs were identified in 44% (48/110) of patients, with fracture lines present on radiography or magnetic resonance imaging. Nonoperative treatment (mean age, 14.4 ± 2.6 years), consisting of protected weightbearing and either a protective boot (69/88 [78%]) or a cast (19/88 [22%]), was trialed in all patients and was successful in 94 patients (85%). Operative treatment (mean age, 17.1 ± 1.4 years) was ultimately pursued for 16 patients (15%). Patients who required surgery had a higher BMI and a higher percentage of fracture lines present on imaging (nonoperative: 36/94 [38%]; operative: 14/16 [88%]). The median time to return to weightbearing, running, and full sport was significantly longer in duration for the operative group than the nonoperative group (P <.05). Complications associated with surgery included 1 case each of delayed union, nonunion, and painful implants, the latter of which required secondary surgery.

CONCLUSION

Adolescent tarsal navicular BSIs were identified most commonly in female patients in leanness sports. Adolescents who required surgery were more likely to be older, have higher BMIs, and have grade 4 BSIs, and they returned to sport within a median of 5 months after single- or double-screw fixation with a low risk of postoperative complications. A better understanding of the presenting signs and symptoms and appropriate diagnostic imaging of navicular BSIs may lead to an earlier diagnosis and improved outcomes.

The Role of Footwear, Foot Orthosis, and Training-Related Strategies in the Prevention of Bone Stress Injuries: A Systematic Review and Meta-Analysis

Objective

To evaluate the effectiveness of footwear, foot orthoses and training-related strategies to prevent lower extremity bone stress injury (BSI).

Design

Systematic review and meta-analysis.

Data sources

Four bibliographic databases (from inception until November 2021): Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE and CINAHL.

Eligibility criteria

Randomised controlled trials (RCTs) that assessed the risk of developing a BSI when using particular footwear, foot orthoses or training-related strategies such as muscle strengthening, stretching, and mechanical loading exercises.

Results

Eleven studies were included in this systematic review. When wearing foot orthoses, the risk ratio of developing a BSI on any lower extremity bone is 0.47 (95% CI 0.26 to 0.87; p = 0.02). When doing pre-exercise dynamic stretching, the risk ratio of suffering a tibial BSI is 1.06 (95% CI 0.67 to 1.68; p = 0.79). No meta-analyses could be performed for footwear or training-related strategies. The quality of evidence for all these results is low considering the high risk of bias in each study, the low number of studies and the low number of cases in each study.

Conclusion

This systematic review reveals the lack of high-quality studies in BSI prevention. Based on studies at high risk of bias, foot orthoses could potentially help prevent BSIs in the military setting. It is still unknown whether footwear and training-related strategies have any benefits. It is crucial to further investigate potential BSI prevention strategies in women and athletes. Research is also needed to assess the influence of running shoes and loading management on BSI incidence.

Part I: Background and Clinical Considerations for Stress Fractures in Female Military Recruits

INTRODUCTION

Stress fractures (SFx) represent a significant proportion of musculoskeletal injuries in military recruits internationally. Incidence rates as high as 40% have been reported, varying by country and branch of military cohorts. Tibial SFx are the most common, followed by other lower extremity sites, and are related to the emphasis on running during training. SFx disproportionately affect female recruits, similarly to a disparity demonstrated in female athletes.

METHODS

A literature review of articles relevant to our review was conducted using PubMed, utilizing keywords stress fracture, military, recruits, diagnosis, management, treatment, prevention, epidemiology, background, and/or female. Articles older than 10 years old (prior to 2010) were not considered. Review articles were considered, but if a research article was cited by a review, the research was included directly. Articles with primary military data, members of the military as subjects, especially when female recruits were included, were strongly considered for inclusion in this review.

RESULTS

SFx can cause medical morbidity and financial burden and can require discharge from military service. SFx management in the military has cost the United States approximately $100 million annually, which may be underestimated due to lost duty hours or medical discharge with resulting compensation. However, SFx incidence rates have been demonstrated to be reducible with concerted efforts in military cohorts.

CONCLUSION

This review, Part I of a two-part series, provides updated information for multidisciplinary management of SFx in female military recruits. There are many similarities to management in athletes, but unique nuances of the military recruit require specific knowledge to reduce the high incidence rates of injury.

Femoral Neck Stress Fracture of a Male, Healthy Marathon Runner - Case Report and Literature Review

In the present report, a case of a healthy, 38-year-old male recreational marathon runner who presented in the emergency department is discussed. He was diagnosed with a stress fracture of the femoral neck and treated surgically using a dynamic hip screw (DHS). One year after surgery, the patient was able to return to most of his previous sports activities. In the present report, the existing literature on the subject is exhibited and the points of interest in terms of incidence, risk factors, diagnosis, classification, treatment, and long-term outcome are analyzed. We suggest operative treatment of stress fractures of the femoral neck even in cases of complete undisplaced ones. This way, the risk of a displacement is counteracted, and patients can quickly return to daily activities without having to withstand long-term immobilization.

Characterising lower-body musculoskeletal morphology and whole-body composition of elite female and male Australian Football players

BACKGROUND

Physical demands and injury rates differ between elite female and male Australian Football (AF) players. To improve understanding of contributing physical factors to these differences, the purpose of this study was to investigate lower-body morphology and whole-body composition of elite footballers competing in the Australian Football League (AFL) and Australian Football League Women's (AFLW).

METHODS

Lower-body morphology and whole-body composition of 23 AFL players and 23 AFLW players were assessed using peripheral Quantitative Computed Tomography and Dual-energy X-ray Absorptiometry at the beginning of pre-season. Differences between cohorts, with sub-analyses of kicking vs. support limbs, and experienced vs. inexperienced player status were assessed using two-sample independent t-tests. Magnitude of differences were assessed using Cohen's d effect sizes.

RESULTS

AFL players had greater absolute (p < 0.001; ES = 3.28) and relative (p < 0.001; ES = 2.29) whole body lean soft-tissue mass, with less absolute (p = 0.004; ES = 0.91) and relative (p < 0.001; ES = 2.29) fat mass than AFLW players. For AFLW players, no significant differences existed between kicking and support limbs with few differences observed between experienced and inexperienced players.

CONCLUSIONS

Greater emphasis on physical development in AFLW players may be required to enable increases in muscle mass and skeletal robustness, to ensure they can tolerate the loads of elite competition.

Prospective Assessment of Clinical Tests Used to Evaluate Tibial Stress Fracture

Background:

Tibial stress fracture (SFx) is the most common SFx of the lower extremity. Presently, diagnostic accuracy of clinical examination techniques for tibial SFx remains suboptimal.

Purpose:

To assess the diagnostic effectiveness of 5 clinical tests for tibial SFx individually versus a test item cluster.

Study Design:

Cohort study (diagnosis); Level of evidence, 3.

Methods:

A total of 50 patients with tibial pain (17 with bilateral symptoms) were assessed with 5 clinical examination tests (tibial fulcrum test, focal tenderness to palpation, heel percussion test, therapeutic ultrasound test, and 128-Hz tuning fork test) before they underwent diagnostic imaging (radionuclide bone scan). The application of the clinical tests was counterbalanced to minimize the likelihood of carryover effects. Patients provided a pain rating immediately before and after the application of each clinical test.

Results:

The prevalence of tibial SFx among the study participants was 52.2%. High levels of specificity were produced by the therapeutic ultrasound test (93.8%), tuning fork test (90.6%), and percussion test (90.6%). The fulcrum test had moderate to high specificity (84.4%). All tests demonstrated low levels of sensitivity, with the highest levels found for focal tenderness to palpation (48.6%) and fulcrum (45.7%). The fulcrum test provided the highest positive likelihood ratio (2.93), followed by the therapeutic ultrasound test (2.30). The fulcrum test had the lowest negative likelihood ratio (0.64), with the focal tenderness to palpation and tuning fork tests having negative likelihood ratios >1.0. Combinations of these clinical tests did not improve the prediction of tibial SFx above that observed among the individual tests.

Conclusion:

The clinical tests evaluated were generally highly specific, but all had low sensitivity. The fulcrum test provided the highest level of diagnostic accuracy; however, it was inadequate for definitive clinical management. Combining tests did not improve the diagnostic accuracy of tibial SFx.

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.

Sacral stress fractures in athletes

PURPOSE

Fatigue stress fractures are a common overuse injury, frequently associated with high load-bearing endurance activities such as running, military training and aerobic exercise. While these fractures can arise at any site, sacral stress fractures are poorly studied with evidence consisting mainly of case reports and limited case series. This review aims to analyze and summarize all reports published to date describing cases of sacral stress fracture in athletes.

METHODS

PubMed, Embase, Web of Science and the Cochrane Database were systematically searched for studies reporting on Stress Fractures of the Sacrum. Insufficiency fractures of the elderly were excluded.

RESULTS

The literature review revealed 49 studies reporting on 124 cases of sacral stress fractures. Seventy-six patients (61%) were professional or collegiate level athletes, and 37 (30%) were military recruits or police officers in training. Seventeen female athletes were identified as suffering from low bone mineral density (25%), 9 of which reported menstrual irregularities. Thirteen female patients (19%) had a history of eating disorders.

CONCLUSION

While most sacral stress fractures occur in normal bones exposed to abnormal repetitive loads, the high percentage of lower bone mineral density can blur the lines between fatigue fractures and insufficiency fractures. The causes of these fractures are multifactorial. High endurance sports and the features of the female athlete triad were found in high percentage of the cases. Conservative treatment is the mainstay of treatment, consisting of ceasing of training and a period of rehabilitation and gradual return to training and competition.

Teriparatide and stress fracture healing in young adults (RETURN - Research on Efficacy of Teriparatide Use in the Return of recruits to Normal duty): study protocol for a randomised controlled trial

Background

Stress fractures are a common and potentially debilitating overuse injury to bone and occur frequently among military recruits and athletes. Recovery from a lower body stress fracture typically requires several weeks of physical rehabilitation. Teriparatide, a recombinant form of the bioactive portion of parathyroid hormone (1–34 amino acids), is used to treat osteoporosis, prevent osteoporotic fractures, and enhance fracture healing due to its net anabolic effect on bone. The study aim is to investigate the effect of teriparatide on stress fracture healing in young, otherwise healthy adults undergoing military training.

Methods

In a two-arm, parallel, prospective, randomised controlled, intention-to-treat trial, Army recruits (n = 136 men and women, 18–40 years) with a magnetic resonance imaging (MRI) diagnosed lower body stress fracture (pelvic girdle, sacrum, coccyx, or lower limb) will be randomised to receive either usual Army standard care, or teriparatide and usual Army standard care. Teriparatide will be self-administered by subcutaneous injections (20 μg/day) for 16 weeks, continuing to 24 weeks where a fracture remains unhealed at week 16. The primary outcome will be the improvement in radiological healing by two grades or more, or reduction to grade zero, 8 weeks after randomisation, assessed using Fredericson grading of MRI by radiologists blind to the randomisation. Secondary outcomes will be time to radiological healing, assessed by MRI at 8, 10, 12, 14, 16, 20 and 24 weeks, until healed; time to clinical healing, assessed using a clinical severity score of injury signs and symptoms; time to discharge from Army physical rehabilitation; pain, assessed by visual analogue scale; health-related quality of life, using the Short Form (36) Health Survey; and adverse events. Exploratory outcomes will include blood and urine biochemistry; bone density and morphology assessed using dual-energy X-ray absorptiometry, peripheral quantitative computed tomography (pQCT), and high-resolution pQCT; physical activity measured using accelerometers; and long-term future fracture rate.

Discussion

This study will evaluate whether teriparatide, in addition to standard care, is more effective for stress fracture healing than standard care alone in Army recruits who have sustained a lower body stress fracture.

Trial registration

ClinicalTrials.govNCT04196855. Registered on 12 December 2019.

A Current Update on Pelvifemoral Conditions That Should be in the Differential Diagnosis for Patients With Lower Extremity Radiculopathy

Patients presenting to an outpatient spine clinic frequently report symptoms of low back pain with associated buttock, groin, and lower extremity pain. While many of these individuals suffer from lumbar spine radiculopathy, a number of different orthopedic pathologies can mimic these symptoms. Management depends substantially on a detailed history and physical examination, in addition to working from a broad list of differential diagnoses when evaluating these patients. It is imperative that spine practitioners have a comprehensive understanding of the differential diagnoses that may mimic those originating from the lumbar spine, especially when a patient's symptoms are atypical from classic radicular pain. Misdiagnosis can lead to unnecessary testing and treatment, while delaying an accurate clinical assessment and treatment plan. This review highlights common orthopedic diagnoses that may present similar to lumbar spine pathologies and the evidence-based evaluation of these conditions.

The Male Athlete Triad-A Consensus Statement From the Female and Male Athlete Triad Coalition Part II: Diagnosis, Treatment, and Return-To-Play

ABSTRACT

The Male Athlete Triad is a medical syndrome most common in adolescent and young adult male athletes in sports that emphasize a lean physique, especially endurance and weight-class athletes. The 3 interrelated conditions of the Male Athlete Triad occur on spectrums of energy deficiency/low energy availability (EA), suppression of the hypothalamic-pituitary-gonadal axis, and impaired bone health, ranging from optimal health to clinically relevant outcomes of energy deficiency/low EA with or without disordered eating or eating disorder, functional hypogonadotropic hypogonadism, and osteoporosis or low bone mineral density with or without bone stress injury (BSI). Because of the importance of bone mass acquisition and health concerns in adolescence, screening is recommended during this time period in the at-risk male athlete. Diagnosis of the Male Athlete Triad is best accomplished by a multidisciplinary medical team. Clearance and return-to-play guidelines are recommended to optimize prevention and treatment. Evidence-based risk assessment protocols for the male athlete at risk for the Male Athlete Triad have been shown to be predictive for BSI and impaired bone health and should be encouraged. Improving energetic status through optimal fueling is the mainstay of treatment. A Roundtable on the Male Athlete Triad was convened by the Female and Male Athlete Triad Coalition in conjunction with the 64th Annual Meeting of the American College of Sports Medicine in Denver, Colorado, in May of 2017. In this second article, the latest clinical research to support current models of screening, diagnosis, and management for at-risk male athlete is reviewed with evidence-based recommendations.

Case Report: Stress Fracture in an International Triple Jumper: Importance of an Integrated Care Approach Which Also Incorporates Biomechanics

Athletes fear stress fracture (SF) injuries as they can put a premature end to their athletic careers. Understanding any mechanical constraints can suggest preventive management approach. Specifically, for the triple jump, the mechanical stresses that occur during the event appear to be the main factors for risk of injury. This clinical case describes three successive episodes of anterior tibial fracture in an international triple jumper between 2011 and 2013. The first fracture received surgical treatment involving intramedullary nailing. The second fracture occurred in the same location and was considered a recurrence requiring medical treatment, whilst the third was a complete fracture of the surgical material and required surgical revision. These recurrent fractures can be explained by the fatigue of materials (bone and nail) induced by triple jump practice and emphasize the importance of integrating biomechanics into an assessment of the case. The use of biomechanical modelization to identify these weaknesses could be an approach for clinical management of such patients. Observation of the intrinsic mechanical stresses during high-level triple jump may lead to identification of modifiable risk factors for bone fragility.

A Novel Stress Fracture Rehabilitation Program: A Pilot Study

INTRODUCTION

Stress fractures (SFx) of the tibia are common and limit military readiness, but there is presently no scientifically validated program that objectively fosters tibia SFx rehabilitation. Therefore, this pilot study evaluated the feasibility of a Graduated Exercise Program (GEP) based on the theory that programmed rest between exercise bouts improves the osteogenic response, which may enhance rehabilitation and military readiness.

METHODS

Participants were randomly assigned to the GEP or standard-of-care exercise program. Both programs use a walk-jog-run progression, but the GEP splits daily exercise into morning and evening episodes and provides 5 days of programmed rest after each stage is completed. The GEP included autonomy support to foster program adherence. Outcome measures included adherence, subjective and ActiGraph-validated objective assessments of exercise duration and intensity, pain assessments, and autonomy support assessments. Participants offered suggestions for program improvement.

RESULTS

Quantitative findings were mixed, but more importantly, this pilot study showed that the measurement, support, and self-reporting parameters were feasible, with high compliance by participants. Barriers to recruitment and retention were identified, along with solutions to overcome these barriers, starting with obtaining unit support for GEP participation.

CONCLUSION

This pilot study demonstrated the feasibility of a GEP with autonomy support, along with challenges and their solutions, providing the foundation for a formal large-sample study.

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.

The Benefits of Strength Training on Musculoskeletal System Health: Practical Applications for Interdisciplinary Care

Global health organizations have provided recommendations regarding exercise for the general population. Strength training has been included in several position statements due to its multi-systemic benefits. In this narrative review, we examine the available literature, first explaining how specific mechanical loading is converted into positive cellular responses. Secondly, benefits related to specific musculoskeletal tissues are discussed, with practical applications and training programmes clearly outlined for both common musculoskeletal disorders and primary prevention strategies.

Navicular Stress Fractures

Navicular stress fractures are multifactorial injuries due to chronic overload on the navicular, particularly in young athletes. The navicular is subject to unique stresses and has a complex blood supply, making it susceptible to stress fractures and potentially delayed union or nonunion. Expeditious diagnosis is critical to prevent a delay in treatment and a poor outcome. Advanced imaging is essential in making the diagnosis and monitoring healing. Both nonsurgical and surgical treatments have demonstrated good results. Nonsurgical management consists of a period of immobilization and nonweight bearing, and surgical management typically involves open reduction and internal fixation. Patients need to be appropriately counseled regarding expectations for these challenging injuries.

Isolated fibular stress fractures: Radiographic parameters

BACKGROUND

Fibular stress fractures are uncommon injuries with an incompletely understood pathogenesis and predisposing characteristics. This study investigated the demographic and radiographic risk factors for fibular stress fractures.

METHODS

A retrospective chart review from 2010 to 2018 revealed thirteen patients with isolated fibular stress fractures. Demographics, history of fracture, fracture location, bone quality, and heel alignment were collected.

RESULTS

The cohort consisted of six men and seven women with a mean age of 41.8 years. The average BMI was 28.5kg/m². Three patients used tobacco. 69.2% of fractures were in the distal third, 23.1% proximal third, and 7.7% middle third. No patients had evidence of osteopenia. Distal fibula stress fractures were more common in women (66.7%) and associated with hindfoot valgus.

CONCLUSION

Distal third fibula stress fractures were most common and associated with hindfoot valgus. This could be due to a greater amount of axial force through fibula in this alignment.

LEVEL OF EVIDENCE

Level IV, Retrospective Case Series.

Delayed-Union of Acetabular Stress Fracture in Female Gymnast: Use of Teriparatide to Augment Healing

Pelvic stress fractures are rare and present unique challenges for medical personnel. Delayed healing can lead to increased physical, psychological, and social stress for athletes. Recent literature suggests effective use of a synthetic derivative of parathyroid hormone, teriparatide, to augment healing of delayed-union stress fractures. We present a case of a female National Collegiate Athletic Association Division I gymnast successfully returned to play after a 12-week course of teriparatide injections for an ischioacetabular stress fracture.

[Factors associated with stress fracture: A case-control study in a Peruvian navy medical center]

Introduction

Stress fractures are injuries produced by the overuse of certain extremities, generating repetitive fatigue in the bone with insufficient rest periods and hormonal disorders, among others. High osteoclastic activity and lower activity of the osteoblasts at the cortical level occurs.

Objective

To determine the factors associated with a stress fracture in a single medical center of the Peruvian navy.

Methods

We conducted an observational, analytical case-control study. The dependent variable was stress fracture confirmed by magnetic resonance imaging of the patients; the independent variables were age, sex, calcemia, socioeconomic status, and time of daily physical activity. All data were extracted from the medical records. Crude and adjusted odds ratios were calculated with 95% confidence intervals.

Results

The sample was comprised of 238 patients (119 cases and 119 controls), of which 79.8% were male, and 20.2% were female; the average age was 20.25. In the bivariate analysis, stress fractures were associated with male sex (odds ratio 3.00; 95% confidence interval 1.51 to 5.95), hypocalcemia (2.83; 2.32 to 3.44), more than two hours of daily physical activity (24.7; 12.51 to 48.95) and socioeconomic level C (6.66; 2.82 to 15.74). Time dedicated to physical activity (adjusted odds ratio 44.46; 95% confidence interval 17.93 to 110.22) and socioeconomic level C (adjusted odds ratio 22.57; 95% confidence interval 7.03 to 72.74) were associated in the multivariate analysis.

Conclusion

We found that stress fractures were associated with physical activity time and a lower socioeconomic level. Further studies are needed to evaluate the relationship with other factors in the military population of Peru.

Bone Stress Injuries Are Associated With Differences in Bone Microarchitecture in Male Professional Soldiers

Bone stress injuries are commonly due to repetitive loading, as often described in competitive athletes or military recruits. The underlying pathophysiology of bone stress injuries is multifactorial. The present cross-sectional study investigated (i) cortical and trabecular bone microstructure as well as volumetric bone mineral density in subjects with bone stress injuries at the tibial diaphysis, measured at the distal tibia and the distal radius by means of high-resolution peripheral quantitative computed tomography (CT), (ii) areal bone mineral density using dual-energy X-ray absorptiometry as well as calcaneal dual X-ray absorptiometry and laser, and (iii) the influence on bone turnover markers of formation and resorption at the early phase after injury. A total of 26 Caucasian male professional soldiers with post-training bone stress injury at the tibial diaphysis were included (case group). A total of 50 male, Caucasian professional soldiers from the same military institution served as controls (control group). High-resolution peripheral quantitative CT revealed a higher total area at the radius within the case group. Cortical bone mineral density was reduced at the radius and tibia within the case group. The trabecular number and trabecular thickness were reduced at the tibia in the case group. The trabecular network was more inhomogeneous at the radius and tibia within the case group. Calcaneal dual X-ray absorptiometry and laser was significantly reduced in the case group. This study quantified differences in bone microstructure among otherwise healthy individuals. Differences in bone microarchitecture may impair the biomechanical properties by increasing the susceptibility to sustain bone stress injuries. © 2019 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 37:2516-2523, 2019.

Association of catastrophic condylar fracture with bony changes of the third metacarpal bone identified by use of standing magnetic resonance imaging in forelimbs from cadavers of Thoroughbred racehorses in the United States

OBJECTIVE To compare bony changes of the third metacarpal bone (MC3) of Thoroughbred racehorse cadavers with (cases) or without (controls) catastrophic condylar fracture by use of standing MRI. SAMPLE 140 forelimbs from 26 case horses (both forelimbs) and 88 control horses (single forelimb). PROCEDURES Bone marrow lesions (BMLs), identified as a decrease in T1-weighted (T1W) signal and increases in T2*-weighted (T2*W) and short tau inversion recovery (STIR) signals, and dense bone volume percentage (DBVP), identified as decreases in T1W, T2*W, and STIR signals, in the distopalmar aspect of MC3 were recorded. Logistic regression was used to compare fractured and nonfractured limbs of cases and fractured limbs of cases with randomly selected limbs of controls. RESULTS Among cases, fractured limbs were significantly more likely to have BMLs (26/26 [100%]) than were nonfractured limbs (7/26 [27%]). Fractured limbs of cases were significantly more likely to have BMLs (26/26 [100%]) than were limbs of controls (6/88 [7%]). Among cases, there was no significant difference in DBVP between fractured and nonfractured limbs in lateral (26% vs 21%, respectively) or medial (25% vs 20%, respectively) condyles. However, DBVP was significantly greater in fractured limbs of cases than in limbs of controls for lateral (26% vs 16%, respectively) and medial (25% vs 18%, respectively) condyles. CONCLUSIONS AND CLINICAL RELEVANCE Standing MRI revealed a significantly greater degree of bone change in racehorses with condylar fracture when comparing fractured and nonfractured limbs of case horses and fractured limbs of case horses with randomly selected limbs of control horses.

A Thoroughbred racehorse with a unicortical palmar lateral condylar fracture returned to training 14 days after surgery: a hypothesis on the role of a single bone screw on crack propagation

A 2-year-old Thoroughbred racehorse had LF lameness that began post high-speed exercise and persisted for two days before the horse once again became sound. Diagnostic analgesia localized the lameness to the LF distal metacarpus, and a standing MRI identified a unicortical condylar fracture. A single 5.5 mm cortical screw was placed in lag fashion. The horse began hand walking at 14 days, racetrack jogging at 30 days, and racing at 5 months after the day of surgery. Placement of a single lag screw ahead of the tip of the crack in unicortical condylar fracture may be useful for reducing the recovery period for horses returning to training and racing.

Injury Surveillance and Reporting for Trainees with Bone Stress Injury: Current Practices and Recommendations

Background

Musculoskeletal injuries, including lower extremity bone stress injuries (BSI) significantly impact initial entry training (IET) in the U.S. Army due to limited duty days, trainee attrition, early medical discharge, and related financial costs. Factors complicating trainee BSI surveillance include inconsistent BSI coding practices, attrition documentation as both administrative separations and medical discharges and the inability to code for BSI grade or severity when using International Statistical Classification of Diseases and Related Health Problems 10th revision (ICD-10) codes.

Methods

A multidisciplinary expert panel developed policy guidance to enhance clinical and administrative management of BSI, following extensive analysis of current, peer-reviewed literature. Policy guidance incorporates leading practices concerning clinical BSI management, including imaging procedures, recommended notifications, early intervention, and ICD-10 diagnostic coding procedures. Policy guidance also standardizes BSI grading criteria for magnetic resonance imaging and skeletal scintigraphy (bone scan).

Findings

Multidisciplinary expert opinion indicates inconsistent BSI diagnosis and management across IET due to variability in trainee BSI grading, documentation, and coding practices. Injury surveillance conducted by the United States Army Medical Command (USAMEDCOM) will benefit from routine, standardized musculoskeletal injury data base searches by BSI severity/grade and anatomical location upon implementation of BSI policy guidance.

Discussion

Effective injury surveillance is critical for determining trainee BSI incidence and attrition, developing anticipated return to duty (RTD) timelines, and assessing long-term outcomes. BSI RTD timelines should account for gender, BSI grade/severity, anatomical location, and type of intervention. Well-defined RTD timelines would benefit administrative decision-making purposes, including whether to grant convalescent leave or enroll in the Warrior Training and Rehabilitation Program during BSI recovery. Enhanced management procedures may improve initial enlistment completion rates for trainees sustaining at least one BSI who eventually complete IET.

Inhibition of CaMKK2 Enhances Fracture Healing by Stimulating Indian Hedgehog Signaling and Accelerating Endochondral Ossification

Approximately 10% of all bone fractures do not heal, resulting in patient morbidity and healthcare costs. However, no pharmacological treatments are currently available to promote efficient bone healing. Inhibition of Ca2+ /calmodulin (CaM)-dependent protein kinase kinase 2 (CaMKK2) reverses age-associated loss of trabecular and cortical bone volume and strength in mice. In the current study, we investigated the role of CaMKK2 in bone fracture healing and show that its pharmacological inhibition using STO-609 accelerates early cellular and molecular events associated with endochondral ossification, resulting in a more rapid and efficient healing of the fracture. Within 7 days postfracture, treatment with STO-609 resulted in enhanced Indian hedgehog signaling, paired-related homeobox (PRX1)-positive mesenchymal stem cell (MSC) recruitment, and chondrocyte differentiation and hypertrophy, along with elevated expression of osterix, vascular endothelial growth factor, and type 1 collagen at the fracture callus. Early deposition of primary bone by osteoblasts resulted in STO-609-treated mice possessing significantly higher callus bone volume by 14 days following fracture. Subsequent rapid maturation of the bone matrix bestowed fractured bones in STO-609-treated animals with significantly higher torsional strength and stiffness by 28 days postinjury, indicating accelerated healing of the fracture. Previous studies indicate that fixed and closed femoral fractures in the mice take 35 days to fully heal without treatment. Therefore, our data suggest that STO-609 potentiates a 20% acceleration of the bone healing process. Moreover, inhibiting CaMKK2 also imparted higher mechanical strength and stiffness at the contralateral cortical bone within 4 weeks of treatment. Taken together, the data presented here underscore the therapeutic potential of targeting CaMKK2 to promote efficacious and rapid healing of bone fractures and as a mechanism to strengthen normal bones. © 2018 American Society for Bone and Mineral Research.

Serial Radiographs Showing Progression of a Patellar Stress Fracture and Beneficial Surgical Technique for a Displaced Patellar Stress Fracture

Stress fractures of the patella occurring in athletes are quite rare and only 23 cases have been introduced in English literatures. Stress fractures of the patella are classified into two types: transverse and longitudinal. They are mostly seen in the distal one-third of the patella on a plain lateral radiograph. We present here a 16-year-old female basketball player with a stress fracture of the patella. Her serial radiographs demonstrated progression of the fracture including a lytic cortex lesion, known as the gray cortex sign for early stage stress fractures, in the distal one-third of the patella on plain lateral radiographs. In addition, we introduce a surgical technique using non-absorbable suture ligatures (No.2 Ethibond) for a displaced transverse stress fracture of the patella when the extensor mechanism is intact. The ligatures are passed through into the patella using suture passers and simply tied down over the top of the patella. In our case, it led to neither hardware-related nor circumferential loop-related irritation postoperatively.

Development and validation of an instrument to measure patient engagement in Hong Kong Special Administrative Region, China

OBJECTIVE

The objective of this study was to develop, pilot test, and psychometrically validate a patient engagement questionnaire, called Patient Engagement Index (PEI), in Hong Kong, China.

METHOD

The method employed was based on a patient engagement framework and literature review and expert panel discussion. A new measure named PEI with 20 items divided into five factors was developed. A pilot study of 40 patients was used to confirm the clarity of PEI. Explored factor analysis was used to confirm the construct validity. Cronbach's alpha, intercorrelation coefficients (ICCs), and weighted kappa were used to assess the internal consistency reliability and test-retest reliability separately. Rasch model and differential item functioning were also used to further confirm the fit of the instrument.

RESULTS

In all, 324 participants successfully completed the survey. Based on the evaluation of exploratory factor analysis and theoretically considerations, a four-factor structure comprising 20 items was identified. Rasch analysis also confirmed that the model has a good fit (ranging from 0.662 to 1.294). All domains were considered internally consistent (alpha >0.7). Test-retest showed both ICC (>0.6) and weighted kappa (>0.4) meeting the minimum recommended standard. No ceiling or floor effect was found. Furthermore, Spearman's correlation coefficient confirmed that PEI had good internal validity.

CONCLUSION

PEI was shown to have good reliability and validity. This is a short, quick, and appropriate tool to assess the extent of patient engagement in both clinical and research settings.

Retrospective analysis of four-year injury data from the Infantry Training Centre, Catterick

Introduction

Musculoskeletal injury (MSKI) represents a considerable threat to the effectiveness and productivity of military organisations globally. The impact on the medical chain, occupational disposal with associated loss of working days and associated financial burden have far-reaching consequence. The moral and legal responsibility to reduce avoidable injuries through risk assessment and prevention strategies is fundamental to governance and a key component of best practice.

Methods

A retrospective observational analysis was performed of 4101 MSKIs presenting from a total inflow of 10 498 British Army Infantry recruits recorded over four consecutive training years between 2012 and 2016. Injury incidence, site, type and week of training were recorded and analysed.

Results

The total incidence of all MSKI was observed as 39.1%. Overuse injuries were the most common subclassification of injury type (24.5%), followed by trauma (8.8%) and then stress fractures (5.7%). Causes of medical discharge over a four-year cumulative incidence were from overuse injuries (59.3%), stress fractures (21.5%) and trauma (19.2%). 45.5% of all MSKIs presented within the first eight weeks of training.

Conclusions

MSKI data highlighted the requirement for a comprehensive service evaluation of the Combat Infantryman’s Course and subsequent justification for the introduction of an injury prevention intervention — Project OMEGA.

Tarsal navicular stress fractures

PURPOSE OF REVIEW

Navicular stress fractures are common in athletes and management is debated. This article will review the evaluation and management of navicular stress fractures.

RECENT FINDINGS

Various operative and non-operative adjunctive treatment modalities are reviewed including the relevance of vitamin D levels, use of shock wave therapy and bone marrow aspirate concentrate (BMAC), and administration of teriparatide. Surgical treatment may be associated with earlier return to sports. The author's preferred treatment algorithm with corresponding images is presented which allows for safe and rapid return to activities in the athletic patient. Future research is needed in evaluating the preventative effects of vitamin D and use of other adjunctive treatments to increase the healing rates of this fracture.

A Subtrochanteric Femoral Stress Fracture following Bisphosphonate Treatment in an Adolescent Girl

Atypical subtrochanteric and diaphyseal femoral fractures (AFFs) have emerged as a potential complication of bisphosphonate treatment in adults. Despite increasing off-label use of bisphosphonates in children and adolescents for a variety of skeletal disorders, there have been no reports of AFFs in children or adolescents outside of the osteogenesis imperfecta population. We present the case of a 16-year-old girl who developed a subtrochanteric femoral stress fracture following pamidronate treatment for idiopathic juvenile osteoporosis.

Radius and Ulna Stress Fractures in a Patient with Neuromyelitis Optica: A Case Report

INTRODUCTION

Stress fractures are more common in the weight-bearing bones of the lower limb and are particularly prevalent in athletes. Whereas, those of the upper limb are usually reported as unique events in rare circumstances.

CASE REPORT

We present a case of a 40-year-old White British female with neuromyelitis optica (NMO) who mobilized in a wheelchair and presented to our center in April 2016 with a week-long history of a hot, swollen, and unstable right forearm. Plain radiographs demonstrated fractures of both the radius and ulna of the dominant right arm. These were managed by open reduction and internal fixation to facilitate mobility and transfer using the forearm. Intra-operatively, these were confirmed to be fatigue fractures, and there was evidence that the fracture was several days old. The neurological deficit in this patient had led to a delayed presentation owing to the lack of pain. Unfortunately, this construct failed within 8days, and a refixation was performed 2months later. 1year following the revision, no further problems have been reported, and there has been satisfactory union.

CONCLUSION

This is the first report in the published literature of a stress fracture in a patient with NMO. We recommend screening for stress fractures with a nuclear bone scan in patients who mobilize in atypical ways, particularly if their sensation is compromised. The use of constructs stronger than those routinely applied to the upper limb should also be considered if patients are weight bearing through their arms.