Imaging of Stress Fractures in Runners

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Pathophysiology

There is a spectrum of osseous stress injuries that occurs, beginning with stress reaction or stress response and eventually leading to stress fracture. The pathophysiology of stress reaction and stress fractures is related to the bone response to the repetitive stresses at the cellular level. With excess stresses, the osteoclasts replace the circumferential lamellar bone with dense osteonal bone. This is accompanied by the development of edema and hyperemia, which is the stress reaction or

Biomechanics of Running

A discussion of running-related injuries necessitates a brief summary of the biomechanics of running. During running, each foot strikes the ground 50 to 70 times per minute for each foot. The force produced is two to four times the runner's body weight. This force is distributed through the runner's footwear, and transmitted upwards through the lower extremities and into the pelvis, sacrum, and spine, exposing these structures to increased axial stresses. There are two main phases of running:

Diagnosis

Patients who have osseous stress injuries most commonly present with insidious onset of activity-related local pain with weight bearing. If the athlete continues to exercise, the pain may become more severe or occur at an earlier stage of exercise [14]. Typically, the pain resolves when the patient is non-weight bearing [8]. Occasionally, the patient may present with additional findings of redness, swelling, and obvious periosteal reaction at the site of stress fracture. In most cases, the

Imaging

MRI of joints in sports medicine requires consideration of multiple technical factors. A dedicated extremity coil appropriate for the particular joint is desired. The type of abnormality clinically suspected, the magnet field strength, the desired anatomic coverage, and the presence of postsurgical change or indwelling hardware are important considerations. In the majority of cases of stress response as well as stress fracture, there is no abnormality on plain film radiographs [14].

Great Toe and Sesamoids

Stress fractures of the great toe and sesamoids are seen less frequently than other sites of stress-related injury, but when they do occur the diagnosis may be more difficult, resulting in a delay in diagnosis if this injury is not considered [8]. Stress fractures of the great toe have been reported in runners, soccer players, and volleyball players. Athletes who have pain in the first metatarsophalangeal joint and who are exposed to excessive running, jumping, and repeated forced dorsiflexion

Metatarsal Bones

Metatarsal stress fractures are a common overuse injury in runners [28], [29]. Along with the tibia, the metatarsals are among the most common stress fractures seen in runners [28].

It is thought that the plantar flexion musculature of the toes help to dissipate stress on the metatarsals. It has been demonstrated that dorsal strains are significantly reduced by simulated contraction of the plantar flexion musculature. It is therefore possible that fatigue of these muscles during strenuous or

Tarsal Bones

Up to 20% of stress fractures in runners may occur in the tarsal bones [8]. Stress fracture of the tarsal bones are too often a diagnostic challenge, because many providers do not consider tarsal stress fractures in the assessment of foot and ankle pain. A high clinical suspicion of stress fractures is required for an accurate and timely diagnosis. The majority of tarsal bone stress fractures occur in the navicular (Fig. 5A, B) [28].

This diagnosis is becoming recognized with increasing

Tibia

The tibia is the most common site of stress-related injury in runners [6], [8]. Leg pain is common in runners, and may be caused by a number of etiologies, including: tibial periostitis (shin splints), stress reaction, stress fractures, muscle/tendon injuries, and compartment syndromes. Tibial stress reaction and stress fractures most commonly present with pain and tenderness along the medial shaft of the tibia, precipitated by exercise.

There is usually focal tenderness to palpation and

Fibula

Stress fractures of the fibula may occur in runners, presenting as local pain and tenderness over the fibula. The incidence of stress fractures in the fibula in running has been quoted between 7% and 12%, and is most common in the distal fibula [6], [8], [66]. Proximal fibular stress fractures may also rarely occur, but are more common in jumpers. A high clinical suspicion is particularly important in making both of these diagnoses. Fractures may present as pain and tenderness over the lateral

Patella

Two types of patellar stress fractures occur: longitudinal and transverse [69]. It has also been suggested that in some cases a chronic symptomatic bipartite patella could represent a chronic patellar stress fracture [70]. An exceptionally rare case of a running related transverse patellar stress fracture in a 12-year-old misdiagnosed for 5 months as Sinding-Larsen-Johansson disease has been reported [71]. These cases illustrate the need to consider stress injuries, even when the patient's

Femur

Stress fractures of the femur in runners may occur in the femoral neck, trochanteric and subtrochanteric region, and femoral shaft. These injuries are often not considered in the initial presentation, and a high index of suspicion must be maintained. Patients commonly present with hip, groin, gluteal, thigh, or knee pain, depending on the location of the injury [18], [72], [73].

In a study by Clement and colleagues [72], 71 patients who had 74 stress fractures of the femur were studied. Nearly

Pelvis

Pelvic stress fractures are relatively uncommon, representing only 1% to 2% of all stress fractures [79], [80]. Pelvic stress fractures in runners most often occur in the pubic rami. Pubic rami fractures are commonly near the symphysis pubis (Fig. 14).

Symptoms most commonly include groin, hip, buttock, or thigh pain [79], [80], [81], [82], [83], [84]. These fractures most commonly occur in long distance female runners [81], [82], [83], [84], [85]. Severe groin pain may make running impossible.

Sacrum

Sacral stress fractures may present as low back or buttock pain, mimicking disk disease, sciatica, or sacroiliac joint pathology. These fractures more commonly affect the female runner; there are reports of adolescent female runners who had low back pain subsequently being diagnosed with sacral stress fractures (Fig. 15) [86].

This emphasizes the need to consider stress injuries in the active pediatric patient population as well [87], [88]. Imaging of sacral stress fractures may include nuclear

Spine

Stress injuries of the spine in runners may occur in the vertebral bodies, pedicles, and in the lamina/pars interarticularis. Patients most commonly complain of low back pain (Fig. 16) [90].

MRI of stress response typically shows intramedullary low T1 signal and corresponding increased T2, fat-saturated or STIR signal intensity, and may show enhancement of the corresponding marrow as well as surrounding soft tissues after contrast administration. An actual stress fracture will show the above

Treatment of Stress Injuries

Successful treatment of stress injuries requires identification of the predisposing factor. A prolonged period of rest may result in resolution of pain, only for the symptoms to recur when the patient resumes running activities. A thorough review of training schedule, footwear, running surfaces, and other predisposing factors such as dietary and hormonal status should be performed. Most stress fractures can be managed with cessation of running and other lower extremity impact-type sports, with

Summary

Stress fractures in runners are a common problem, but their diagnosis and treatment are often challenging. A high level of suspicion and awareness of these injuries should be maintained when caring for physically active patients, in order to avoid misdiagnoses or delays in diagnosis. MRI can be particularly helpful for the diagnosis and characterization of osseous stress injuries in the running athlete.

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References (90)

  • J.T. Bencardino et al.

    Imaging of hip disorders in athletes

    Radiol Clin North Am

    (2002)
  • E.B. Hershman et al.

    Femoral shaft stress fractures in athletes

    Clin Sports Med

    (1990)
  • J.M. Lapp

    Pelvic stress fracture: assessment and risk factors

    J Manipulative Physiol Ther

    (2000)
  • R.H. Michael et al.

    The soleus syndrome: a cause of medial tibial stress (shin splints)

    Am J Sports Med

    (1985)
  • D. Resnick

    Physical injury: concepts and terminology

  • K.A. Egol et al.

    Stress fractures of the femoral neck

    Clin Orthop Relat Res

    (1998)
  • S. Myers et al.

    Repetition of an unusual stress fracture in an anorexic man: a case report

    J Orthop Surg (Hong Kong)

    (2002)
  • G.P. Montoleone

    Stress fractures in the athlete

    Orthop Clin North Am

    (1995)
  • G.O. Matheson et al.

    Stress fractures in athletes. A study of 320 cases

    Am J Sports Med

    (1987)
  • M. Csizy et al.

    “Bone tumor” diagnostic error in stress fracture of the medial tibial plateau

    Unfallchirurg

    (2000)
  • K.H. Myburgh et al.

    Low bone density is an etiologic factor for stress fractures in athletes

    Ann Intern Med

    (1990)
  • R. Korpelainen et al.

    Risk factors for recurrent stress fractures in athletes

    Am J Sports Med

    (2001)
  • D.M. Brody

    Running injuries; prevention and management

    Clin Symp

    (1987)
  • P. Brukner et al.

    Stress fractures in female athletes. Diagnosis, management and rehabilitation

    Sports Med

    (1997)
  • H. Nielens et al.

    Occurrence of a painful stress fracture of the femoral neck simultaneously with six other asymptomatic localizations in a runner

    J Sports Med Phys Fitness

    (1994)
  • G.M. Ivanic et al.

    Stress fractures of the tarsal navicular bone. Causality, diagnosis, therapy, prophylaxis

    Orthopade

    (2003)
  • T. Scheerlinck et al.

    Bilateral stress fractures of the femoral neck complicated by unilateral displacement in a child

    J Pediatr Orthop B

    (1998)
  • A. Wagenitz et al.

    Improved diagnosis of stress fractures with contrast MRI

    Sportverletz Sportschaden

    (1994)
  • M. Shiraishi et al.

    Stress fracture of the proximal phalanx of the great toe

    Foot Ankle

    (1993)
  • M.J. Petrizzi

    Foot injuries

  • D. Karasick et al.

    Disorders of the hallux sesamoid complex: MR features

    Skeletal Radiol

    (1998)
  • C.J. Ashman et al.

    Forefoot pain involving the metatarsal region: differential diagnosis with MR imaging

    Radiographics

    (2001)
  • E.G. Richardson

    Injuries to the hallucal sesamoids in the athlete

    Foot Ankle

    (1987)
  • A. Hulkko et al.

    Stress fractures of the sesamoid bones of the first metatarsophalangeal joint in athletes

    Arch Orthop Trauma Surg

    (1985)
  • A. Hulkko et al.

    Stress fractures in athletes

    Int J Sports Med

    (1987)
  • P. Brukner et al.

    Stress fractures: a review of 180 cases

    Clin J Sport Med

    (1996)
  • R.T. Hockenbury

    Forefoot problems in athletes

    Med Sci Sports Exerc

    (1999)
  • R. Weist et al.

    The influence of muscle fatigue on electromyogram and plantar pressure patterns as an explanation for the incidence of metatarsal stress fractures

    Am J Sports Med

    (2004)
  • T.S. Gross et al.

    A mechanical model of metatarsal stress fracture during distance running

    Am J Sports Med

    (1989)
  • D. Drez et al.

    Metatarsal stress fractures

    Am J Sports Med

    (1980)
  • M.W. Anderson et al.

    Stress fractures

    Radiology

    (1996)
  • R.H. Daffner et al.

    Stress fractures: current concepts

    AJR Am J Roentgenol

    (1992)
  • A. Saxena et al.

    Proximal fourth metatarsal injuries in athletes: similarity to proximal fifth metatarsal injury

    Foot Ankle Int

    (2001)
  • G. Portland et al.

    Acute surgical managemen of Jones' fractures

    Foot Ankle Int

    (2003)
  • J. Kavanaugh et al.

    The Jones' fracture revisited

    J Bone Joint Surg Am

    (1978)
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