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Bone stress injuries (BSIs) are a common form of injury in runners of both sexes.
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Both biological and biomechanical risk factors may contribute to BSI.
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History and physical examination are helpful to diagnose BSI, and MRI may be useful for radiographic confirmation and grading BSI.
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Prevention strategies include screening for risk factors during preparticipation evaluation, promoting optimal nutrition, and encouraging appropriate bone loading activities, including ball sports.
Physical Medicine and Rehabilitation Clinics of North America
Bone Stress Injuries in Runners
Section snippets
Key points
Incidence and Distribution
The incidence of BSI varies by age and sex. In a study comparing high school sports, female and male athletes participating in cross-country had the first and third highest incidences of injuries at 10.62 and 5.42 per 100,000 athletic exposures, respectively.6 In a separate investigation, adolescent runners of both sexes sustained stress fractures at a similar rate of approximately 4% to 5% annually.7 Elite collegiate runners may sustain BSIs at a rate exceeding 20% per year.2 Common sites for
Risk factors
Risk factors for BSI can be divided into biological and biomechanical risk factors (Table 1). Genetics are reported to modulate fracture risk.8 Medications, including steroids, anticonvulsants, antidepressants, and antacids, may impair bone health. Nutritional deficiencies in calcium and vitamin D increase risk for BSI.9, 10, 11 Female athletes seem to be at greater risk for BSI than male athletes.12 Sex-specific differences include the female athlete triad (hereafter referred to as the triad),
Clinical Evaluation
Clinicians should complete a full history and physical examination in runners who present for evaluation of a BSI. A complete running history should be obtained (including changes in running volume, shoe type and duration of use, frequency of racing, and change in foot strike pattern strategy). In female runners, screening for triad risk factors is important, including dietary restriction behaviors, daily servings of foods rich in calcium and vitamin D, menstrual dysfunction, history of
Anatomy and imaging
The anatomic locations for BSI can be divided into high-risk, moderate-risk, and low-risk locations based on time to heal and risk for nonunion (Table 2). Table 2 is based on a modified version of previously published high-risk32 and low-risk classifications,33 including a moderate-risk category that may be more challenging to address given biological and biomechanical forces that can contribute to risk for impaired bone healing.
MRI is commonly used to evaluate BSI because of the value in
Activity Modification and Aerobic Activity
After the initial healing phase to achieve pain-free ambulation and no pain with provocative maneuvers on physical examination, most athletes initiate a nonimpact loading activity to maintain fitness and strength, including deep water running. Athletes should be counseled to maintain good caloric intake to meet the metabolic demands of cross-training and not inadvertently restrict caloric intake, which may risk delayed healing response. Use of an antigravity treadmill may allow for progressive
Recommendations by anatomic site
Some of the most common locations for injury and management recommendations are discussed here.
Femoral Neck and Lesser Trochanter
Femoral neck BSI are considered high risk because of complications that may occur with nonunion, particularly on the tension side of the bone. Tension-side fractures may be managed with bed rest, as long as widening of the cortical fracture is not observed on serial imaging.41 Fractures adjacent to the lesser trochanter may also progress to femoral neck stress fractures if non–weight-bearing precautions are not followed during initial management.30 For compression side fractures and lesser
Sacrum and Pelvis
Most injuries in the sacrum have radiographic evidence of high-grade BSI. Crutches and other assistive devices to ensure pain-free mobility are important early in the clinical course and can be discontinued with pain-free ambulation. Runners usually return to full running activity around 12 weeks.51
Tarsals Cuboid and Cuneiform
Given their location, both cuboid and cuneiform BSIs can be difficult to heal given the biomechanical forces and loads encountered through the foot. Management includes immobilization if needed to
Tibia
Injuries are typically located at the distal third posterior medial aspect of the tibia. Clinical features suggestive of more severe injuries include focal pain, tenderness elicited with direct or indirect palpation, and associated MRI grading criteria can predict length of recovery ranging from 3 to 12 weeks.5
Fibula
Easy to examine given the surface bony anatomy, these injuries tend to heal quickly and allow prompt return to running when asymptomatic.1
Calcaneus
Heel pain in an athlete may be a clue to the
Participation in Ball Sports During Adolescence
We have proposed prehabilitation strategies, including ball sports (basketball and soccer) and related activities, during adolescence for 2 years to reduce BSI risk.52 These findings are based on prior research showing that military recruits and runners who participated in ball sports during youth have reduced risk for stress fractures.7, 53, 54
Adequate Calcium and Vitamin D Intake
Calcium and vitamin D intake may reduce risk for BSI. We recommend meeting daily calcium and vitamin D intake levels published by the Institute of
Summary
BSI is a common form of overuse injury in runners of both sexes. Clinicians should consider these injuries on the differential diagnosis for musculoskeletal complaints in runners. Early and effective management of the injury can help facilitate return to sport, and addressing underlying risk factors may prevent future injury. Early screening for triad risk factors, optimizing nutrition, and encouraging participation in higher-impact activities, including ball sports during adolescence, may
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Conflicts of interest: The authors have no conflicts of interest to disclose, and no funding was received in the preparation of this review.