Stress fractures in athletes

Ross Hauser, MD

Stress fractures, especially of the lower extremities, are often the result of increasing the amount or intensity of an activity too rapidly. Much has been written about foot strike impacts and increased physical activity as primary causes.

New research from the Harvard Medical School gives a summary

  • The most common stress fractures of the foot and ankle are:
    • Low-risk stress fractures:
      • posteromedial tibia (the back, middle portion of the shin bone)
      • the calcaneus (heel bone)
      • and the second and third metatarsals (bones of the second and third toe).
      • The distal fibula (lower, outer part of shin comprising the ankle complex) is less common
      • stress fractures of the cuboid (mid foot bone) and cuneiforms (three bones of the midfoot) are very rare.
    • High-risk stress fractures are more prone to delayed union or nonunion (non-healing) include:
      • the anterior tibial cortex (a less common cause of shin bone stress fracture).
      • medial malleolus (ankle fracture)
      • navicular (foot bone above the cuneiforms)
      • The base of the second metatarsal
      • proximal fifth metatarsal (the base of the pinky toe)
      • hallux sesamoids (Big toe),
      • and the talus (the large bone of the ankle)
        • Of these high-risk types, stress fractures of the anterior tibial cortex, the navicular, and the proximal tibial cortex may be predisposed to poor healing because of the low blood supply in these locations.


Looking at joint instability and Body Mass Index in stress fractures

Shin Splints ProlotherapyDoctors at Tokyo Medical and Dental University examined runners for Medial tibial stress syndrome (shin splints) and tibial stress fracture to determine risk factors for High School age athletes.

Here are their findings on stress fractures:

  • In males, doctors are recommended to look for hip instability and low back pain problems via the straight leg raising (SLR) test as there is a higher risk factor for stress fracture in low scoring.1

Researchers from Brazil and Columbia University in New York examined the role of endocrinology disorders on female athletes suffering from stress fractures.

  • Stress fractures account for up to 20% of athletic injuries, more commonly sustained by women and in those who engage in track-and-field events.
  • Although most stress fracture are reported among women who may experience menstrual disturbances, low body mass index, low energy intake and sometimes low bone mass, these individuals do not regularly seek endocrinological attention.

The researchers were able to suggest protocols for individuals whose bone mineral density is reduced along with low intake of dietary calcium and low circulating levels of 25-hydroxy vitamin D.

  • Limited systematic experience suggests that calcium and vitamin D supplementation might be beneficial.
  • There is not enough evidence for a protective effect of oral contraceptives in premenopausal athletes to recommend their use.2

1 Mandell JC, Khurana B, Smith SE. Stress fractures of the foot and ankle, part 2: site-specific etiology, imaging, and treatment, and differential diagnosis. Skeletal Radiol. 2017 Mar 25. doi: 10.1007/s00256-017-2632-7. [Pubmed]

2 Yagi S, Muneta T, Sekiya I. Incidence and risk factors for medial tibial stress syndrome and tibial stress fracture in high school runners. Knee Surg Sports Traumatol Arthrosc. 2013 Mar;21(3):556-63. doi: 10.1007/s00167-012-2160-x. Epub 2012 Aug 9.

3 Moreira CA, Bilezikian JP. Stress fractures: concepts and therapeutics. J Clin Endocrinol Metab. 2016 Oct 12:jc20162720.

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