Original article
Stress Fractures in the Young Athlete: A Pictorial Review

https://doi.org/10.1067/j.cpradiol.2009.12.001Get rights and content

Stress fractures are an uncommon but important source of pain and disability in young athletes. The presentation and differential diagnosis of stress fractures in young athletes differs from that of older athletes. This pictorial review outlines the pathogenesis and imaging features of stress fractures. Other pathologies that can mimic stress fractures and the advantages of the use of magnetic resonance imaging will be discussed. An imaging algorithm for a suspected stress fracture is suggested.

Section snippets

Pathogenesis

There are 2 main types of stress fractures—fatigue stress fractures and insufficiency stress fractures. Fatigue fractures occur in normal healthy bone because of abnormal muscular stress of unusual forces. These injuries are more common in young athletes when there is a continuous repetitive strain on the bones. There is often a history of a rapid increase in the training program. Females are slightly more often affected than males.

Insufficiency fractures occur in unhealthy bone that is mineral

Conventional Radiographs

If the classic findings of periosteal reaction, endosteal thickening, and/or a radiolucent cortical line (indicating the fracture site) are present then a confident diagnosis can be made. However, stress fractures may have similar features to pathologic fractures or chronic osteomyelitis on conventional radiographs, and other imaging modalities are often required to distinguish between these entities.10

In cancellous bone, stress fractures can be very hard to identify on conventional

Differential Diagnoses and Pitfalls

The main differential diagnoses for stress fractures that should be considered are as follows: infection, neoplastic processes, tendinitis, periostitis, osteoid osteoma, stain, sprain, compartment syndrome, and intermittent claudication.

Conventional radiographic changes of cortical thickening or periosteal reaction in long bones of children and adolescents are often nonspecific. Stress fractures are often misdiagnosed for infection or neoplastic processes.5 Obtaining a meticulous clinical

Lower Limb

Ninety-five percent of pediatric stress fractures occur in the lower limb with an equal male-to-female ratio.4, 33, 34 The age of the patient and type of activity plays an important role in the distribution of fractures. Femoral and tarsal fractures occur in older athletes, whereas in the pediatric population tibial and fibular fractures are more common. Endurance athletes are more likely to sustain metatarsal fractures, whereas those who are involved in sports with jumping and sudden stopping

Outcome

Most stress fractures tend to be treated conservatively with rest and nonweight-bearing with good result. Only a few studies have investigated outcome in the pediatric athlete.2, 3 Niemeyer et al found that around two-thirds of stress fractures were symptom free, when managed conservatively, 3 months after diagnosis.2 In the remainder of cases, there were persistent symptoms at 1 year. There were no pseudoarthroses. Delay in the diagnosis or poor patient compliance can lead to delayed healing

Conclusions

The presentation of stress fractures in the young athlete is variable, which may lead to confusion with other conditions such as tumors and osteomyelitis. More than 90% of the stress fractures occur in the lower limb, particularly the tibia and metatarsals. A suggested imaging algorithm for a suspected stress fracture is presented in Fig 26. Conventional radiographs, although insensitive, remain the initial imaging modality in most circumstances. If the diagnosis is clear, no further imaging is

References (58)

  • G. Horev et al.

    The enigma of stress fractures in the pediatric age: Clarification or confusion through the new imaging modalities

    Pediatr Radiol

    (1990)
  • S.J. Koenig et al.

    Stress fractures and stress reactions of the diaphyseal femur in collegiate athletes: An analysis of 25 cases

    Am J Orthop

    (2008)
  • R. Korpelainen et al.

    Risk factors for recurrent stress fractures in athletes

    Am J Sports Med

    (2001)
  • J. Wolff

    Concerning the interrelationship between form and function of the individual parts of the organismBy Julius Wolff, 1900

    Clin Orthop Relat Res

    (1988)
  • R.H. Daffner et al.

    Stress fractures: Current concepts

    AJR Am J Roentgenol

    (1992)
  • L.M. Fayad et al.

    Distinction of long bone stress fractures from pathologic fractures on cross-sectional imaging: How successful are we?

    AJR Am J Roentgenol

    (2005)
  • R.B. Greaney et al.

    Distribution and natural history of stress fractures in U.S. Marine recruits

    Radiology

    (1983)
  • R.H. Daffner

    Anterior tibial striations

    AJR Am J Roentgenol

    (1984)
  • M.W. Anderson et al.

    Stress fractures

    Radiology

    (1996)
  • M.J. Kiuru et al.

    MR imaging, bone scintigraphy, and radiography in bone stress injuries of the pelvis and the lower extremity

    Acta Radiol

    (2002)
  • M.B. Nielsen et al.

    Tibial periosteal reactions in soldiersA scintigraphic study of 29 cases of lower leg pain

    Acta Orthop Scand

    (1991)
  • P. de la Cuadra et al.

    Pediatric stress fractures

    Int Orthop

    (2000)
  • A.G. Bergman et al.

    Asymptomatic tibial stress reactions: MRI detection and clinical follow-up in distance runners

    AJR Am J Roentgenol

    (2004)
  • M. Gaeta et al.

    CT and MR imaging findings in athletes with early tibial stress injuries: Comparison with bone scintigraphy findings and emphasis on cortical abnormalities

    Radiology

    (2005)
  • K.A. Slocum et al.

    Resolution of abnormal MR signal intensity in patients with stress fractures of the femoral neck

    AJR Am J Roentgenol

    (1997)
  • M. Fredericson et al.

    Tibial stress reaction in runnersCorrelation of clinical symptoms and scintigraphy with a new magnetic resonance imaging grading system

    Am J Sports Med

    (1995)
  • W. Ammann et al.

    Femoral stress abnormalities: Improved scintigraphic detection with frog-leg view

    Radiology

    (1988)
  • L.R. Bryant et al.

    Comparison of planar scintigraphy alone and with SPECT for the initial evaluation of femoral neck stress fracture

    AJR Am J Roentgenol

    (2008)
  • F. Banal et al.

    Ultrasound ability in early diagnosis of stress fracture of metatarsal bone

    Ann Rheum Dis

    (2006)
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