Stress Fractures
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A stress fracture is a
fatigue Fatigue is a state of tiredness (which is not sleepiness), exhaustion or loss of energy. It is a signs and symptoms, symptom of any of various diseases; it is not a disease in itself. Fatigue (in the medical sense) is sometimes associated wit ...
-induced
bone fracture A bone fracture (abbreviated FRX or Fx, Fx, or #) is a medical condition in which there is a partial or complete break in the continuity of any bone in the body. In more severe cases, the bone may be broken into several fragments, known as a ''c ...
caused by repeated stress over time. Instead of resulting from a single severe impact, stress fractures are the result of accumulated
injury Injury is physiological damage to the living tissue of any organism, whether in humans, in other animals, or in plants. Injuries can be caused in many ways, including mechanically with penetration by sharp objects such as teeth or with ...
from repeated submaximal loading, such as running or jumping. Because of this mechanism, stress fractures are common
overuse injuries A repetitive strain injury (RSI) is an injury to part of the musculoskeletal or nervous system caused by repetitive use, vibrations, compression or long periods in a fixed position. Other common names include repetitive stress injury, repetitiv ...
in athletes. Stress fractures can be described as small cracks in the bone, or hairline fractures. Stress fractures of the foot are sometimes called "
march fracture March fracture is the fracture of the distal third of one of the metatarsal bones occurring because of recurrent stress. It is more common in soldiers, but also occurs in hikers, organists, and other people whose duties entail much standing (s ...
s" because of the injury's prevalence among heavily marching soldiers. Stress fractures most frequently occur in weight-bearing bones of the lower extremities, such as the
tibia The tibia (; : tibiae or tibias), also known as the shinbone or shankbone, is the larger, stronger, and anterior (frontal) of the two Leg bones, bones in the leg below the knee in vertebrates (the other being the fibula, behind and to the outsi ...
and
fibula The fibula (: fibulae or fibulas) or calf bone is a leg bone on the lateral side of the tibia, to which it is connected above and below. It is the smaller of the two bones and, in proportion to its length, the most slender of all the long bones. ...
(bones of the lower leg),
calcaneus In humans and many other primates, the calcaneus (; from the Latin ''calcaneus'' or ''calcaneum'', meaning heel; : calcanei or calcanea) or heel bone is a bone of the Tarsus (skeleton), tarsus of the foot which constitutes the heel. In some other ...
(heel bone),
metatarsal The metatarsal bones or metatarsus (: metatarsi) are a group of five long bones in the midfoot, located between the tarsal bones (which form the heel and the ankle) and the phalanges ( toes). Lacking individual names, the metatarsal bones are ...
and navicular bones (bones of the foot). Less common are stress fractures to the
femur The femur (; : femurs or femora ), or thigh bone is the only long bone, bone in the thigh — the region of the lower limb between the hip and the knee. In many quadrupeds, four-legged animals the femur is the upper bone of the hindleg. The Femo ...
,
pelvis The pelvis (: pelves or pelvises) is the lower part of an Anatomy, anatomical Trunk (anatomy), trunk, between the human abdomen, abdomen and the thighs (sometimes also called pelvic region), together with its embedded skeleton (sometimes also c ...
,
sacrum The sacrum (: sacra or sacrums), in human anatomy, is a triangular bone at the base of the spine that forms by the fusing of the sacral vertebrae (S1S5) between ages 18 and 30. The sacrum situates at the upper, back part of the pelvic cavity, ...
,
lumbar spine The lumbar vertebrae are located between the thoracic vertebrae and pelvis. They form the lower part of the back in humans, and the tail end of the back in quadrupeds. In humans, there are five lumbar vertebrae. The term is used to describe t ...
(lower back),
hips In vertebrate anatomy, the hip, or coxaLatin ''coxa'' was used by Celsus in the sense "hip", but by Pliny the Elder in the sense "hip bone" (Diab, p 77) (: ''coxae'') in medical terminology, refers to either an anatomical region or a joint ...
,
hands A hand is a prehensile, multi-fingered appendage located at the end of the forearm or forelimb of primates such as humans, chimpanzees, monkeys, and lemurs. A few other vertebrates such as the koala (which has two opposable thumbs on each "han ...
, and
wrists In human anatomy, the wrist is variously defined as (1) the carpus or carpal bones, the complex of eight bones forming the proximal skeletal segment of the hand; "The wrist contains eight bones, roughly aligned in two rows, known as the carpal ...
. Stress fractures make up about 20% of overall sports injuries. Treatment usually consists of rest followed by a gradual return to exercise over a period of months.


Signs and symptoms

Stress fractures are typically discovered after a rapid increase in exercise. Symptoms usually have a gradual onset, with complaints that include isolated pain along the shaft of the bone and during activity, decreased muscular strength and cramping. In cases of fibular stress fractures, pain occurs proximal to the lateral malleolus, that increases with activity and subsides with rest. If pain is constantly present it may indicate a more serious bone injury. There is usually an area of localized tenderness on or near the bone and generalized swelling in the area. Pressure applied to the bone may reproduce symptoms and reveal crepitus in well-developed stress fractures. Anterior tibial stress fractures elicit focal tenderness on the anterior tibial crest, while posterior medial stress fractures can be tender at the posterior tibial border.


Causes

Bones are constantly attempting to remodel and repair themselves, especially during a sport where extraordinary stress is applied to the bone. Over time, if enough stress is placed on the bone that it exhausts the capacity of the bone to remodel, a weakened site—a stress fracture—may appear on the bone. The fracture does not appear suddenly. It occurs from repeated traumas, none of which is sufficient to cause a sudden break, but which, when added together, overwhelm the
osteoblast Osteoblasts (from the Greek combining forms for " bone", ὀστέο-, ''osteo-'' and βλαστάνω, ''blastanō'' "germinate") are cells with a single nucleus that synthesize bone. However, in the process of bone formation, osteoblasts fu ...
s that remodel the bone. Potential causes include overload caused by muscle contraction,
amenorrhea Amenorrhea or amenorrhoea is the absence of a menstrual period in a female organism who has reached reproductive age. Physiological states of amenorrhoea are most commonly seen during pregnancy and lactation (breastfeeding). In humans, it is wher ...
, an altered stress distribution in the bone accompanying muscle fatigue, a change in ground reaction force (concrete to grass) or the performance of a rhythmically repetitive stress that leads up to a vibratory summation point. Stress fractures commonly occur in sedentary people who suddenly undertake a burst of exercise (whose bones are not used to the task). They may also occur in athletes completing high volume, high impact training, such as running or jumping sports. Stress fractures are also commonly reported in soldiers who march long distances.
Muscle fatigue Muscle fatigue is when muscles that were initially generating a normal amount of force, then experience a declining ability to generate force. It can be a result of vigorous exercise, but abnormal fatigue may be caused by barriers to or interfer ...
can also play a role in the occurrence of stress fractures. In a runner, each stride normally exerts large forces at various points in the legs. Each shock—a rapid acceleration and energy transfer—must be absorbed. Muscles and bones serve as
shock absorbers A shock absorber or damper is a mechanical or hydraulic device designed to absorb and damp shock impulses. It does this by converting the kinetic energy of the shock into another form of energy (typically heat) which is then dissipated. Most sho ...
. However, the muscles, usually those in the lower leg, become fatigued after running a long distance and lose their ability to absorb shock. As the bones now experience larger stresses, this increases the risk of fracture. Previous stress fractures have been identified as a risk factor. Along with history of stress fractures, a narrow tibial shaft, high degree of hip external rotation,
osteopenia Osteopenia, known as "low bone mass" or "low bone density", is a condition in which bone mineral density is low. Because their bones are weaker, people with osteopenia may have a higher risk of fractures, and some people may go on to develop o ...
,
osteoporosis Osteoporosis is a systemic skeletal disorder characterized by low bone mass, micro-architectural deterioration of bone tissue leading to more porous bone, and consequent increase in Bone fracture, fracture risk. It is the most common reason f ...
, and pes cavus are common predisposing factors for stress fractures. Common causes in sport that result in stress fractures include: * Over training * Going back to competition too soon after an injury or illness * Going from one event to another without proper training for the second event * Starting initial training too quickly * Changing habits or the environment like training surface or shoes


Diagnosis

X-rays An X-ray (also known in many languages as Röntgen radiation) is a form of high-energy electromagnetic radiation with a wavelength shorter than those of ultraviolet rays and longer than those of gamma rays. Roughly, X-rays have a wavelength ran ...
usually do not show evidence of new stress fractures, but can be used approximately three weeks after onset of pain when the bone begins to remodel. A
CT scan A computed tomography scan (CT scan), formerly called computed axial tomography scan (CAT scan), is a medical imaging technique used to obtain detailed internal images of the body. The personnel that perform CT scans are called radiographers or ...
,
MRI Magnetic resonance imaging (MRI) is a medical imaging technique used in radiology to generate pictures of the anatomy and the physiological processes inside the body. MRI scanners use strong magnetic fields, magnetic field gradients, and rad ...
, or 3-phase bone scan may be more effective for early diagnosis. MRI appears to be the most accurate diagnostic test.
Tuning fork A tuning fork is an acoustic resonator in the form of a two-pronged fork with the prongs ( ''tines'') formed from a U-shaped bar of elastic metal (usually steel). It resonates at a specific constant pitch when set vibrating by striking it ag ...
s have been advocated as an inexpensive alternative for identifying the presence of stress fractures. The clinician places a vibrating tuning fork along the shaft of the suspected bone. If a stress fracture is present, the vibration would cause pain. This test has a low positive likelihood ratio and a high negative likelihood ratio meaning it should not be used as the only diagnostic method.


Prevention

Altering the biomechanics of training and training schedules may reduce the prevalence of stress fractures. Orthotic insoles have been found to decrease the rate of stress fractures in military recruits, but it is unclear whether this can be extrapolated to the general population or athletes. On the other hand, some athletes have argued that cushioning in shoes actually causes more stress by reducing the body's natural shock-absorbing action, thus increasing the frequency of running injuries. During exercise that applies more stress to the bones, it may help to increase daily
calcium Calcium is a chemical element; it has symbol Ca and atomic number 20. As an alkaline earth metal, calcium is a reactive metal that forms a dark oxide-nitride layer when exposed to air. Its physical and chemical properties are most similar to it ...
(2,000 mg) and
vitamin D Vitamin D is a group of structurally related, fat-soluble compounds responsible for increasing intestinal absorption of calcium, magnesium, and phosphate, along with numerous other biological functions. In humans, the most important compo ...
(800 IU) intake, depending on the individual.


Treatment

For low-risk stress fractures, rest is the best management option. The amount of recovery time varies greatly depending upon the location and severity of the fracture, and the body's healing response. Complete rest and a stirrup leg brace or walking boot are usually used for a period of four to eight weeks, although periods of rest of twelve weeks or more are not uncommon for more-severe stress fractures. After this period, activities may be gradually resumed as long as the activities do not cause pain. While the bone may feel healed and not hurt during daily activity, the process of bone remodeling may take place for many months after the injury feels healed. Instances of refracturing the bone are still a significant risk. Activities such as running or sports that place additional stress on the bone should only gradually be resumed. Rehabilitation usually includes muscle strength training to help dissipate the forces transmitted to the bones. With severe stress fractures (see "prognosis"),
surgery Surgery is a medical specialty that uses manual and instrumental techniques to diagnose or treat pathological conditions (e.g., trauma, disease, injury, malignancy), to alter bodily functions (e.g., malabsorption created by bariatric surgery s ...
may be needed for proper healing. The procedure may involve pinning the fracture site, and rehabilitation can take up to six months.


Prognosis

Anterior tibial stress fractures can have a particularly poor prognosis and can require surgery. On radiographic imaging, these stress fractures are referred to as the "dreaded black line." When compared to other stress fractures, anterior tibial fractures are more likely to progress to complete fracture of the tibia and displacement. Superior femoral neck stress fractures, if left untreated, can progress to become complete fractures with avascular necrosis, and should also be managed surgically. Proximal metadiaphyseal fractures of the fifth
metatarsal The metatarsal bones or metatarsus (: metatarsi) are a group of five long bones in the midfoot, located between the tarsal bones (which form the heel and the ankle) and the phalanges ( toes). Lacking individual names, the metatarsal bones are ...
(middle of the outside edge of the foot) are also notorious for poor bone healing. These stress fractures heal slowly with significant risk of refracture.


Epidemiology

In the United States, the annual incidence of stress fractures in athletes and military recruits ranges from 5% to 30%, depending on the sport and other risk factors. Women and highly active individuals are also at a higher risk. The incidence probably also increases with age due to age-related reductions in bone mass density (BMD). Children may also be at risk because their bones have yet to reach full density and strength. The
female athlete triad Relative energy deficiency in sport (RED-S) is a syndrome in which disordered eating (or ''low energy availability''), amenorrhoea/ oligomenorrhoea (in women), and decreased bone mineral density (osteoporosis and osteopenia) are present. It is ca ...
also can put women at risk as disordered eating and osteoporosis can cause the bones to be severely weakened. This type of injury is mostly seen in lower extremities, due to the constant weight-bearing (WB). The bones commonly affected by stress fractures are the
tibia The tibia (; : tibiae or tibias), also known as the shinbone or shankbone, is the larger, stronger, and anterior (frontal) of the two Leg bones, bones in the leg below the knee in vertebrates (the other being the fibula, behind and to the outsi ...
, tarsals,
metatarsals The metatarsal bones or metatarsus (: metatarsi) are a group of five long bones in the midfoot, located between the tarsal bones (which form the heel and the ankle) and the phalanges (toes). Lacking individual names, the metatarsal bones are nu ...
(MT),
fibula The fibula (: fibulae or fibulas) or calf bone is a leg bone on the lateral side of the tibia, to which it is connected above and below. It is the smaller of the two bones and, in proportion to its length, the most slender of all the long bones. ...
,
femur The femur (; : femurs or femora ), or thigh bone is the only long bone, bone in the thigh — the region of the lower limb between the hip and the knee. In many quadrupeds, four-legged animals the femur is the upper bone of the hindleg. The Femo ...
,
pelvis The pelvis (: pelves or pelvises) is the lower part of an Anatomy, anatomical Trunk (anatomy), trunk, between the human abdomen, abdomen and the thighs (sometimes also called pelvic region), together with its embedded skeleton (sometimes also c ...
and spine. Upper extremity stress fractures occur less frequently and are usually created in the upper torso by muscle forces. The population that has the highest risk for stress fractures is athletes and military recruits who are participating in repetitive, high intensity training. Sports and activities that have excessive, repetitive ground reaction forces have the highest incidence of stress fractures. The site at which the stress fracture occurs depends on the activity/sports that the individual participates in. Women are more at risk for stress fractures than men due to factors such as lower aerobic capacity, reduced muscle mass, lower bone mineral density, among other anatomical and hormone-related elements. Women also have a two- to four-times increased risk of stress fractures when they have
amenorrhea Amenorrhea or amenorrhoea is the absence of a menstrual period in a female organism who has reached reproductive age. Physiological states of amenorrhoea are most commonly seen during pregnancy and lactation (breastfeeding). In humans, it is wher ...
compared to women who are eumenorrheic. Reduced bone health increases the risk of stress fractures and studies have shown an inverse relationship between bone mineral density and stress fracture occurrences. This condition is most notable and commonly seen on the femoral neck.


Other animals


Dinosaurs

In 2001, Bruce Rothschild and other
paleontologists Paleontology, also spelled as palaeontology or palæontology, is the scientific study of the life of the past, mainly but not exclusively through the study of fossils. Paleontologists use fossils as a means to classify organisms, measure geolo ...
published a study examining evidence for stress fractures in
theropod Theropoda (; from ancient Greek , (''therion'') "wild beast"; , (''pous, podos'') "foot"">wiktionary:ποδός"> (''pous, podos'') "foot" is one of the three major groups (clades) of dinosaurs, alongside Ornithischia and Sauropodom ...
dinosaurs and analyzed the implications such injuries would have for reconstructing their behavior. Since stress fractures are due to repeated events they are probably caused by expressions of regular behavior rather than chance
trauma Trauma most often refers to: *Psychological trauma, in psychology and psychiatric medicine, refers to severe mental and emotional injury caused by distressing events *Traumatic injury, sudden physical injury caused by an external force, which doe ...
. The researchers paid special attention to evidence of injuries to the hand since dinosaurs' hind feet would be more prone to injuries received while running or migrating. Hand injuries, meanwhile, were more likely to be caused by struggling prey. Stress fractures in dinosaur bones can be identified by looking for bulges on the shafts of bones that face toward the front of the animal. When X-rayed, these bulges often show lines of clear space where the X-rays have a harder time traveling through the bone. Rothschild and the other researchers noted that this "zone of attenuation" seen under the X-ray typically cannot be seen with the naked eye. The researchers described theropod phalanges as being "
pathognomonic Pathognomonic (synonym ''pathognomic'') is a term, often used in medicine, that means "characteristic for a particular disease". A pathognomonic sign is a particular sign whose presence means that a particular disease is present beyond any doubt. ...
" for stress fractures; this means they are "characteristic and unequivocal diagnostically”. Rothschild and the other researchers examined and dismissed other kinds of injury and sickness as causes of the lesions they found on the dinosaurs' bones.
Lesions A lesion is any damage or abnormal change in the tissue of an organism, usually caused by injury or diseases. The term ''Lesion'' is derived from the Latin meaning "injury". Lesions may occur in both plants and animals. Types There is no de ...
left by stress fractures can be distinguished from
osteomyelitis Osteomyelitis (OM) is the infectious inflammation of bone marrow. Symptoms may include pain in a specific bone with overlying redness, fever, and weakness. The feet, spine, and hips are the most commonly involved bones in adults. The cause is ...
without difficulty because of a lack of bone destruction in stress fracture lesions. They can be distinguished from benign bone
tumors A neoplasm () is a type of abnormal and excessive growth of tissue. The process that occurs to form or produce a neoplasm is called neoplasia. The growth of a neoplasm is uncoordinated with that of the normal surrounding tissue, and persists ...
like
osteoid osteoma An osteoid osteoma is a benign (non-cancerous) bone tumor that arises from osteoblasts and some components of osteoclasts. It was originally thought to be a smaller version of an osteoblastoma. Osteoid osteomas tend to be less than 1.5 cm ...
by the lack of a sclerotic perimeter. No disturbance of the internal bony architecture of the sort caused by malignant bone tumors was encountered among the stress fracture candidates. No evidence of
metabolic disorders A metabolic disorder is a disorder that negatively alters the body's processing and distribution of macronutrients, such as proteins, fats, and carbohydrates. Metabolic disorders can happen when abnormal chemical reactions in the body alter the ...
like
hyperparathyroidism Hyperparathyroidism is an increase in parathyroid hormone (PTH) levels in the blood. This occurs from a disorder either within the parathyroid glands ( primary hyperparathyroidism) or as response to external stimuli ( secondary hyperparathyroi ...
or
hyperthyroidism Hyperthyroidism is a endocrine disease in which the thyroid gland produces excessive amounts of thyroid hormones. Thyrotoxicosis is a condition that occurs due to elevated levels of thyroid hormones of any cause and therefore includes hyperth ...
was found in the specimens, either. After examining the bones of many kinds of dinosaur the researchers noted that ''
Allosaurus ''Allosaurus'' ( ) is an extinct genus of theropod dinosaur that lived 155 to 145 million years ago during the Late Jurassic period ( Kimmeridgian to late Tithonian ages). The first fossil remains that could definitively be ascribed to th ...
'' had a significantly greater number of bulges on the shafts of its hand and foot bones than the
tyrannosaur Tyrannosauroidea (meaning 'tyrant lizard forms') is a superfamily (or clade) of coelurosaurian theropod dinosaurs that includes the family Tyrannosauridae as well as more basal relatives. Tyrannosauroids lived on the Laurasian supercontinent b ...
''
Albertosaurus ''Albertosaurus'' (; meaning "Alberta lizard") is a genus of large tyrannosaurid theropod dinosaur that lived in northwestern North America during the early to middle Maastrichtian age of the Late Cretaceous period, about 71 million yea ...
'', or the
ostrich dinosaurs Ornithomimosauria ("bird-mimic lizards") are theropod dinosaurs which bore a superficial resemblance to the modern-day ostrich. They were fast, omnivorous or herbivorous dinosaurs from the Cretaceous Period of Laurasia (now Asia, Europe and Nort ...
''
Ornithomimus ''Ornithomimus'' (; "bird mimic") is a genus of ornithomimid theropod dinosaurs from the Campanian and Maastrichtian ages of Late Cretaceous Western North America. ''Ornithomimus'' was a swift, bipedal dinosaur which fossil evidence indicates wa ...
'' and ''
Archaeornithomimus ''Archaeornithomimus'' (meaning "ancient bird mimic") is a genus of ornithomimosaurian theropod dinosaur that lived in Asia during the Late Cretaceous period, around 96 million years ago in the Iren Dabasu Formation. Discovery and naming In 1 ...
''. Most of the stress fractures observed along the lengths of ''Allosaurus'' toe bones were confined to the ends closest to the hind foot, but were spread across all three major digits in "statistically indistinguishable" numbers. Since the lower end of the third metatarsal would have contacted the ground first while a theropod was running it would have borne the most stress and should be most predisposed to develop stress fractures. The lack of such a bias in the examined fossils indicates an origin for the stress fractures from a source other than running. The authors conclude that these fractures occurred during interaction with prey. They suggest that such injuries could occur as a result of the theropod trying to hold struggling prey with its feet. The presence of stress fractures provide evidence for very active predation-based feeding rather than scavenging diets.Rothschild, B., Tanke, D. H., and Ford, T. L. (2001). "Theropod stress fractures and tendon avulsions as a clue to activity", in ''Mesozoic Vertebrate Life'', edited by Tanke, D. H., and Carpenter, K., Indiana University Press, p. 331–336.


References


External links

{{DEFAULTSORT:Stress Fracture Overuse injuries Bone fractures Osteopathies de:Knochenbruch#Ermüdungsfraktur