Imaging of stress fractures in the athlete

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Mechanism of injury

Stress fractures occur when normal bone is subjected to repetitive stress. Although no individual stress is capable of producing a fracture, over time bone fatigue and failure result. Stress is the force or absolute load applied to a bone that may arise from weight-bearing or muscular action. The force may be applied as an axial, bending, or torsional load [2], [10], [11].

The precise pathogenesis of stress fracture is poorly understood; however, there are several theories to explain the

Clinical features

In most circumstances the athlete sustaining a stress injury is engaged in a vigorous activity to which he or she is not accustomed. Alternatively, a conditioned athlete may sustain a stress injury when he or she changes a training regimen, performs a new repetitive activity, returns to activity too soon after an injury, changes footwear, uses worn-out footwear, changes training surfaces, or in general uses poor training techniques. Women athletes with amenorrhea are especially susceptible to

Radiography

In early osseous stress injury and fracture, radiographs may initially be normal and more sensitive and specific tests, such as magnetic resonance (MR) imaging and bone scintigraphy, may be necessary. The sensitivity of early fracture detection by radiography can be as low as 15%, and follow-up radiographs may demonstrate diagnostic findings in only 50% of cases [3].

In bones that are predominantly cancellous, such as the calcaneus or femoral neck, radiographs demonstrate a line of sclerosis

Sites of injury

Although most common in the lower extremity, stress injury to bone and stress fractures have been reported in nearly every bone in the body [10], [34]. Stress fracture sites in the upper extremity include the ulna (Fig. 13), humerus, carpal bones, and ribs. Lower-extremity stress fractures can also occur anywhere and include the pubic symphysis; lumbar spine (spondylolysis); femur; tibia; distal fibula; medial malleolus (Fig. 14) [31]; calcaneus; tarsal navicular; metatarsals; and sesamoids.

Summary

Osseous stress fractures and stress reactions represent the effect of abnormal repetitive stress on normal bone. An accurate and thorough clinical history and sequential radiographs often suffice to make the diagnosis especially when the fracture occurs in one of the common locations, such as the tibia, metatarsals, or calcaneus. In cases that are atypical in location or clinical presentation the authors rely more on MR imaging, radionuclide bone scanning, and occasionally CT. MR imaging

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