What are the common types of stress fractures in children. How are pediatric stress fractures diagnosed using imaging techniques. What are the risk factors for stress fractures in young athletes. How can stress fractures be prevented in pediatric sports.

Understanding Pediatric Stress Fractures: Causes and Risk Factors

Pediatric stress fractures have become increasingly common as more children participate in organized and competitive sports at younger ages. These injuries result from repetitive forces on the musculoskeletal system without adequate time for recovery and adaptation. Several factors make children more susceptible to stress fractures compared to adults:

• Weaker osteochondral junctions
• Thinner cortices
• Hormonal changes during growth
• Decreased bone mineralization
• Demanding training schedules with insufficient recovery time

The physis (growth plate) and apophysis (where tendons attach to bone) are particularly vulnerable sites in children due to their relative weakness. Abnormal stresses at these locations can disrupt normal bone growth and development.

Types of Pediatric Stress Fractures

Stress fractures in children generally fall into two categories:

1. Fatigue fractures: Caused by excessive forces on normal bone
2. Insufficiency fractures: Result from normal forces on abnormal or weakened bone

Diagnostic Challenges in Pediatric Stress Fractures

Diagnosing stress fractures in children can be challenging for several reasons:

• Limited ability of young children to provide detailed medical histories
• Difficulty in performing thorough physical examinations on pediatric patients
• Initial radiographic occultness of stress fractures
• Progressive nature of radiographic changes with continued stress

Given these challenges, both orthopedic surgeons and radiologists must be familiar with the radiographic and magnetic resonance imaging (MRI) features of common stress fractures in children.

Imaging Modalities for Diagnosing Pediatric Stress Fractures

Various imaging techniques play crucial roles in diagnosing and evaluating pediatric stress fractures:

Radiography

Plain radiographs are often the initial imaging study performed. However, stress fractures may not be visible on early radiographs. Serial imaging over time may reveal progressive changes.

Magnetic Resonance Imaging (MRI)

MRI is highly sensitive for detecting early stress reactions and fractures. It can reveal bone marrow edema and soft tissue changes before radiographic abnormalities appear.

Computed Tomography (CT)

CT scans provide detailed bony anatomy and are particularly useful for certain fracture types, such as spondylolysis.

Single Photon Emission Computed Tomography (SPECT)

SPECT can be helpful in confirming diagnoses that are indeterminate on MRI, especially for spondylolysis.

Spondylolysis: A Common Spinal Stress Fracture in Young Athletes

Spondylolysis is a stress fracture that occurs through the pars interarticularis of the vertebra, and occasionally through the pedicle. It is commonly seen in young athletes who participate in sports requiring repeated spinal extension and rotation.

Clinical Presentation

Lower back pain in a young patient should raise suspicion for spondylolysis. The pain is typically exacerbated by activities involving spinal extension.

Imaging Findings

MRI findings of spondylolysis include:

• Low signal intensity on T1-weighted images at the pars interarticularis or pedicle
• Increased signal intensity on T2-weighted or STIR sequences in the same areas

CT is considered superior to MRI for detecting spondylolysis but involves ionizing radiation. SPECT can be useful in confirming indeterminate cases on MRI.

Acromial Apophysiolysis and Os Acromiale: Shoulder Stress Injuries

The acromion develops from multiple ossification centers that typically fuse between 15-25 years of age. Chronic repetitive traction forces from the deltoid muscle can lead to a condition called acromial apophysiolysis.

Clinical Presentation

Patients with acromial apophysiolysis or os acromiale often present with chronic, insidious-onset shoulder pain.

Diagnostic Challenges

Differentiating between a normal unfused acromial apophysis and pathologic os acromiale can be challenging in adolescents due to the variable timing of normal fusion. Key imaging features that suggest pathology include:

• Irregular cortical margins
• Abnormal marrow signal on MRI
• Adjacent soft tissue edema

Prevention Strategies for Pediatric Stress Fractures

Preventing stress fractures in young athletes requires a multifaceted approach:

1. Proper training progression: Gradually increase intensity and volume of training
2. Adequate rest and recovery: Ensure sufficient time between training sessions
3. Cross-training: Incorporate varied activities to reduce repetitive stress
4. Proper nutrition: Emphasize calcium and vitamin D intake for bone health
5. Biomechanical assessment: Address any underlying movement patterns that may increase injury risk
6. Appropriate footwear: Use properly fitted shoes designed for the specific sport
7. Education: Teach young athletes, parents, and coaches about the signs and symptoms of stress fractures

Management of Pediatric Stress Fractures

The treatment of stress fractures in children typically involves:

• Activity modification or temporary cessation of the offending activity
• Physical therapy to address any underlying biomechanical issues
• Gradual return to sport with careful monitoring
• In some cases, immobilization or bracing may be necessary
• Surgical intervention is rarely required but may be considered for certain high-risk stress fractures or those that fail to heal with conservative management

Long-term Considerations

Are there potential long-term consequences of pediatric stress fractures? While most stress fractures heal well with appropriate management, some considerations include:

• Increased risk of recurrence if underlying risk factors are not addressed
• Potential for growth disturbances if the physis is involved
• Psychological impact on young athletes who may experience frustration or anxiety about returning to sport

Emerging Research in Pediatric Stress Fractures

The field of pediatric sports medicine continues to evolve, with ongoing research focused on improving our understanding and management of stress fractures in children. Some areas of current interest include:

Advanced Imaging Techniques

Researchers are exploring the use of novel imaging modalities to detect stress reactions earlier and with greater accuracy. These include:

• High-resolution peripheral quantitative CT (HR-pQCT) for detailed bone microarchitecture analysis
• Positron emission tomography (PET) combined with CT or MRI for metabolic imaging of bone stress
• Ultrashort echo time (UTE) MRI sequences for improved visualization of cortical bone

Genetic Factors

Are there genetic predispositions to stress fractures in young athletes? Scientists are investigating genetic markers that may influence bone strength, remodeling, and susceptibility to stress injuries. This research could potentially lead to personalized risk assessments and prevention strategies.

Bone Health Optimization

Studies are underway to determine optimal nutrition and exercise protocols for maximizing bone strength in growing athletes. This includes research on:

• Ideal calcium and vitamin D supplementation regimens
• The role of other micronutrients in bone health
• Impact of different types of physical activity on bone accrual during growth

Biomechanical Interventions

Researchers are developing and testing new approaches to modify biomechanics and reduce stress on vulnerable areas. This includes:

• Wearable technology for real-time biomechanical feedback
• Novel training programs designed to improve movement patterns and reduce injury risk
• Advanced orthotics and footwear designs tailored to individual biomechanics

The Role of Education in Preventing Pediatric Stress Fractures

Education plays a crucial role in preventing and managing stress fractures in young athletes. Key stakeholders who should be educated include:

Athletes

Young athletes should be taught:

• The importance of listening to their bodies and recognizing early warning signs of overuse injuries
• Proper nutrition and hydration practices for optimal bone health
• The value of rest and recovery in preventing stress fractures
• How to communicate effectively with coaches and parents about their physical condition

Parents

Parents should be educated on:

• The risks associated with early sports specialization and year-round training
• The importance of encouraging diverse physical activities for overall athletic development
• How to recognize signs of overtraining or burnout in their children
• The role of proper nutrition in supporting bone health during growth

Coaches and Trainers

Coaches and trainers should receive education on:

• Proper training progression and periodization to reduce injury risk
• How to design practice sessions that incorporate adequate rest and recovery
• Recognizing early signs of stress injuries in young athletes
• The importance of individualized training plans based on each athlete’s developmental stage and physical readiness

Healthcare Providers

Pediatricians, sports medicine physicians, and other healthcare providers should stay updated on:

• Latest research and guidelines for diagnosing and managing pediatric stress fractures
• Appropriate use of imaging modalities for different clinical scenarios
• Evidence-based prevention strategies to share with patients and families
• Interdisciplinary approaches to managing young athletes with stress fractures

The Future of Pediatric Stress Fracture Management

As our understanding of pediatric stress fractures continues to grow, several exciting developments are on the horizon:

Personalized Risk Assessment

Advances in genetic testing and biomechanical analysis may soon allow for highly individualized risk assessments. This could enable the development of tailored prevention strategies for each young athlete based on their unique genetic, anatomical, and biomechanical profile.

Novel Treatment Approaches

Emerging treatments for stress fractures in children may include:

• Targeted biologic therapies to enhance bone healing
• Low-intensity pulsed ultrasound (LIPUS) to stimulate bone formation
• 3D-printed, customized orthotics and braces for optimal support during healing

Improved Rehabilitation Protocols

Future rehabilitation approaches for pediatric stress fractures may incorporate:

• Virtual reality-based exercises for improved engagement and adherence
• Machine learning algorithms to optimize return-to-play progressions
• Telehealth monitoring for closer follow-up and adjustment of treatment plans

Advanced Imaging and Monitoring

The future may bring:

• Portable, low-radiation imaging devices for point-of-care assessment of bone health
• Implantable biosensors to monitor bone stress in real-time during athletic activities
• Artificial intelligence-assisted image analysis for more accurate and early detection of stress reactions

As research progresses and technology advances, the management of pediatric stress fractures will likely become increasingly precise and personalized. This evolution in care has the potential to significantly reduce the incidence and impact of these injuries, allowing young athletes to participate safely in their chosen sports while optimizing their long-term musculoskeletal health.

Pediatric stress fractures: a pictorial essay

Iowa Orthop J. 2016; 36: 138–146.

Copyright and License information Disclaimer

More children are participating in organized and recreational athletics at a younger age. It has been well documented that increased athletic specialization and year-round activities have resulted in higher incidences of overuse injuries, including stress fractures and stress reactions. Initially, stress fractures can be radiographically occult. Continued stress on the injured bone or cartilage can lead to progressive radiographic changes. Because of the prevalence of these injuries, both orthopedic surgeons and radiologists should be aware of the radiographic and magnetic resonance imaging (MRI) features of common stress fractures in children. This article reviews frequently encountered stress fractures involving various bones in the pediatric population.

A recent increase in the number of children participating in competitive sports has resulted in an increase in stress injuries¹. These stress injuries can be difficult to diagnose. In young children, the clinical examination is often difficult given the inability of children to provide detailed histories or fully participate in the physical exam. Detection of the hallmark features of common stress injuries on both radiographs and MRI can aid in the diagnosis.

Stress fractures are the result of repetitive forces on the musculoskeletal system that has not had sufficient time to recover². In children, factors such as weaker osteochondral junctions, thinner cortices, hormonal changes, and decreased mineralization predispose to stress fractures^3,4. This is further compounded by participation in sports with demanding schedules which may not allow adequate time for the child to recover. The physis and the apophysis, which are among the weaker parts of the musculoskeletal system in children, are common sites for stress fractures. Abnormal stresses at these sites may result in disruption of endochondral ossification, ultimately resulting in physeal widening⁵. Repetitive microtrauma also leads to bony cortical defects and stress fractures, which can be in the form of fatigue fractures (excessive forces on normal bone) or insufficiency fractures (normal forces on abnormal bone)². This article reviews the classic radiographic and MR findings of common stress fractures in children

Spondylolysis is a stress fracture which occurs through the pars interarticularis, and occasionally through the pedicle. It is the result of repeated bouts of extension and rotation about the spine⁶. It has been observed with higher frequency not only in young athletes, but in certain populations that require repetitive flexion and extension of their spine, such as the Eskimos^{7, 8}. Lower back pain in the young patient should prompt a search for spondylolysis⁷. Conventional computed tomography (CT), MRI, and single photon emission computed tomography (SPECT) are all acceptable diagnostic modalities. CT is superior to MRI in the detection of spondylolysis, but involves the use of ionizing radiation. SPECT can help confirm the diagnosis in cases which are indeterminate on MRI^{9, 10}. Typical MRI findings include low signal on T1 and increased signal on T2 or STIR sequences at the pars interarticularis and/or pedicle (Figures & ).

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13-year-old basketball player complaining of low back pain. (A) Axial T1 image demonstrates transversely oriented low signal (arrow) through the L5 pedicle and pars. (B) Axial T2 image demonstrates corresponding edema (arrow), confirmed on sagittal T1 (C) and STIR (D) sequences (arrows). Findings are consistent with unilateral stress fracture through the left pars interarticularis.

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16-year-old baseball pitcher with recent onset of low back pain. (A) Axial T1, (B) T2 and (C) sagittal STIR images demonstrates
bone marrow edema (arrows) in the left L3 pedicle, consistent with non-displaced stress fracture.

Acromial Apophysiolysis/Os Acromiale

One to four ossification centers are seen at the acromion by 15-18 years of age. From anterior to posterior, these ossification centers are the pre-acromion, the mesoacromion, the meta-acromion, and the basi-acromion. Failure of fusion of the acromion in the background of chronic repetitive traction forces from the deltoid has been termed acromial apophysiolysis¹¹. Without healing, this may progress to an os acromiale, which can in turn lead to impingement symptoms in the shoulder. Patients typically present with chronic shoulder pain of insidious onset. In younger patients, differentiating between an os acromiale and normal apophyseal development can be challenging, as the age range of acromial fusion can vary from 18 – 25¹². However, irregular cortical margins and abnormal marrow signal with adjacent bony edema favors the diagnosis of acromial apophysiolysis¹³ (Figure ).

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Collegiate American football player with shoulder pain and known lesser tuberosity avulsion. (A) Axillary shoulder radiograph performed to follow up lesser tuberosity avulsion demonstrates an unfused apophysis (arrow) at the acromion. (B) Follow up MRI demonstrates edema at the apophysis (arrow), consistent with acromial apophysiolysis.

Little Leaguer’s Shoulder

“Little leaguer’s shoulder” is a term used to describe injury to the proximal humeral physis typically caused by repetitive overhead throwing. It is often observed inmale baseball pitchers between the ages of 11 and 16 in whom the excessive rotational forces of overhead throwing lead to physeal injury¹⁴. Patients tend to present with focal pain over the anterolateral shoulder that is worse with overhead throwing. Radiographs demonstrate physeal widening and irregularity¹⁵ (Figure ). MR findings include similar findings of widening of the physis, along with marrow edema on fluid sensitive sequences¹⁶

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13-year-old baseball pitcher. AP radiograph of the (A) right shoulder shows diffuse widening of the right proximal humeral physis (arrow). (B) For comparison, the left shoulder demonstrates normal width of the physis.

Elbow: Little Leaguer’s Elbow

“Little Leaguer’s elbow” is a term used to describe injury to the medial epicondylar apophysis¹⁷. Patients are usually young adolescent pitchers or catchers presenting with medial elbow pain either with direct palpation or valgus stress to the elbow. Children can present with mild flexion contracture at the elbow secondary to pain¹⁷. While generally the physical examination is sufficient for making the diagnosis, radiographs demonstrate widening or fragmentation of the apophysis (Figure ). The contralateral asymptomatic elbow can be used for reference in determining physeal widening. MRI demonstrates marrow edema and aids in determining the integrity of the common flexor tendon and ulnar collateral ligament¹⁸.

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14-year-old baseball pitcher with medial elbow pain for 1 month duration. (A) AP radiograph demonstrates asymmetric widening of the right medial epicondyle physis (arrow). (B) The left elbow, submitted for comparison, is unremarkable. (C,D) MRI performed the following day demonstrates edema within the medial condyle epiphysis (arrow) and the adjacent metaphysis of the humerus. The ulnar collateral ligament (not fully shown) was intact.

Wrist: Gymnast’s Wrist

Gymnasts frequently start intense training at a young age, when repetitive stress on the upper extremities can lead to physeal injury. Mechanical forces of dorsiflexion and compression triggers physeal injury at the distal radius¹⁹. Similar forces can lead to the same injury in weight lifters. Analogous to Little Leaguer’s shoulder, radiographs can demonstrate widening and fraying or irregularity of the physis, while MRI demonstrates edema through the metaphysis (Figure ). Severe or chronic disease can lead to premature fusion and positive ulnar variance, TFCC injury, and scapholunate or lunotriquetral ligament disruption¹⁹.

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11-year-old gymnast just days away from a championship meet, with ongoing wrist pain. (A) AP radiograph of the wrist is essentially unremarkable. Specifically, there is no evidence of physeal widening, irregularity, or fraying. (B, C) T1 and T2FS coronal MRI images demonstrate marrow edema through the distal metaphyses of the radius and ulna (white arrows), and to a lesser extent, the radial and ulnar styloids (red arrows).

Sacral Stress Fractures

Sacral stress fractures are known to have a higher incidence in female athletes, particularly in runners²¹. The female athlete triad describes the relationship between caloric imbalance, hormonal dysregulation, and impaired bone health²². The injury, therefore, has components of both a fatigue and insufficiency fracture. Radiographs are often normal, while MRI demonstrates linear low signal intensity on T1 images with corresponding edema (Figure ). In endurance athletes, similar findings of a stress fracture can be seen in the inferior pubic rami²³ (Figure ).

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18-year-old female cross country runner with gradually worsening low back pain. (A) Coronal T1, (B) coronal STIR, and (C) oblique coronal T2 fat saturated images demonstrate a stress fracture of the left sacral ala extending to the sacral foramen.

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15-year-old female cross country runner with pubic pain, referred for MRI to “rule out sports hernia.” (A) Axial T1 and (B) T2FS images demonstrate a healing fracture (arrows) through the left inferior pubic ramus. This was radiographically occult.

Pelvic Apophyseal Injury

Traction apophysitis in the pelvis is a commonly recognized overuse injury in children. When chronic, children can present with dull pelvic or hip pain. This injury is more frequently found in athletes involved in twisting activity resulting in traction on the apophyses, such as dancers, runners, football and lacrosse players. The most common sites of injury include the anterior superior iliac spine (origin of the sartorius and tensor fasciae lata), the anterior inferior iliac spine (origin of the rectus femoris), and the ischial tuberosity (origin of the hamstrings)²⁴. Radiographs can demonstrate a spectrum of findings from cortical irregularity to frank avulsion of bone. MRI most typically demonstrates marrow edema and variable signal intensity in the corresponding tendons, depending on the extent of their injury (Figure ).

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13-year-old baseball player (shortstop) with gradually worsening groin pain. (A) Axial T1 and (B) axial T2FS images demonstrate bone marrow edema at the left ischial tuberosity (arrows). The hamstring tendons appeared normal. (C) Retrospective review of the radiograph shows subtle cortical irregularity along the lateral aspect of the left ischium (arrow).

Femoral stress fractures are relatively rare in comparison to stress fractures of the tibia, fibula, and foot²⁵. Stress fractures of the femur result from repetitive loading, and are most common in endurance runners, jumpers, and dancers. Repetitive loading results in subperiosteal bone resorption and microfractures which are not given sufficient time to heal. Femoral stress fractures can present with pain at the groin, hip, or knee, and are typically aggravated by activity. While the most common site of fracture is the femoral neck, fractures can occur anywhere along the femoral diaphysis (24). While lacking in sensitivity early in the disease, radiographs will classically show linear sclerosis, periosteal elevation, and cortical thickening, consistent with a protracted healing response. MRI reveals the problem earlier, showing linear low signal intensity on T1 sequences and corre sponding edema on fluid sensitive images (Figure ). Subperiosteal fluid, when present, is a useful finding to confirm the diagnosis³.

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9-year-old boy with history of renal transplant on chronic immunosuppressive therapy presenting with thigh pain. (A, B) Frontal and lateral radiographs demonstrate a linear band of sclerosis (arrow in A) through the distal femoral metaphysis and periosteal reaction (arrow in B), consistent with healing stress fracture. Incidental note is made of fracture progression through a non-ossifying fibroma along the medial cortex.

Osgood-Schlatter Disease

Osgood-Schlatter is one of the most common causes of anterior knee pain in young athletes, caused by repetitive microtrauma and subsequent traction apophysitis of the tibial tuberosity. It is commonly seen in 12-15 year old boys or 8-12 year old girls who participate in jumping activities²⁴. Patients present with anterior knee pain and swelling. Physical examination is usually diagnostic, with radiographs demonstrating soft tissue edema overlying the anterior tibial tuberosity, and some degree of fragmentation and irregularity of the tibial tubercle. MRI demonstrates edema in the tibial tuberosity and distal patellar tendon. Hoffa’s fat pad may also show increased signal on fluid sensitive sequences (Figure ).

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16-year-old female runner with prior history of pelvic stress fracture, now complaining of tibial pain. Sagittal STIR image demonstrates edema at the insertion of the patellar ligament (arrow), consistent with active Osgood Schlatter disease. There is mild pretibial edema in the soft tissues anterior to the tuberosity. There is minimally increased signal within the ligament itself.

Diaphyseal Stress Fracture

A common site for stress fractures in adolescents is the tibia, followed by the fibula²⁵. They are commonly found in children participating in football, soccer, tennis, and running. Radiographs demonstrate cortical irregularity and periosteal reaction, typically along the posteromedial proximal third of the tibial shaft (Figure ). MRI can be useful in equivocal cases. The Fredericson classification system classifies MR findings for tibial stress injury, with grades 1-3 deemed as “stress response” and grade 4 as “stress fracture”26 ().

Table 1

Fredericson MRI Classification System for Tibial Stress Injury

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3-year-old girl with a limp. Lateral radiograph demonstrates
an area of uninterrupted periosteal reaction along the
posteromedial aspect of the left tibia at the middle third of the tibia,
consistent with stress fracture.

Ankle and Foot

In children, the most common sites of stress fractures in the foot are the metatarsals and calcaneus, followed by the cuboid, talus, and navicular²⁷.It has been postulated that following lower extremity immobilization for conventional traumatic fractures, the child is more susceptible to subsequent stress fracture distally in the ipsilateral extremity²⁷. At our institution, a ten year informal review of lower extremity fractures in children who were previously immobilized for other fractures yielded several cases of stress fractures (Figure ). Radiographic findings of sclerosis and marrow edema are equivalent to stress fractures at other sites (Figure , ).

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Two different patients. The patient in (A) is a 12-year old-girl who had been immobilized following a Lisfranc injury. The second patient in (B) is a 12-year-old girl who had been immobilized following medial cuneiform osteotomy. (A) Lateral radiograph demonstrates a vertically oriented sclerotic line in the calcaneal tuberosity (arrow). (B) AP radiograph demonstrates periosteal reaction (arrow) surrounding the second metatarsal, consistent with stress fracture.

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14-year-old boy involved in multiple sports presents with worsening ankle pain. (A) Sagittal T1 and (B) T2FS images of the ankle demonstrate linear signal abnormality in the distal tibia consistent with stress fracture (white arrow). Multiple additional areas of signal abnormality (red arrows) are also consistent with stress reaction.

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8-year-old girl with foot pain and a limp. (A) Lateral radiograph demonstrates subtle sclerosis in the cuboid (arrow). (B) Follow up MRI demonstrates a linear low T1 signal intensity focus (arrow) through the lateral aspect of the cuboid with (C) corresponding edema on T2 (arrow), consistent with stress fracture.

With the increasing number of children participating in sports, it is important for orthopedists and radiologists to be aware of the radiographic and MRI findings associated with common overuse injuries. Familiarity with these findings leads to prompt diagnosis and helps prevent future disability.

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Stress Fractures | Boston Children’s Hospital

How are stress fractures diagnosed?

The first step in treating a stress fracture is forming an accurate, timely diagnosis. Your child’s doctor or sports medicine specialist will take a medical history and perform a physical exam.

Your child’s diagnosis will likely also include x-rays so their clinician can look for signs of a fracture. But because some stress fractures can’t be seen on x-ray, the clinician may also use an MRI (magnetic resonance imaging) or CT scan to get detailed images of the injury and determine if there’s a stress fracture. In rare cases, they may also order a bone scan.

How are stress fractures treated?

The primary therapy for most stress fractures is simply to rest the injured foot or leg — restricting weight-bearing actions and all activities that involve stressing the injured area for a period of weeks or months.

Your child’s doctor may recommend “R.I.C.E.” (rest, ice, compression, and elevation), as well as medications to help control pain and swelling.

• Rest: Your child should not exert themselves in any way that involves the injured area. They can use crutches or a cane, if it helps keep weight off of their injured leg.
• Ice: Wrap a towel around ice cubes, or use a bag of frozen vegetables, to ice the area at two-hour intervals, for 20 minutes each time.
• Compression: Wrap a bandage or soft brace (from the drugstore) around the injury.
• Elevation: Your child should remain seated or reclining with their leg elevated as much as possible.

Your child’s doctor may also recommend a cast or walking boot in order to:

• relax the stress on the leg
• protect the leg from further damage
• force the athlete to rest

If your child has a more severe stress fracture, their treatment options may include:

• temporary use of crutches or a wheelchair
• physical therapy to stretch and strengthen the injured muscles and tendons
• surgery (less common, but is sometimes needed)

How long will it take for my child to recover from a stress fracture?

Depending on the severity of the injury, your child should heal in a matter of weeks or months. Your child’s doctor will give you guidance regarding:

• how long your child should rest their foot or leg in order for it to heal
• tools for getting the injured foot or leg back in shape, such as massage, stretching exercises, and strength training

Most kids with stress fractures can return to sports and regular activities after several weeks or months of rest and healing. But during the healing period, it’s important for you and your family to support your young athlete’s resolve to rest the healing area. Many athletes feel disappointed and sad when they are not able to play their sport.

Once your child’s fracture has fully healed, their doctor will clear them to go back to sports.

How we care for fractures

Every year the Orthopedics and Sports Medicine Center at Boston Children’s Hospital treats thousands of children, adolescents, and young adults with fractures of all complexities. Thanks to our pediatric expertise, we can precisely diagnose conditions related to the growing musculoskeletal system and optimal care plans.

At our Orthopedic Urgent Care Clinics, we care for injuries that require prompt medical attention but are not serious enough to need emergency room care. We offer urgent care services in four locations: Boston, Waltham, Peabody, and Weymouth.

How to reduce the risk of stress fracture?

• Science and medicine
• About the sore

We have already written about what cumulative trauma is, and now we are citing a chapter on this topic from our favorite book “Cardio or Strength” by Alex Hutchinson – with the permission of Alpina .

Evan Lysacek had a stress fracture in his left foot the year before he won gold in figure skating at the 2010 Olympics. Tiger Woods had two of these fractures in his left leg. A journalist from the Globe and Mail once suffered a similar injury while rushing in high heels from one event to another at the Toronto International Film Festival. ( That’s what you definitely need to give up – it’s heels! – approx. Zozhnik ).

Stress fracture is one of the most common (and daunting) diagnoses. It is especially typical for sports where you have to run and jump. Usually athletes are out of action until the end of the season because the only treatment in this case is rest for the injured limb for at least 8-10 weeks.

Picture from the text on Zozhnik “Epitaph for high heels“.

Bone is a living tissue that constantly balances between deformation due to overload and recovery. When damage from repeated exposure accumulates faster than the tissue can repair itself, microscopic cracks form. Eventually these cracks come together and form a stress (fatigue) fracture – a micro-crack in the bone that is the result of weeks or months of constant crushing rather than one hard blow. It has long been believed that the only way to prevent stress fractures is to have strong, healthy bones. However, the latest research has found two other factors that may reduce the risk of this injury.

Shorter stride for less risk of injury

First discovered by scientists at Iowa State University who used a computer model of bone damage and repair to evaluate the effects of changing stride length. It is clear that if you shorten your stride, then you will get more steps per kilometer, which means you will make more pushes that affect the bones, but at the same time each step will be a little softer. So which is preferable? The researchers observed 10 subjects with different stride lengths on a treadmill, measuring the corresponding forces using motion capture cameras and force measuring platforms, and then loading the data into a computer model. The output is: A 10% reduction in stride length reduces the risk of stress fracture by 3-6%.

Changing stride length while running is definitely not easy. However, other experiments also confirm that excessive stride length is one of the most common missteps of inexperienced runners: professional athletes usually take 180 steps per minute, regardless of running speed, and beginners – significantly less. Therefore, by concentrating on taking short but quick steps, you will reap several benefits at once, including reducing the risk of a stress fracture.

Few muscles – more risk of fracture

The second factor was discovered thanks to scientists from the University of Minnesota. They carefully examined 39 women runners, half of whom had a history of stress fractures. A series of measurements were taken to determine the size, structure, and density of the subjects’ bones and muscles.

Not surprisingly, female athletes with a history of stress fractures had tibias that were 7-8% smaller and 9-10% weaker. However, interestingly, these differences were proportional to the size of the calf muscles, but no differences were found in bone mineral density.

This suggests that women suffering from stress fractures were by no means deficient in calcium: the relative weakness of their bones was a reaction to insufficient muscle volume in the legs .

The fix is ​​quite simple: you need to develop the calf muscles by regularly performing exercises such as calf raises. Strengthened muscles absorb some of the harmful effects of running and jumping. (And it’s not just your calves: the best way to make your bones stronger is to strengthen the muscles around them.)

Source: Cardio or Strength book

Orthopedist-traumatologist – about dangerous simulators, cumulative and running injuries, menisci, cases from practice

Does the risk of injury increase when running on hard surfaces?

Post-workout: cold water or sauna

Moderate exercise increases, intense exercise reduces immunity

How refeeds affect fat loss

Don’t blame Manchester United doctors for Rashford’s injury.

It’s just that Solskjaer really needed the player Artem does not stop: this is his third text that gets on the main page in 2020. So put pluses, write comments and subscribe to the blog, if for some reason (how so?) Have not done this yet.

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Marcus Rashford was injured in the FA Cup against Wolverhampton Wolves, Solskjaer has confirmed that the striker will miss six weeks to three months due to a stress fracture in his back. The coach even admitted that the club would have to buy someone to attack.

I confess, when I saw the first versions and the official statement about the “stress fracture of the spine”, I was a little embarrassed, because I had not yet seen such a localization of a stress fracture. Indeed, there are no detailed statistics, there are only small studies, but on average, among all such injuries, a stress fracture of the spine is about 0.4% (!!!).

And if you google “stress fracture” / “stress fracture” – the search engine will return only pictures of the lower limb. Why? Everything is simple. It is the bones of the foot, lower leg and thigh that account for more than 2/3 of all these injuries for a fairly understandable reason – in football, the leg suffers most often.

What is a “stress fracture”?

If you think that fractures are rare, then I will surprise you: microdamages occur almost from every collision or, say, during a long run . However, there are also regeneration processes in the body (not like Deadpool, but it will do too). And the younger the person, the better this mechanism works. As long as the balance between the volume of microdamages and the body’s ability to heal them is closer to the second, there can be no talk of any stress fractures.

Accordingly, when this balance is disturbed, microtraumas do not have time to heal, moreover, they begin to accumulate, sooner or later developing from a microdamage into a full-fledged fracture.

Why might this happen?

This can be summed up in one phrase: “impairment of the internal metabolism of the bone. ” In human terms and in a little more detail, there are 4 main reasons:

• Vitamin D deficiency. In beautiful northern countries like ours, vitamin D deficiency is quite a common problem, but for athletes (including amateurs) it takes on a different scale . Vitamin D helps absorb calcium and phosphorus into the intestines, key building blocks of bone tissue. Nothing to cover up the crack? She will grow. Everything is logical.

• Disruption of hormonal regulation. A fairly large number of hormones affect bone growth and regeneration. In case of detection of stress fractures, it is necessary to check first of all the level of parathyroid hormone (it is synthesized by the parathyroid gland, is responsible for calcium metabolism) and sex hormones (they control tissue growth and their metabolism). A decrease in the level of these hormones can lead to malnutrition of the bone tissue.

• Calorie deficit. Just like vitamin D, you can’t build a house without bricks.

• Violation of the training regimen or technique . Stress fracture refers to the so-called overuse injuries, that is, injuries of increased use. This type of damage is also referred to as a “stress fracture”. And therefore, if an athlete is overloaded, or some exercises are performed incorrectly, then the body simply cannot cope with the excess load.

How is the diagnosis made?

The main and often the only symptom is pain. It occurs during exercise, or in more severe cases – even at rest, its localization corresponds to the fracture site.

MRI or CT is best for confirming the diagnosis. Since on x-rays we may not see any changes. The result is a situation: “Do you see the fracture? No. And he is.” MRI and CT are a much more sensitive and informative method, but there is a difficulty – all procedures must be justified.

Even with Manchester United’s budget, a doctor can’t say, “Ah, go ahead and do a CT scan of everything. ” No. They start with an x-ray, already on it you can notice small changes, but if it is not enough, then CT and MRI are used to clarify the diagnosis.

How are these injuries classified?

There are two classifications – according to the degree of damage and the risk of complications (progression of the disease).

Kaeding-Miller stress fracture classification. According to the degree of damage:

According to the risk of complications. Low – places with good blood supply. High – with bad, they are mainly located on the lower limb and this is another reason why stress fractures of the lower limb are much more common.

Treatment tactics and why Manchester United doctors are unlikely to have made a mistake

I focused on the classification for a reason, it depends on what we will do with the athlete next.

So, in the case of small fractures without displacement, conservative treatment is quite effective: they reduce the load, normalize nutrition, daily routine, resort to physiotherapy. If there are hormonal disorders, they are corrected. In the event that they turn out to be ineffective, if an operation is necessary, such beauty in the spine awaits him:

This is a transpedicular fixation – an operation, the essence of which is to stabilize the vertebra by inserting screws through the pedicles (pediculus – stem, hence the name) into the vertebral body. The technique allows you to securely fix the screw in the vertebral body and is one of the most common types of treatment for traumatic injuries and chronic diseases of the spine. With the help of this design, the vertebra grows well, the rehabilitation time is reduced, but it must be said that in the case of stress fractures of the spine, this rarely happens.

Much easier to use non-invasive methods like this device.

Marcus Rashford carries ‘bone fracture healing device’ amid injury speculation https://t.co/IjZ7Sk7XCb pic.twitter.com/xG7cdKHtxm

— Mirror Football (@MirrorFootball) January 13, 2020

This case is called melmak faster fracture healing. Device for the accelerated treatment of fractures (literally translated). It locally improves blood flow by means of intense ultrasound signals – and improved blood supply = accelerated healing.

Rash was seen with this device after the match against Norwich, where, by the way, he did not play the whole match, and Solskjaer pierced that the pains bothered Markus even before the New Year. Since then, the striker has played 6 matches. And the question arises, how could a football player play every 4 days if he should have been suspended for at least a week?

Are doctors and Solskjaer personally to blame? Doctors are unlikely. Solskjaer and Rashford – probably because they could not have been unaware of the risks . Why? I see 4 possible scenarios:

1) The doctors saw only the I degree of damage and watched Marcus. After Norwich, he still needed treatment, he used this device to speed up healing and / or prevent complications.

It seemed to them that four days of rest before Wolverhampton was enough. However, it got worse. There was such a risk, and both Solskjaer and Markus were obviously warned about it. The desire of the Englishman and his indispensability in the coach’s scheme played a role.

2) The doctors diagnosed the II degree. And they considered 4 days of pause to be a sufficient rest, since the pictures showed good dynamics, Markus felt fine and Solskjaer really needed him. And then “everything went wrong.” But still I am confused by such tight deadlines. Although the head coach himself said that Marcus usually recovers quickly and is counted on, this is still not enough.

3) Same thing, but at one point the forward lied about being in pain to play against the Wolves, and Solskjaer crushed the med staff. Conspiracy theory is pure water, but such cases do happen.

4) The doctors underestimated the severity of the injury. It can also be – the injury is complex, rare, but still this is the Premier League, I hardly believe that such mistakes are possible at this level and it is unlikely that the team’s doctors continued to work at the club after such a serious puncture.