define the location and extent of bony injury, lack of
exposure to ionizing radiation and significantly less
imaging time than a triple phase bone scan
(Fredericson et al, 1995).GENERAL PRINCIPLE OF TREATMENT
- Less critical or not-at-risk fractures can be treated with
a two-phase protocol. Phase one includes pain control
with ice massage and physical therapy modalities. - Weight bearing is allowed for normal activities within
the tolerance of pain. Running is discontinued. A
modified activity program such as pool running,
rowing, or cycling is designed to maintain strength
and fitness but to reduce impact loading to the skele-
ton. - Phase two, graduated return to sport, generally begins
one week following the resolution of focal bony ten-
derness. The athlete can return to running, starting at
a slow pace for 10–15 min running only every other
day for the first two weeks. Then, over a 3- to 6-week
period, a gradual increase in distance and frequency is
permitted (Fredericson, Bergman, and Matheson,
1997). - Functional foot orthoses are capable of either reduc-
ing abnormal pronation in those patients with a
markedly everted rearfoot or providing better shock
absorption in athletes with a rigid, inverted rearfoot. - If there is a positive history of late onset menarche or
irregular menses or amenorrhea, then consideration
should be given to obtaining a bone mineral density
test and endocrine work-up. - A recent study showed that women with stress frac-
tures in trochanteric bone often have osteopenia
(Marx et al, 2001) - In general, treatment of higher risk stress fractures
mandates immediate diagnosis, nonweightbearing,
and occasionally internal fixation.
SPECIFIC SITES OF STRESS FRACTURE
PELVIS
SACRUM
- Stress fracture in the sacrum are most common in
women distance runners with low bone density, but
can be seen in those with normal bone mineralization.
These stress fractures tend to involve the anteroinfe-
rior aspect of the sacral wing unilaterally
(Fredericson, Salamancha, and Beaulieu, 2003). - MRI is recommended for diagnosis, with intermediate
signal intensity on T1-weighted images and high
signal intensity on T2-weighted images (Fredericson,
Salamancha, and Beaulieu, 2003).PUBICRAMI- More commonly, a bony stress reaction may develop
in runners at the symphysis pubis (osteitis pubis) or at
the inferior pubic ramus adjacent to the symphysis
and are believed related to overuse of the adductor
muscles for pelvic stabilization. - Treatment for the above pelvic stress fractures
requires a period of rest and temporary use of crutches
if there is any pain during ambulation. Symptoms usu-
ally resolve within several weeks and return to full
activity can be safely advised at between 8 and 10
weeks, depending on the severity of injury.
ISCHIUM- An ischial ramus stress reaction is not considered a
true stress fracture, as it is seen in association with
proximal hamstring tendinitis or hamstring bursitis,
secondary to chronic traction of the muscle origin
(Bergman and Fredericson, 1999; Fredericson,
Bergman, and Matheson, 1997).
FEMURFEMORALNECK- Stress fractures of the femoral neck are high risk frac-
tures and should be considered in any athlete, espe-
cially a distance runner, who presents with hip, thigh,
or groin pain. Pain and symptoms are worse with
weightbearing, and there is often reduced range of
movement in the hip, particularly internal rotation
(Lombardo and Benson, 1982; Keen and Lash, 1992). - Early detection of femoral neck stress fractures is cru-
cial, as continued stress may lead to a displaced fracture,
with associated risk of avascular necrosis and irre-
versible damages to the joint (Lombardo and Benson,
1982; Keen and Lash, 1992; Volpin et al, 1990). - Compression fractures are more common in younger
athletic patients and are located at the cortex of the
lower medial margin of the femoral neck. The early
radiographic appearance of these fractures is subtle
endosteal lysis or sclerosis along the inferior cortex of
the femoral neck, followed by progressive sclerosis
and appearance of a fracture line. - If the radiographic findings are subtle or absent, MRI
can be used to detect marrow edema and the presence
or absence of a low signal intensity line that indicates
a fracture. - If a stress reaction without a fracture line is detected,
treatment is conservative, with a 2- to 3-month period
of progressive weight bearing followed by a gradual
392 SECTION 4 • MUSCULOSKELETAL PROBLEMS IN THE ATHLETE