A 12-Month Prospective Study of the Relationship Between Stress Fractures and Bone Turnover in Athletes

Bennell, Kim L; Malcolm, S. A.; Brukner, Peter; Green, R. M.; Hopper, John L.; Wark, John D.; Ebeling, Peter R.

doi:10.1007/s002239900493

Cited by 64 publications

(37 citation statements)

References 20 publications

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“…1,2 We have recently reported a 2.7% estimated lifetime prevalence of this injury in female adolescents, 3 which compares favorably with estimates ranging from 1.0% to 2.6% among general collegiate athletes. 4,5 Although these overall rates seem low, certain subgroups, such as college freshmen 6 and other young adult women participating in track and field [7][8][9][10][11] may have rates of stress fracture between 6.9% 6 and 21.1%. 11 Stress fractures are particularly concerning in active female adolescents and young adults because they may signify insufficiency of the bones to withstand repetitive loading.…”

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Family History Predicts Stress Fracture in Active Female Adolescents

Loud

Micheli²,

Bristol

et al. 2007

Pediatrics

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OBJECTIVE-Increased physical activity and menstrual irregularity have been associated with increased risk for stress fracture among adult women active in athletics. The purposes of this study were to determine whether menstrual irregularity is also a risk factor for stress fracture in active female adolescents and to estimate the quantity of exercise associated with an increased risk for this injury.PATIENTS AND METHODS-A case-control study was conducted of 13-to 22-year-old females diagnosed with their first stress fracture, each matched prospectively on age and selfreported ethnicity with 2 controls. Patients with chronic illnesses or use of medications known to affect bone mineral density were excluded, including use of hormonal preparations that could alter menstrual cycles. The primary outcome, stress fracture in any extremity or the spine, was confirmed radiographically. Girls with stress fracture had bone mineral density measured at the lumbar spine by dual-energy x-ray absorptiometry.RESULTS-The mean ± SD age of the 168 participants was 15.9 ± 2.1 years; 91.7% were postmenarchal, with a mean age at menarche of 13.1 ± 1.1 years. The prevalence of menstrual irregularity was similar among cases and controls. There was no significant difference in the mean hours per week of total physical activity between girls in this sample with stress fracture (8.2 hours/week) and those without (7.4 hours/week). In multivariate models, case subjects had nearly 3 times the odds of having a family member with osteoporosis or osteopenia. In secondary analyses, participants with stress fracture had a low mean spinal bone mineral density for their age.CONCLUSIONS-Among highly active female adolescents, only family history was independently associated with stress fracture. The magnitude of this association suggests that further investigations of inheritable skeletal factors are warranted in this population, along with evaluation of bone mineral density in girls with stress fracture. NIH Public Access Author ManuscriptPediatrics. Author manuscript; available in PMC 2011 October 25. Stress fractures are particularly concerning in active female adolescents and young adults because they may signify insufficiency of the bones to withstand repetitive loading. Although a "fracture threshold"is not yet defined for children and adolescents, ~80% to 90% of in vitro skeletal strength in adults is determined by bone mineral density (BMD). 12 A woman's peak bone mass is achieved by her early 20s 13,14 and is one of the strongest predictors of her long-term risk of osteoporosis. 15,16 Understanding the risk factors that predispose to stress fracture in this population could, therefore, indirectly elucidate the risk factors for a low BMD.To our knowledge, no data exist regarding risk factors for stress fracture in adolescents younger than age 17 years. We, therefore, constructed a pathogenetic model of stress fracture on the basis of studies in the adult literature and the observations of experienced clinicians. The risk factors deem...

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Family History Predicts Stress Fracture in Active Female Adolescents

Loud

Micheli²,

Bristol

et al. 2007

Pediatrics

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“…In addition, the results from studies of older adolescent girls have not been consistent with those from studies of adult women. [20][21][22][23][24][25] Bennell et al 22 conducted a retrospective study of 53 Australian, female, track and field athletes 17 to 26 years of age and found that menstrual irregularities and restrictive eating behaviors were risk factors for stress fractures but low BMD was unrelated to fractures; however, in a prospective follow-up study of the same cohort, Bennell et al 23 found that lower bone density and a history of menstrual disturbances were significant predictors of stress fractures. A similar prospective study of 50 US, collegiate, track and field athletes found that a history of stress fracture and low BMD were significant predictors of stress fractures but menstrual history was not.…”

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Correlates of Stress Fractures Among Preadolescent and Adolescent Girls

Gordon²,

et al. 2005

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ABSTRACT. Objective. Although stress fractures are a source of significant morbidity in active populations, particularly among young female athletes, the causes of stress fractures have not been explored among females <17 years of age or in the general population. The purpose of this study was to examine correlates of stress fractures in a large, population-based, national, cohort study of preadolescent and adolescent girls.Methods. A cross-sectional analysis of data from 5461 girls, 11 to 17 years of age, in the Growing Up Today Study, an ongoing longitudinal study of the children of registered female nurses participating in Nurses' Health Study II, was performed. Mothers self-reported information regarding their children's histories of stress fractures on their 1998 annual questionnaire. Growing Up Today Study participants self-reported their weight and height, menarcheal status, physical activity, dietary intake, and disordered eating habits on annual surveys.Results. In 1998, the mean age of the participants was 13.9 years. Approximately 2.7% of the girls had a history of stress fracture, 3% engaged in disordered eating (using fasting, diet pills, laxatives, or vomiting to control weight), and 16% participated in >16 hours per week of moderate to vigorous activity. Age at menarche, z score of BMI in 1998, calcium intake, vitamin D intake, and daily dairy intake were all unrelated to stress fractures after controlling for age. Independent of age and BMI, girls who participated in >16 hours per week of activity in 1998 had 1.88 greater odds of a history of stress fracture than did girls who participated in <4 hours per week (95% confidence interval [CI]: 1.18 -3.30). Girls who participated in >16 hours per week of activity were also more likely than their peers to engage in disordered eating (4.6% vs 2.8%); however, disordered eating did not have an independent association with stress fractures (odds ratio Conclusions. These findings suggest that, although activity can be beneficial for bone health, there is a threshold over which the risk of stress fracture increases significantly among adolescent girls. High-impact activities, particularly running, cheerleading, and gymnastics, appear to be higher risk than other activities. Prospective studies are needed to explore the directionality of these relationships, as well as the role of menstrual history. In the meantime, clinicians should remain vigilant in identifying and treating disordered eating and menstrual irregularities among their highly active, young, female patients. Pediatrics 2005; 115:e399-e406. URL: www.pediatrics.org/cgi[

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“…Several studies and reviews have focused on stress fractures in military recruits Giladi, Milgrom, Simkin, & Danon, 1991) or athletes Khan, Brukner, Kearney, Fuller, Bradshaw, & Kiss, 1994;Bennell, et al, 1998) but there is a dearth of information specifically about stress reactions . The description, exploration and analysis of the present case studies will presumably add to the body of knowledge for health care professionals with information useful in diagnosis, treatment and management of stress reactions.…”

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Stress Reactions of Division-I Track Athletes

Skarda

2000

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Problem: Track and field athletes, along with cross-country athletes have multiple and back to back seasons, creating overuse injuries. Stress fractures or stress reactions to the bone are the overuse injuries focused on in this study and literature review. There is a lack of information in the literature regarding stress reactions. Purpose:The goal of the study is to understand more information about stress reactions to bone and possibly increase the knowledge of health care professionals.Methods: Three case studies were examined through pre-existing medical chart notes and athletic trainer's notes regarding the stress reactions. A literature review was also performed to provide further information about stress fractures and stress reactions. Conclusions:There are multiple risk factors for stress injuries. All three of the athletes in the case studies are female, which is found to be a risk factor. Many risk factors need more studies to provide support. Magnetic Resonance Imaging (MRI) was obtained in all three case studies where there was found to be a stress reaction. These three females also had a recent increase in activity level and had similar symptoms to each other and what is found in the literature.ii Dedication My thesis is dedicated to my athletes, family and friends who have been supportive, but especially to my grandmother who passed away during my time at Portland State. She was the strongest and most amazing woman I have known.iii Acknowledgements

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A 12-Month Prospective Study of the Relationship Between Stress Fractures and Bone Turnover in Athletes

Cited by 64 publications

References 20 publications

Family History Predicts Stress Fracture in Active Female Adolescents

Family History Predicts Stress Fracture in Active Female Adolescents

Correlates of Stress Fractures Among Preadolescent and Adolescent Girls

Stress Reactions of Division-I Track Athletes

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