Update on stress fractures in female athletes: epidemiology, treatment, and prevention

Abstract

Stress fractures are a common type of overuse injury in athletes. Females have unique risk factors such as the female athlete triad that contribute to stress fracture injuries. We review the current literature on risk factors for stress fractures, including the role of sports participation and nutrition factors. Discussion of the management of stress fractures is focused on radiographic criteria and anatomic location and how these contribute to return to play guidelines. We outline the current recommendations for evaluating and treatment of female athlete triad. Technologies that may aid in recovery from a stress fracture including use of anti-gravity treadmills are discussed. Prevention strategies may include early screening of female athlete triad, promoting early participation in activities that improve bone health, nutritional strategies, gait modification, and orthotics.

Risk Factors for Tibial Stress Injuries

“…20 By contrast, we did not observe differences in BMD between groups, and BMD was normal for the whole cohort, despite previous reports of low BMD as an independent risk factor for stress fractures. [9][10][11][14][15][16][17]22 We observed an association between lower calcium consumption and presence of TSI in men only. Reviews of studies of nonspecific stress fracture published in 1999 and 2004 found only 1 study (of 10, total) has reported an association between lower calcium intake and an increased risk for exercise-induced stress fractures.…”

“…Volunteers with anterior mid-tibial shaft stress fractures ("dreaded black lines" that often progress to nonunion), those who were pregnant, used a pacemaker, had a metabolic 14 Corrarino 15 Shindle et al 11 Ben Chihaoui et al 16 Warden et al 12 Tuan et al 22 Bennell et al 17 Narrow tibia* Cosman et al 9 Corrarino 15 Female* (amenorrhea, etc.) Chen et al 10 Duckham et al 23 Wentz et al 1 Ben Chihaoui et al 16 Warden et al 12 Kadel 2 Tuan et al 22 Korpelainen et al 24 Macintyre and Joy 3 Pes planus* Barnes et al 4 Tuan et al 22 bone disease or took medication known to influence bone healing were excluded. Secondary diagnosis of TSI was performed by a single member of the research team from a comprehensive injury assessment to standardized evaluation criteria based on patient history and condition.…”

From Sméagol to Gollum: Mechanical Stress and Bone Remodelling

“…In addition, a blend of irregular menstrual periods, inadequate nutrient intake, and overall bone loss contribute to what is known as the "female athlete triad". In fact, the incidence of stress fractures in female athletes is 3.2% more than the males [41]. Hence, athletes with a stress fracture or inclining towards one particularly in females should be examined by taking a detailed medical history and in females possibly identify a presence of the triad to help prevent setbacks in the practice of sport.…”

Female athlete triad: At breaking point

“…Although the incidence of tibial bone stress injury in runners has not been elucidated [11], they are the most common stress fractures seen in active populations [12]. Bone stress injuries can be divided into those that are at high risk and those that are of low risk of malunion (Table 1) [5,10,[13][14][15][16].…”

“…An exercise prescription, prescribing aerobic exercise which minimised impact and load, such as cycling, swimming and using an elliptical cross-trainer, was provided to the patient to maintain cardiovascular fitness. Weight bearing was initially allowed as the patient was able to ambulate without pain [15]. A multi-modal pain management regime of analgesics, activity modification as described and appropriate loading was prescribed.…”