Stress Fractures: Diagnosis, Differential Diagnosis, and Treatment ...

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Adriaensen ME, Mulhall KJ, Borghans RA, Magill P,. Kavanagh EC (2009) Transient ..... 2012 · American family physician. Aharon S Finestone · Charles Milgrom.
Stress Fractures: Diagnosis, Differential Diagnosis, and Treatment

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Gideon Mann, Iftach Hetsroni, Naama Constantini, Eran Dolev, Ezequiel Palmanovich, Alex Finsterbush, Eran Keltz, Omer Mei-Dan, Iris Eshed, Niv Marom, Eugene Kots, and Meir Nyska

Contents Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Clinical Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Imaging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Position Emission Tomography-CT (PET-CT) . . . .

Differential Diagnosis and Treatment . . . . . . . . . . . 2097 2092 2092 2092 2093

G. Mann (*) Service of Sports Injuries, Department of Orthopaedic Surgery, Meir Medical Centre, Tel Aviv University, Tel Aviv, Israel e-mail: [email protected]; [email protected] I. Hetsroni Department of Orthopedic Surgery, Meir Medical Centre, Kfar Saba, Israel Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel e-mail: [email protected] N. Constantini Department of Orthopedic Surgery, The HadassahHebrew University Medical Center, Jerusalem, Isarel e-mail: [email protected] E. Dolev • E. Palmanovich Orthopedic Department, Meir Medical Centre, Kfar Saba, Israel e-mail: [email protected]; [email protected] A. Finsterbush Unit of Sports Medicine, Department of Orthopedics, Hadassah University Hospital, Jerusalem, Israel e-mail: afi[email protected] E. Keltz Orthopedic Surgery Department, Rambam Health Care Campus, Haifa, Israel e-mail: [email protected] # Springer-Verlag Berlin Heidelberg 2015 M.N. Doral, J. Karlsson (eds.), Sports Injuries, DOI 10.1007/978-3-642-36569-0_294

Summary and Conclusions . . . . . . . . . . . . . . . . . . . . . . . 2099 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2099

O. Mei-Dan Orthopedics Department, Sports Devision, Hip Preservation Service, University of Colorado Medical School, Boulder, CO, USA e-mail: [email protected] I. Eshed Orthopedic Department, Meir Medical Centre, Kfar Saba, Israel Department of Diagnostic Imaging, Sheba Medical Center, Tel Hashomer, Israel e-mail: [email protected] N. Marom Department of Orthopedic Surgery, Meir University Hospital Medical Center, Kfar-Saba, Israel e-mail: [email protected] E. Kots Department of Diagnostic Radiology, Meir Medical Center, Kfar Saba, Israel e-mail: [email protected] M. Nyska Department of Orthopaedic Surgery, Meir Medical Center, Jerusalem, Israel The Sackler School of Medicine, Tel-Aviv University, Kfar Saba, Israel e-mail: [email protected]; [email protected]

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Abstract

The diagnosis of stress fractures is based on clinical assessment and on imaging modalities. Simple radiography (X-rays), scintigraphy (bone scan), and computerized tomography (CT) are widely used, though today magnetic resonance (MRI) is accepted as the more safe and accurate diagnostic tool. Differential diagnosis may include a variety of pathologic conditions, as tumors, infections, metabolic diseases, or normal growth variations. Treatment is essentially conservative and may include relative rest, various modalities as external support, shock waves (SW), low-intensity pulsed ultrasound (LIPU), and occasionally surgical intervention.

Diagnosis Clinical Diagnosis Clinical diagnosis has been discussed in the previous edition of this book (Finestone and Milgrom 2012). A high degree of suspicion is important especially in fractures of the femur, neck of the femur, pelvis, sacrum, spine, and thorax, all of which tend to obscure as muscle pain or undefined discomfort, as discussed previously in this chapter. The use of therapeutic ultrasound and a tuning fork as diagnostic tools should be considered with caution as their accuracy has been questioned (Hung and Chang 2012; Schneiders et al. 2012), although good diagnostic ability for ultrasound has been recently shown by Papalada et al. in 2012 (Papalada et al. 2012).

Imaging Imaging is discussed in detail in a separate chapter of this book. Basic points only are mentioned in the following lines:

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X-rays: Simple radiography has been the key stone to diagnosis being the most reliable means following clinical assessment (Breithaupt 1855; Fricker and Purdam 1995). Since X-rays have been utilized in medical practice, diagnosis could be better defined and pathology located and treated (Pirker 1934; Wilson and Katz 1969; Hulkko 1988). Since scintigraphy has been introduced (Matheson et al. 1987; Zwas et al. 1987; Allen et al. 1995), diagnosis became easier as the pathology was located in an early stage and the scan covered the whole body disclosing many sights of bone activity possibly unrelated to the specific fracture location. The high overdiagnosis is still a major problem today. Clement (1987) showed in 1987 that only in 30 % did positive scintigraphic sites show as stress fractures when using roentgenography. Scintigraphy: Zwas et al. (1987) in 1987 devised the classification and interpretation guidelines which most of us use today concerning scintigraphy in stress fractures. This method of diagnosis is doubtless the widest used today and often the only method used both in adults and in children (Conway 1986). Zwas’ classification is widely used even though it is basically constructed for the classification of stress fractures in long bones. Sensitivity, specificity, accuracy, and positive predictive value have been investigated, comparing bone scintigraphy to MRI (Halperin et al. 1983). Although MRI may be preferable because of wider diagnostic ability and lack of ionizing radiation, the bone scan showed very good diagnostic ability in all the above categories (Halperin et al. 1983). Computerized tomogram: Computed tomography is of high importance as it can disclose the breaching of bone continuity and could assist in problem cases as sacral fractures (Martin et al. 1995), spondylolysis (Abel 1985; Read 1994), and in differentiating tumor, infection, or bone stress reaction from stress fractures (Lysens et al. 1987; Horev et al. 1990; Tuite et al. 1995) especially in the interesting longitudinal fractures which could resemble a tumor in the femur

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(Schubert and Carter 1994; Soubrier et al. 1995) or the tibia (Krauss and Van Meter 1994; Saifuddin et al. 1994; Keatig et al. 1995; Umans and Kaye 1996). The computerized tomogram is useful in determining location, morphology, distraction, and healing though it is not routinely used (Knap and Garrett 1997; Taun et al. 2004). Magnetic resonance imaging is also often used in problem cases as it would disclose early changes in chemical structure which would not be disclosed by other methods (Lee and Yao 1988; Santi et al. 1988; Newberg and Wetzner 1994; Saifuddin et al. 1994; Steinbronn et al. 1994; Tyrrell and Davies 1994; Fredericson et al. 1995; Soubrier et al. 1995; Umans and Kaye 1996; Arendt and Griffiths 1997). The use of magnetic resonance in stress fractures has been reviewed by Spitz and Newberg in 2002 (Spitz and Newberg 2002). The role of magnetic resonance will often be most obvious in stress fractures of cancellous bone as the calcaneum or femoral condyles. It has been used effectively for the diagnosis of pelvic (Miller et al. 2003) and sacral fractures (Shah and Stewart 2002) and for fractures of the neck of the femur (Nachtrab et al. 2012). Good results were observed with 3.0 T and with 1.5 T machines (Sormaala et al. 2011). Lassus et al. in 2002 (Lassus et al. 2002) emphasized the MRI grading of bone stress injuries. Fredericson et al. (1995) developed in 1995 an MRI grading system for tibial stress fractures, and the method was further developed by Arendt in 1997 adding to the grading system for stress fractures by MRI a protocol for MRI diagnosis (Arendt and Griffiths 1997). Grades I and II were considered as “low-grade” stress fractures, while grades III and IV were defined as “high-grade” stress fractures (Arendt and Griffiths 1997; Taun et al. 2004). The lack of ionizing radiation and its high accuracy makes the MRI an attractive diagnostic tool. Schlezinger and Smith have prepared a position paper submitted to the International Federation of Sports Medicine (FIMS) for approval in 2002. This paper suggests the MRI as the diagnostic modality of choice for

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stress fractures (Schlezinger and Smith 2001) (Figs. 1c, 2, 3c, and 4a–c). Using the MRI as the diagnostic tool of choice for stress fractures was discussed for groin pain diagnosis by Davies et al. in 2009 (Davies et al. 2009).

Position Emission Tomography-CT (PET-CT) PET-CT has been reported as an additional tool in sports injuries and in stress reactions of bone (Krestan et al. 2011). It seems to have a special role in differentiating these injuries from benign or malignant tumors (Krestan et al. 2011). Ultrasound: Ultrasonography as a diagnostic tool causing local pain at an intensity of 2–3 W/cm2 was first published by Moss and Mowart in 1983 (Moss and Mowart 1983). The method is not accurate and failed to gain popularity (Moss and Mowart 1983; Giladi et al. 1984; Hulkko 1988). Ultrasonography was recently introduced showing relatively high accuracy in the diagnosis of metatarsal stress fractures by Banal et al. in 2009 (Banal et al. 2009). Thermography: Thermography is a method aimed at locating heat differences over the fracture area (Goodman et al. 1985; McBryde et al. 1985; McBryde 1985; Hulkko 1988). It is not in wide use today. In conclusion of this section three points should be discussed: 1. Does an “asymptomatic” stress fracture exist? The “asymptomatic” stress fracture has been well recognized since scintigraphy was introduced disclosing multiple sights of fracture or bone activity in areas which were not painful (Sahi et al. 1987). This was recently discussed concerning the dreaded femoral neck fracture by Nielens in 1994 (Nielens et al. 1994). Ha et al. considered that 9 % of fractures are asymptomatic (Ha et al. 1991). Most if not all of these fractures are probably false-positive bone scans showing bone stress, trauma, or soft tissue calcification or fractures causing

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Fig. 1 (a) Bipartite patella on lateral X-ray. (b) Bipartite patella on axial X-ray. (c) Bipartite patella on MRI. (d) A stress fracture of the patella in a 17-year-old youth involved in uphill running preparing for his army service

Fig. 2 Stress fracture of the tibial plateau seen on MRI in an elderly female walker

pain which was interpreted as muscle pain or knee pain, a phenomenon so well known in fractures of the femur or femoral neck. Flinn in 2002 defined a stress fracture as “clinical symptoms with a corresponding radiographic change” (Flinn 2002), thus excluding, to his opinion, the term “asymptomatic stress fracture.” During a meeting on stress fractures in 1987 (Mann 1987) and following letters in the medical press by J. Torg and by C. Noble, all participants were asked if in their experience and belief, a real “asymptomatic” fracture could exist. No

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Fig. 3 A top level male high jumper complained of pain over the medial aspect of the ankle. Ultrasound did not disclose specific pathology and further imaging was performed only after conservative treatment failed.

(a) Medial malleolus stress fracture seen on CT imaging. (b) Medial malleolus stress fracture seen on CT imaging. (c) Medial malleolus stress fracture seen on MR imaging. (d) After reduction and fixation

hand was raised. It seems that existence of the entity should be severely questioned. 2. Could a stress fracture exist with a negative bone scan? When no bone activity occurs and the fracture is not healing, a negative bone scan could exist in a true and hazardous stress fracture. This has been described both in transverse anterior cortex tibial fractures (Blank 1987) and in the neck of the femur (Keene and Lash 1992). It is important to keep this in mind as these fractures are not involved in a healing process and are liable to nonunion and displacement. 3. Is the entity of tibial stress syndrome (or tibialis posterior syndrome – TPS) related to stress fractures? (Fig. 5). Our tendency is to accept these entities as nonrelated. The TPS has been shown in our experience to

affect approximately one third of the border police recruits to some degree or other often unrelated to any of the controlled parameters as heel position, foot type, shoe, or insole (Mann et al. 2001). The entity is often named “shin splints” which is really a wider entity inaccurate in description and which should be used cautiously (Batt 1995). A possible relation between tibial stress syndrome and stress fracture, both which would be disclosed by scintigraphy (Allen et al. 1995) and differentiated by the diffuse and unlocalized appearance of the uptake in tibial stress syndrome, has been pointed out by Ekenman in 1995 (Ekenman et al. 1995). Ekenman tried to explain according to the variation in the tibial origin of the flexor muscles why some athletes would develop a tibial stress syndrome and others a

Fig. 4 Longitudinal stress fracture of the tibia: (a) a longitudinal stress fracture of the tibia in a 51-year-old female walker as seen on a bone scan. This picture was suspected to be a tumor or an infection. (b) A longitudinal fracture of the tibia seen on a

computerized tomogram. (c) Magnetic resonance imaging in a longitudinal stress fracture of the tibia in a 51-year-old female walker

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Fig. 5 Tibial stress syndrome (tibialis posterior syndrome)

stress fracture. Fredericson (Fredericson et al. 1995) working with magnetic resonance assumed that untreated tibial stress syndrome may develop into a stress fracture, and the condition should not be overlooked, as the tibial stress syndrome as known may be an early stage in the development of a stress fracture. Taun et al., in a recently published review (Taun et al. 2004) based on the literature, concludes that though the mechanism causing tibial stress syndrome and stress fractures is similar and though the pathologies may be in continuum, they represent separate entities differentiated by bone scintigraphy which shows diffuse uptake in one and localized uptake in the other.

Differential Diagnosis and Treatment Differential diagnosis in stress fractures is important because of the wide variety of conditions which could be difficult to differentiate on scintigraphy (Hulkko 1988). Tibial stress syndrome has been mentioned above. Other conditions would be tumors (Hulkko 1988; Tuite et al. 1995), benign or malignant, infection, myositis ossificans (Fig. 6), growth plate normal appearance in children (Fig. 7), subperiosteal hematoma after direct trauma, arthritic processes, or soft tissue calcification (Fig. 8).

Fig. 6 Myositis ossificans after muscle injury in a youth involved in Martial Arts

Once diagnosis has been established, the great majority of fractures would be treated conservatively by modifying activity. Specific cases as the neck of the femur especially with a negative bone scan (Keene and Lash 1992) may require bed

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Fig. 7 Iselin’s disease: This is not an unusual picture of the developing growing plate of the fifth metatarsal bone. This is not a traumatic event and needs no treatment

Fig. 8 A bone scan showed bilateral local uptake in the foot in a regular exercising middle-aged woman. A computerized bone scan and X-ray fail to show a stress fracture, and the case was diagnosed as arthritic changes

rest or occasionally surgical intervention (Fullerton and Snowdy 1988; Derman and Schwellnus 1996). Anterior cortex tibial stress fractures or the Jones fracture in athletes would often do better with surgical treatment.

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Most non-displaced stress fractures when diagnosed by scintigraphy will grossly need about half the time a full fracture of the same bone would need to heal; this would include not rest but only reduced activity. The approximate time would be 4–6 weeks in the tibia, 6–8 weeks in the femur, and 3–4 weeks in the metatarsals. In general pain and X-ray control are good predictors for a safe return to activity. In specific cases, like the neck or the femur, MRI follow-up would be of advantage. In the military, it is convenient to use a flow chart which makes the decisions easier to control (Finestone and Lavon 2006). Occasionally a fracture will displace or progress to nonunion. In these cases, surgical intervention may be required. This may be needed in the femoral neck, in a transverse fracture of the anterior tibial cortex, in the ankle, the tarsal navicular bone, the fifth metatarsal, or the great toe sesamoids (Orava and Hulkko 1987; Hulkko 1988; Orava et al. 1995). Orava and Hulkko in 1987 reviewed 37 delayed and nonunions which comprised 10 % of their total series of stress fractures. 6 % of the total series eventually needed surgical intervention (Orava and Hulkko 1987). Similar figures were shown by Hulkko in 1988 (Hulkko 1988) and by Ha et al. in 1991 (Ha et al. 1991). Intra-articular subchondral stress fractures of the femoral head could lead to fast deterioration and joint destruction, as described in four healthy adults by Buttaro et al. in 2003 (Buttaro et al. 2003) and further described by Song in 2004 (Song et al. 2004). A possible association of avascular necrosis of the tibial or femoral condyles to a stress fracture at the same location was suggested by Narvaez et al. in 2003 (Narvaez et al. 2003). Relation of a subchondral stress fracture of the femural head to transient osteoporosis or of a subchondral stress fracture of the femural condyle to avascular necrosis has been described by Adriaensen et al. in 2009 (Adriaensen et al. 2009). This has been previously discussed in this chapter. Various physical modalities have been tried in the treatment of stress fractures, as capacitively coupled electric fields (Beck et al. 2008), shock wave therapy, or low-frequency pulsed

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ultrasound. These are discussed by Hetsroni et al. in a separate chapter in the previous edition of this book (Hetsroni and Mann 2012). Both low-intensity pulsed ultrasound (LIPU) (Martinez de Albornoz et al. 2011) and shock wave therapy (SWT) (Furia et al. 2010) have shown good results in enhancing the healing of these lesions. Thus, their use has been proposed as noninvasive alternatives for treatment (Shindle et al. 2012). Other authors (material reviewed in the Cochrane data base system review) did not find convincing evidence for the effectiveness of these modalities (Griffin et al. 2012), although SWT was still shown to reduce pain to a small but significant effect (Griffin et al. 2012). Prescription of nonsteroidal anti-inflammatory drugs (NSAID), once widely used in stress fracture treatment for their pain-reducing effect, is not encouraged today because of their observed negative effect on bone healing (Stivitz and Arendt 2004; Wheeler and Batt 2005; Krischak et al. 2007; Finestone et al. 2008).

Summary and Conclusions 1. Diagnosis Diagnosis is based on the clinical history and examination. This is assisted by X-ray, scintigraphy, computed tomography, magnetic resonance, and ultrasound. X-ray and scintigraphy should probably be done in most patients, while scintigraphy, though important, should be utilized with certain care. Computerized tomography and magnetic resonance should probably still be reserved for special cases. This approach, though, may well change in the near future as computed tomography is today accurate, fast, and available (Knap and Garrett 1997; Taun et al. 2004), and experience is accumulating in the magnetic resonance diagnosis of stress fractures (Fredericson et al. 1995; Arendt and Griffiths 1997; Taun et al. 2004) appreciated for its accuracy and safety (Schlezinger and Smith 2001). 2. Differential diagnosis Differential diagnosis would include tumors, infections, other trauma to the bone

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and soft tissues, normal bone reaction to stress, myositis ossificans, and soft tissue calcifications. Overdiagnosis by scintigraphy should be remembered and also the rare but hazardous possibility that a fracture would occur with a negative bone scan. The possible overlap of the tibial stress syndrome progressing from a benign condition to a tibial stress fracture should also be kept in mind. A true “asymptomatic” stress fracture probably does not exist. 3. Treatment Treatment would basically be to reduce activity to the limit of pain and in general enable relative rest for approximately half the time as a full fracture of the same bone would take to heel. Rest enforcement would be considered in the military environment and usually only in potential hazardous conditions such as advanced stages of femoral neck fractures. In certain cases, 5–6 % of total fractures may eventually not unite, displace, and require surgical intervention. Various modalities as shock wave, low-intensity pulsed ultrasound, and coupled electric fields may have a supportive role.

References Abel MS (1985) Jogger’s fracture and other stress fractures of the lumbo-sacral spine. Skeletal Radiol 13(3):221–227 Adriaensen ME, Mulhall KJ, Borghans RA, Magill P, Kavanagh EC (2009) Transient osteoporosis of the hip and spontaneous osteonecrosis of the knee: a common aetiology? Ir J Med Sci. 2012 Sep; 181(3):341–343. Epub 2009, doi: 10.1007/s11845009-0407-4 Allen MJ, O’Dwyer FG, Barnes MR, Belton IP, Finlay DB (1995) The value of 99 cm-MDP bone scans in young patients with exercise-induced lower leg pain. Nucl Med Commun 16(2):88–91 Arendt EA, Griffiths HJ (1997) The use of MR imaging in the assessment and clinical management of stress reaction of bone in high performance athletes. Clin Sports Med 16:291–306 Banal F, Gandjbakhch F, Foltz V, Goldcher A, Etchepare F, Rozenberg S, Koeger AC, Bourgeois P, Fautrel B (2009) Sensitivity and specificity of ultrasonography in early diagnosis of metatarsal bone stress fractures: a pilot study of 37 patients. J Rheumatol 36(8):1715–1719. Epub 30 June2009

2100 Batt ME (1995) Shin splints-a review of terminology. Clin J Sport Med 5(1):53–57 Beck BR, Matheson GO, Bergman G, Norling T, Fredericson M, Hoffman AR, Marcus R (2008) Do capacitively coupled electric fields accelerate tibial stress fracture healing? A randomized controlled trial. Am J Sports Med 36(3):545–553 Blank S (1987) Transverse tibial stress fractures – a special problem. Am J Sports Med 15(6):597 Breithaupt J (1855) Zur pathologie der mensclichen fusses. Med Zeitung 24:169–171 Buttaro M, Della-Valle AG, Morandi A, Sabas M, Pietrani M, Piccaluga F (2003) Insufficiency subchondral fracture of the femoral head: report of 4 cases and review of the literature. J Arthroplasty 18(3):377–382 Clement DB (1987) Stress fractures of the foot and ankle. Med Sport Sci 23:56–70 Conway JJ (1986) Radionuclide bone scintigraphy in pediatric orthopedics. Ped Clin North Am 33(6):1313 Davies AG, Clarke AW, Gilmore J, Wotherspoon M, Connell DA (2009) Review: imaging of groin pain in the athlete. Skeletal Radiol (2010) 39:629–644. Published online: 27 August 2009 Derman EW, Schwellnus MP (1996) Stress fractures and bone stress injuries of the hip and pelvis. S A J Sports Med 3(3):14–18 Ekenman I, Tsai-Fellander L, Johansson C, O’Brien M (1995) The plantar flexor muscle attachments on the tibia. A cadaver study. Scand J Med Sci Sports 5(3):160–164 Finestone AS, Lavon HW (2006) Israel medical corps. Command. Instruction no. 09:01 Finestone AS, Milgrom C (2012) Diagnosis and treatment of stress fractures. In: Doral MN, Tandoğan RN, Mann G, Verdonk R (eds) Sports injuries, prevention, diagnosis, treatment and rehabilitation. Springer, Heidelberg/New York, pp 775–785 Finestone AS, Milgrom C, Moran DS (2008) Summary of the state of science stress fracture research conference, Columbia (Ft. Jackson), South Carolina. J Isr Milit Med 5:41–44 Flinn SD (2002) Changes in stress fracture distribution and current treatment. Curr Sports Med Rep 1(5):272–277 Fredericson M, Bergman AG, Hoffman KL, Dillingham MS (1995) Tibial stress reaction in runners. Correlation of clinical symptoms and scintigraphy with a new magnetic resonance imaging grading system. Am J Sports Med 23(4):472–481 Fricker P, Purdam C (1995) Stress fractures of the femoral shaft in athletes- more common than expected. Am J Sports Med 23(3):372 Fullerton LR Jr, Snowdy HA (1988) Femoral neck stress fractures. Am J Sports Med 16(4):365–377 Furia JP, Rompe JD, Cacchio A, Maffulli N (2010) Shock wave therapy as a treatment of nonunions, avascular necrosis, and delayed healing of stress fractures. Foot Ankle Clin 15(4):651–662

G. Mann et al. Giladi M, Ziv Y, Aharonson Z, Nili E, Danon YL (1984) Comparison between radiography, bone scan and ultrasound in the diagnosis of stress fractures. Mil Med 149:459–461 Goodman PH, Heaslet MW, Pagliano JW, Rubin BD (1985) Stress fracture diagnosis by computer-assisted thermography. Phys Sportsmed 13:114–132 Griffin XL, Smith N, Parsons N, Costa ML (2012) Ultrasound and shockwave therapy for acute fractures in adults. Cochrane Database Syst Rev 2, CD008579. doi:10.1002/14651858.CD008579.pub2 Ha KI, Hahn SH, Chung M, Yang BK, Yi SR (1991) A clinical study if stress fractures in sports activities. Orthopedics 14:41 Halperin N, Copeliovitch L, Schachner E (1983) Radiating leg pain and positive straight leg raising in spondylolysis in children. J Pediatr Orthop 3(4):486–490 Hetsroni I, Mann G (2012) Various modalities to hasten stress fracture healing. In: Doral MN, Tandoğan RN, Mann G, Verdonk R (eds) Sports injuries, prevention, diagnosis, treatment and rehabilitation. Springer, Heidelberg/New York, pp 859–861 Horev G, Korenreich L, Ziv N, Grunebaum M (1990) The enigma of stress fracture in the pediatric age clarification of confusion through the new imaging modalities. Pediatr Radiol 20:469 Hulkko A (1988) Stress fractures in athletes – a clinical study of 368 cases. Thesis, University of OULU Hung CY, Chang KV (2012) Is therapeutic ultrasound a reliable tool for the diagnosis of bone stress injuries? Letter to the editor. Am J Sports Med 40(9):NP25 Keatig JF, Beggs I, Thorpe GW (1995) Three cases of longitudinal stress fracture of the tibia. Acta Orthop Scand 66(1):41–42 Keene J, Lash E (1992) Negative bone scan in a femural neck stress fracture. A case report. Am J Sports Med 20(2):234–236 Knap TP, Garrett WE Jr (1997) Stress fractures: general concepts. Clin Sports Med 16:339–356 Krauss MD, Van Meter CD (1994) A longitudinal tibial stress fracture. Orthop Rev 23(2):163–166 Krestan CR, Nemec U, Nemec S (2011) Imaging of insufficiency fractures. Semin Musculoskelet Radiol 15(3):198–207 Krischak GD, Augat P, Blakytny R, Claes L, Kinzl L, Beck A (2007) The non-steroidal anti-inflammatory drug diclofenac reduces appearance of osteoblasts in bone defect healing in rats. Arch Orthop Trauma Surg 127:453–458 Lassus J, Tulikoura I, Konttinen YT, Salo J, Santavirta S (2002) Bone stress injuries of the lower extremity: a review. Acta Orthop Scand 73(3):359–368 Lee JK, Yao L (1988) Stress fracture: MR imaging. Radiology 169:217 Lysens RJJ et al (1987) A one-year prospective study of the intrinsic risk factors of sports injuries in young adults. In: Mann G (ed) Sports injuries: proceedings of the

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third Jerusalem symposium, Freund Publishing House Ltd., London Mann G (1987) Sports injuries: proceedings of the third Jerusalem symposium. Freund Publishing House, London Mann G, Matan Y, Nyska M, Lau Y, Peretz M, Siderer M, Barak Y, Hakimi I, Godschmidt R, Ziv B, Borovsky A (2001) The effect of personal factors of the fighter, a custom-made insole and a new boot on the occurrence of over-use injuries and stress fractures in border police recruits in an infantry course. The State of Israel, The Ministry of Internal Security, Chief Scientist Office, Hebrew Martin J, Brandser EA, Shin MJ, Buckwalter JA (1995) Fatigue fracture of the sacrum in a child. Can Assoc Radiol J 46(6):468–470 Martinez de Albornoz P, Khanna A, Longo UG, Forriol F, Maffulli N (2011) The evidence of low-intensity pulsed ultrasound for in vitro, animal and human fracture healing. Br Med Bull 100:39–57 Matheson GO, Clement DB, McKenzie DC, Taunton JE, Lloyd-Smith DR, MacIntyre JG (1987) Scintigraphic uptake of 99mTc at non-painful sites in athletes with stress fractures. The concept of bone strain. Sports Med 4:65–75 McBryde AM Jr (1985) Stress fractures in runners. Clin Sports Med 4:737–752 McBryde AM Jr, Jackson DW, James CM (1985) Injuries in runners and joggers. In: Schneider RC, Kennedy JC, Plant ML (eds) Sports injuries. Williams & Wilkins, Baltimore, pp 395–416 Miller C, Major N, Toth A (2003) Pelvic stress injuries in the athlete: management and prevention. Sports Med 33(13):1003–1012 Moss A, Mowart AG (1983) Ultrasonic assessment of stress fractures. Br Med J 286:1479–1480 Nachtrab O, Cassar-Pullicino VN, Lalam R, Tins B, Tyrrell PN, Singh J (2012) Role of MRI in hip fractures, including stress fractures, occult fractures, avulsion fractures. Eur J Radiol 81(12):3813–3823 Narvaez JA, Narvaez J, De-Lama E, Sanchez A (2003) Spontaneous osteonecrosis of the knee associated with tibial plateau and femoral condyle insufficiency stress fracture. Eur Radiol 13(8):1843–1848 Newberg AH, Wetzner SM (1994) Bone bruises: their patterns and significance. Semin Ultrasound CT MR 15(5):396–409 Nielens H, Devogalaer JP, Malghem J (1994) Occurrence of a painful stress fracture of the femoral neck simultaneously with six other asymptomatic localizations in a runner. J Sports Med Phys Fitness 34(1):79–82 Orava S, Hulkko A (1987) Treatment of delayed and non unions of stress fractures in athletes. In: Mann G (ed) Sports injuries: proceedings of the third Jerusalem symposium. Freund Publishing House, London Orava S, Karpakka J, Taimela S, Hulkko A, Permi J, Kujala U (1995) Stress fractures of the medial malleolus. J Bone Joint Surg Am 77(3):362–365 Papalada A, Malliaropoulos N, Tsitas K, Kiritsi O, Padhiar N, Del Buono A, Maffulli N (2012) Ultrasound

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as a primary evaluation tool of bone stress injuries in elite track and field athletes. Am J Sports Med 40(4):915–919 Pirker H (1934) Bruch der Oberschenkeldiaphyse durch Muskelzug. Arch Klin Chir 175:155–168 Read MT (1994) Single photon emission computed tomography (SPECT) scanning for adolescent back pain. A sine qua non? Br J Sports Med 28(1):56–57 Sahi T et al (1987) Epidemiology, etiology and prevention of stress fractures in the Finnish defense forces and the frontier guard. In: Mann G (ed) Sports injuries: proceedings of the third Jerusalem symposium. Freund Publishing House, London Saifuddin A, Chalmers AG, Butt WP (1994) Longitudinal stress fractures of the tibia: MRI features in two cases. Clin Radiol 49(7):490–495 Santi M, Sartoris DJ, Resnick D (1988) Magnetic resonance imaging in the diagnosis of metatarsal stress fracture. J Foot Surg 27(2):172 Schlezinger LC, Smith JA (2001) Diagnostic imaging of stress fracture. Position paper submitted to the FIMS Scientific committee Schneiders AG, Sullivan SJ, Hendrick PA, Hones BD, McMaster AR, Sugden BA, Tomlinson C (2012) The ability of clinical tests to diagnose stress fractures: a systematic review and meta-analysis. J Orthop Sports Phys Ther 42(9):760–771 Schubert F, Carter S (1994) Longitudinal stress fracture in the femoral diaphysis. Australas Radiol 38(4):336–338 Shah MK, Stewart GW (2002) Sacral stress fractures: an unusual cause of low back pain in an athlete. Spine 27(4):E104–E108 Shindle MK, Endo Y, Warren RF, Lane JM, Helfet DL, Schwartz EN, Ellis SJ (2012) Stress fractures about the tibia, foot, and ankle. J Am Acad Orthop Surg 20(3):167–176 Song WS, Yoo JJ, Koo KH, Yoon KS, Kim YM, Kim HJ (2004) Subchondral fatigue fracture of the femoral head in military recruits. J Bone Joint Surg Am 86-A(9):1917–1924 Sormaala MJ, Ruohola JP, Mattila VM, Koskinen SK, Pihlajam€aki HK (2011) Comparison of 1.5 T and 3 T MRI scanners in evaluation of acute bone stress in the foot. BMC Musculoskelet Disord 12:128 Soubrier M, Dubost JJ, Rami S, Ristori JM, Bussiere JL (1995) Longitudinal insufficiency fractures of the femoral shaft. Rev Rhum Engl Ed 62(1):48–52 Spitz DJ, Newberg AH (2002) Imaging of stress fractures in the athlete. Radiol Clin N Am 40(2):313–331 Steinbronn DJ, Bennett GL, Kay DB (1994) The use of magnetic resonance imaging in the diagnosis of stress fractures of the foot and ankle: four case reports. Foot Ankle Int 15(2):80–83 Stivitz SD, Arendt EA (2004) NSAIDs should not be used in treatment of stress fractures. Am Fam Physician 70(8):1452–1454 Taun K, Wu S, Sennett B (2004) Stress fractures in athletes: risk factors, diagnosis, and management. Orthopedics 27:583–592

2102 Tuite MJ, De-Smet AA, Gaynon PS (1995) Tibial stress fracture mimicking neuroblastoma metastasis in two young children. Skeletal Radiol 24(4):287–290 Tyrrell PN, Davies AM (1994) Magnetic resonance imaging appearances of fatigue fractures of the long bone of the lower limb. Br J Radiol 67(796):332–338 Umans HR, Kaye JJ (1996) Longitudinal stress fractures of the tibia: diagnosis by magnetic resonance imaging. Skeletal Radiol 25(4):319–324

G. Mann et al. Wheeler P, Batt ME (2005) Do non-steroidal anti-inflammatory drugs adversely affect stress fracture healing? A short review. Br J Sports Med 39:65–69 Wilson ES Jr, Katz FN (1969) Stress fractures. An analysis of 250 consecutive cases. Radiology 92(3):481–486 Zwas ST, Elkanovitch R, Frank G (1987) Interpretation and classification of bone scintigraphic findings in stress fractures. Nucl Med 28:452