Stress fractures
1 / 20

Stress Fractures - PowerPoint PPT Presentation

  • Updated On :

Stress Fractures. (emphasis on Medial Tibial ). Stress Fracture-Scope of Disease. First described by Breithraupt in 1855 5 th metatarsal in marching Prussian soldiers (march fx ) Incidence around 10% of all musculoskeltal injuries (including military training)

I am the owner, or an agent authorized to act on behalf of the owner, of the copyrighted work described.
Download Presentation

PowerPoint Slideshow about 'Stress Fractures' - nia

An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.

- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -
Presentation Transcript
Stress fractures l.jpg

Stress Fractures

(emphasis on Medial Tibial)

Stress fracture scope of disease l.jpg
Stress Fracture-Scope of Disease

  • First described by Breithraupt in 1855

    • 5th metatarsal in marching Prussian soldiers(march fx)

  • Incidence around 10% of all musculoskeltal injuries (including military training)

  • 95% of all stress fractures occur in lower extremity

    • 46% tibia

    • 15% navicular

    • 12% the fibula

Pathophysiology l.jpg

  • Repetitive loading alters bone’s microstructure (↑ number & size microfx)

  • Response is ↑’d oseteoclastic & osteoblastic activity

  • Usually results in a stronger bone able to withstand greater loads

  • Initially osteoblasticactivity lags behind resorptive properties of osteoclasts

  • Process leaves bone susceptible to fatigue failure if the area is continually stressed without adequate time for repair

  • Couple this w muscle dysfxnfrom overuse results in focal bending stresses exceeding structural & physiologic tolerance of bone

    Usually takes at least 2-3 weeks to develop

Extrinsic factors l.jpg
Extrinsic Factors

  • Training Regime

    Too Much Too Hard Too Soon (10% Rule)

  • Equipment

    • Shoes

      • Right Shoe (pronator vs. supinator)

      • Old Shoe (change shoes every 500 miles-6 months)

    • Running Surface

  • Nutritional Habits

    • Calcium/Vit D (1000mg/800IU)

    • Adequate Calories

  • Rest

  • Medications- DepoProvera (? other progestins)

Intrinsic factors l.jpg
Intrinsic Factors

  • Muscle Endurance (most outshape, highest risk)

  • Excessive Hip External Rotation >60 deg

  • Leg Length Abnormality

  • PesCavus

  • Morton’s Foot hypermobile 1st ray &long 2nd ray

  • Hormonal Factors (lack of estrogen- ♀ athlete triad)

Diagnosis l.jpg

  • First Pain at end of training

  • Then during whole training session

  • Then continuous

  • Pain w palpation

  • Swelling

  • Fulcrum Test

  • Hop Test

    Definitive Dx requires radiographic confirmation

Imaging l.jpg

  • Plain Films-findings lag behind or nonexsistent

  • Bone Scan Sens 84-100%- poor specf-can’t use for f/u

  • MRI-high sens and spec and good for f/u

  • CT-excellent bone detail but ↑ radiation

  • U/S-operator and location dependent

    Sensitivity % of pts w disease who test +

    Specificity % of pts w/o disease who test -

Slide8 l.jpg

(A) Endosteal remodeling and cortical thickening (arrow) consistent with a stress fracture.

(B) Sagittal high-resolution fast spin echo MRI of same patient

demonstrating moderate cortical thickening and a faint cortical fracture line (arrow).

Slide9 l.jpg

phase 1 (flow phase)

phase 2 (blood-pool phase)

phase 3 (delayed phase)

Soft tissue injuries increased uptake in only phases 1 and 2

Shin splints have increased signal only in the delayed-phase images

Stress Fractures are + in all phases but take months to years to go to normal

Must correlate with symptoms

Slide10 l.jpg

(A) Sagittal fast inversion recovery MRI of lateral ankle margin with bone marrow edema pattern in the fibula with periosteal reaction consistent with stress fracture.

(B) Sagittal fast spin echo MRI in the same patient demonstrates mild ill-defined

endosteum and periosteal new bone formation (arrow ).

Slide11 l.jpg

Sagittal T2 fat saturation showing diffuse marrow edema.

Sagittalshowing diffuse marrow edema.

Slide12 l.jpg

Ultrasound showing periosteal elevation and increased blood flow

Grading scale l.jpg
Grading Scale

Time to Heal

3.3 Weeks

5.5 Weeks

11.4 Weeks

14.3 Weeks

Arendt EA, Griffiths HJ. The use of MR imaging in the assessment and clinical management of stress reactions of bone in high-performance athletes. Clin Sports Med 1997;16:291–306

Differential diagnosis l.jpg
Differential Diagnosis




Stress Fx



  • Muscle strain

  • Medial/Anterior tibia stress syndrome (shin splints-MTSS/ATSS)

  • Stress reaction

  • Exertional Compartment Syndrome (ECS)

  • Infection

  • Bursitis

  • Neoplasm

  • Nerve entrapment

MTSS Stress Reaction Stress Fracture


Treatment l.jpg

  • Relative Rest and Activity Modification

  • Pneumatic Braces

  • Foot Orthoses

  • Pulsed U/S (little less force than lithotripsy)

  • Bone Stimulators

  • Bisphosphonate (shuts down osteoclasts)

  • ? Avoid NSAIDs (Cox2 is needed for fx repair)

  • Correct Training Errors (no more 10% ↑ week)

  • Improve Muscular and Aerobic Capacity

Slide18 l.jpg

Anterior Tibial Cortex

“Dreaded Black Line”

Slide19 l.jpg

Stress Fx vs. Insufficiency Fx

Abnl Stress to Nl bone Nl stress to Abnl Bone

Cortical Fx vs. CancellousFx(consider DEXA if not good hx)

Long Bones Femoral Neck/Talus/Navicular

Low-grade fx at a low-risk site can be allowed to continue to compete

Low-grade fx at a high-risk site needs to heal before full return to activity

High Risk

Femoral Neck


Anterior tibialdiaphysis



5th Metatarsal

Low Risk

Femoral shaft

Medial tibia


Ulna shaft

1st -4th Metatarsals