STRESS FRACTURES IN ATHLETES : diagnosis and management.

Description

Preface Contents Contributors Part I: General Evaluation Principles for Stress Fractures 1: Risk Factors for Developing Stress Fractures Introduction Intrinsic Risk Factors Non-modifiable Intrinsic Risk Factors Demographics Gender Race Age Previous History of Stress Fracture Genetics Lower Extremity Alignment Modifiable Intrinsic Risk Factors Relative Energy Deficiency Syndrome Low Energy Availability with or Without Disordered Eating Functional Hypothalamic Amenorrhea Osteoporosis Calcium and/or Vitamin D Deficiency Low Body Weight/BMI Biomechanics and Strengthening Medication Use Contraceptives Other Medications Substance Abuse Tobacco and Alcohol Consumption Extrinsic Risk Factors Non-modifiable Extrinsic Risk Factors Time of Season Modifiable Intrinsic Risk Factors Training Variables Equipment Variables (Footwear and Inserts) Type of Sport Prediction Algorithms Based on Risk Factors Conclusion References 2: Sideline and Training Room Evaluation and Treatment for Suspected Stress Fractures Philosophy Behind the Decision-Making on the Sideline and in the Training Room Evaluation History Physical Examination Imaging Stress Fractures of the Hip History Physical Examination Imaging Return to Play Current Game Game Day Treatment Training Room Treatment Decision Points Stress Fractures of the Femur History Physical Examination Imaging Return to Play Current Game Game Day Treatment Training Room Treatment Decision Points Stress Fractures of the Tibia History Physical Examination Imaging Return to Play Current Game Game Day Treatment Training Room Treatment of Stress Fractures References 3: Pathophysiology and Epidemiology of Stress Fractures Stress Fracture Pathophysiology Bone Biology Bone Pathophysiology in Stress Fracture Host Risk Factors for the Development of Bone Stress Injury Bone Mineral Density and Bone Thickness Genetics Nutritional Factors Menstrual Irregularity Summary Stress Fracture Epidemiology Stress Fracture Epidemiology – Military Stress Fracture Epidemiology – Athletics Stress Fracture Epidemiology – Tennis Stress Fracture Epidemiology – Pediatric/Adolescent Athletes Stress Fracture Epidemiology – Other Sports Stress Fracture Epidemiology – Incidence and Return to Play Summary – Epidemiology References 4: Diagnostic Imaging Evaluation of Stress Fractures Evolution of Imaging Imaging Techniques Radiography Radionuclide Scintigraphy Ultrasound Computed Tomography Magnetic Resonance Imaging Conclusion References 5: Classification of Stress Fractures Defining a Stress Fracture Features of a Quality Classification System High-Risk vs. Low-Risk Stress Fractures Current and Historical Classification Systems Kaeding–Miller Classification System [22] Conclusion References 6: Insufficiency Fractures Causes of Insufficiency Fractures Osteopenia/Osteoporosis The Female Athlete Triad and Decreased Bone Mineral Density Osteomalacia and Rickets: Role in Fracture Risk Paget’s Disease of Bone Hyperparathyroidism and Brown Tumors Radiation-Induced Fracture Presentation and Diagnosis of Insufficiency Fracture Spine Pelvis and Sacrum Hip and Femur Tibia Foot Upper Extremity Conclusion References Part II: Maximizing Healing Potential for Stress Fractures 7: The Holistic Approach to Stress Fracture Treatment Introduction The Economic Impact of Stress Fractures Global Economic Impact Individual Economic Impact Using a Holistic Approach Biomechanical Modifications Nutritional Optimization Hormonal Balance Mental and Emotional Fitness Risk Factors for Developing Stress Fractures Biomechanical Vitamin D Insufficiency Relative Energy Deficiency in Sport and the Female Athlete Triad The Male Endurance Athlete Tetrad Pathophysiology Clinical Presentation Radiologic Evaluation Radiographs Bone Scintigraphy Computed Tomography (CT Scan) Magnetic Resonance Imaging (MRI) Classification/Grading Risk Assessment Low-, Intermediate-, and High-Risk Stress Fractures Treatment of High-Risk Stress Fractures Treatment of Low-Risk Stress Fractures Return to Sports Participation Biologic Healing Enhancement Autologous Platelet-Rich Technologies Concentrated Bone Marrow Aspirate Injectable Bone Graft Substitutes Electrical Osseous Stimulation Parathyroid Hormone Stimulation Summary References 8: Biomechanics and Stress Fractures: Utility of Running Gait Analysis Introduction Activity-Related Loading Biomechanical Risk Factors Bone Characteristics Skeletal Alignment Movement Patterns Load Characteristics Treatment Implications and Utility of Running Analysis Bone Strength Load Progression Faulty Running Mechanics Evaluation and Intervention 2D Running Gait Analysis Lateral View (Fig. 8.14) 2D Running Gait Analysis Sagittal View  (Fig. 8.15) Additional Variables Gait Retraining Conclusion References 9: Nutritional Optimization for Athletes with Stress Fractures The Relationship of Energy Intake and Balance to Bone Health Nutritional Assessment Energy Dietary Recommendations Protein Carbohydrate Fat Micronutrients Calcium Vitamin D Iron Other Important Micronutrients Resources References 10: Systemic Treatment Modalities for Stress Fractures Introduction Teriparatide (TPTD) Mechanism of Action Clinical Use Benefits and Considerations Side Effects Extracorporeal Shockwave Therapy Mechanism of Action Clinical Use Benefit and Considerations Bone Stimulation Devices Mechanism of Action Clinical Use Benefit and Considerations Conclusion References 11: Orthobiologic Treatment Options for Stress Fractures Orthobiologics Bone Grafting Site-Specific “Bone Grafting” Use Tibial Diaphysis Navicular Metatarsal Great Toe Sesamoid Spondylolysis Femoral Neck Upper Limb Bone Marrow Aspirate Concentrate Site-Specific “Bone Marrow Aspirate Concentrate” Use Metatarsal (Fig. 11.4) Medial Malleolus Navicular Cuneiform Tibial Diaphysis (Fig. 11.5) Bone Morphogenetic Protein Site-Specific “Bone Morphogenetic Protein” Use Spondylolysis Tibial Diaphysis Bone Graft Substitute Navicular Tibial Diaphysis Future Orthobiologic Treatment Options for Stress Fractures Platelet-Rich Plasma Platelet-Derived Growth Factor Conclusion References Part III: Management of Common Stress Fracture Sites 12: Stress Fractures of the Ribs and Shoulder Girdle Introduction Risk Factors Clinical Presentation Physical Examination Differential Diagnosis Causative Activities Stress Fracture of the Ribs First Rib Second Through Twelfth Ribs Sternum Scapula Clavicle Proximal Humerus Little Leaguer’s Shoulder Diagnostic Imaging X-Ray CT Bone Scan MRI Classification General Treatment Principles Return to Sports Participation Prevention of Rib and Shoulder Girdle Stress Fractures Conclusions References 13: Upper Extremity Stress Fractures Epidemiology Pathophysiology Imaging First Rib Coracoid Proximal Humerus Medial Epicondyle Olecranon Ulna Shaft Distal Radius Conclusion References 14: Stress Fractures of the Lumbar Spine Introduction Etiology, Epidemiology, and Biomechanics History and Presentation Physical Examination Imaging Plain Radiographs Bone Scintigraphy Computed Tomography Magnetic Resonance Imaging Diagnostic Algorithm Treatment Bracing Activity Modification Low-Intensity Pulsed Ultrasound (LIPUS) Rehabilitation and Return to Sport Surgical Management Outcomes Cervical and Thoracic Stress Fractures Diagnosis Management Surgical Treatment Summary References 15: Stress Fractures of the Pelvis and Sacrum Introduction Predisposing Factors and Training Differential Diagnosis Patient History and Physical Examination Imaging Evaluation Radiographs MRI and Bone Scintigraphy CT Bone Density and Body Composition Testing Laboratory Workup Nonoperative Treatment Operative Treatment Adjunctive Treatment Conclusion References 16: Stress Fractures of the Hip and Femur Introduction Anatomy Patient Evaluation History Physical Examination Imaging: Plain Radiographs Imaging: MRI Management: Non-surgical Management: Surgical Conclusions References 17: Stress Fractures of the Tibia Introduction Relevant Anatomy and Biomechanics Definition and Classification Risk Factors History and Presentation Pain Localization Exacerbating and Relieving Factors Other Findings Physical Examination Tibia-Specific Physical Examination Inspection Palpation Motion, Strength, and Special Testing Imaging Treatment Biologic Healing Augmentation Summary References 18: Stress Fractures of the Ankle and Hindfoot Introduction Medial Malleolus Distal Tibia Distal Fibula Talus Calcaneus Navicular References 19: Stress Fractures of the Midfoot and Forefoot First Through Fourth Metatarsal Stress Fracture Introduction Pathophysiology Diagnosis Clinical Presentation Imaging Treatment Nonoperative Management Operative Management Fifth Metatarsal Stress Fractures Introduction Anatomy Classification Pathophysiology Diagnosis Clinical Presentation Imaging Treatment Nonoperative Management Operative Treatment Navicular Stress Fractures Introduction Diagnosis Clinical Presentation Imaging Classification Treatment Nonoperative Treatment Operative Treatment Cuboid Stress Fractures Introduction Pathophysiology Diagnosis Imaging Treatment Cuneiform Stress Fractures Introduction Pathophysiology Diagnosis Imaging Treatment Sesamoid Stress Fractures Introduction Diagnosis Clinical Presentation Imaging Treatment Nonoperative Treatment Operative Treatment Sesamoidectomy Bone Grafting Internal Fixation Return to Play Summary References Index