Bone Stress Injuries
This article is currently under review and may not be up to date. Please come back soon to see the finished work! (Template:28/2/21)
Original Editor - Puja Gaikwad
Top Contributors - Puja Gaikwad, Kim Jackson, Vidya Acharya, Rucha Gadgil and Lucinda hampton
Introduction[edit | edit source]
Bone Stress Injuries (BSI) are overuse injuries associated with repeated loading of bone by strenuous weight-bearing activities (such as running, jogging, marching) and inadequate recovery periods. BSI’s represent the failure of skeleton bone to withstand repetitive loading, leading to structural fatigue, localized bone pain, and tenderness around the area.[1] Bone Stress Injuries (BSI) are commonly seen in avid runners, track and field athletes, endurance athletes, military recruits, gymnasts, dancers, but also among otherwise healthy people who have recently started the new or intensive physical activity [2]accounting for 10% of all sports-related injuries.[3] BSI differs in severity, with initial findings of periosteal edema and marrow edema. In more severe conditions, stress fractures with distinct fracture lines are present. Stress fractures account for > 10% of total sports-related injuries and it could be as high as 30% in running. [4]
Pathophysiology[edit | edit source]
When the bone is subjected to mechanical forces the forces cause adaptive changes in the trabecular (i.e internal architecture of bone), followed by secondary adaptive changes in the bone cortex (i.e external architecture of bone). In trabecular bone, the initial response to mechanical forces is the microdamage of the trabecular which is repaired by a microcallus. In cortical bone, the initial response to an increase in mechanical forces is osteoclastic activity (bone break down) which leads to resorption of bone.[5] Osteoblastic cellular activity fills the resorption cavities with a lamellar bone. However, bone formation is slower than bone resorption.[6]
Bone Stress Continuum[edit | edit source]
There is a continuum of bone stress injury varying from "normal to bone strain to stress reaction to the ultimate progression of a stress fracture. These injuries sit on a continuum whereby they start with a stress reaction (often called a ‘hot spot) which can progress towards a stress fracture and finally towards a complete bone fracture. Essentially, as the BSI progresses along the continuum, the longer it takes to recover.[7] Therefore, an understanding and early recognition of these injuries are critical to any athlete and their sports-specific goals.
On the continuum, bone is accruing microdamage following mechanical forces from loading, for example from running. Microdamage accrues proportionate to the number of loading cycles, rate of loading, and strain magnitude of the skeleton bone. When the bone is given adequate time between loading cycles to recover the rate of bone resorption is met by the rate of bone repair and remodeling. However, when insufficient time is given for the bone to adapt to external mechanical forces, an imbalance may occur between bone remodeling and microdamage to the bone resulting in structural deformation of bone and fatigue This accumulative microdamage can continue to progress and result in further pathology. It can progress from the bone being in a state of stress reaction through to stress fracture and at times even frank cortical fracture. [8]
Risk Factors in Runners[edit | edit source]
Bone stress injury risk factors could be grouped into two categories as proposed by Warden[9]:
- Biomechanical factors: Factors that modify and affect the load applied to a bone/skeleton
- Biological factors: Factors that modify how bone resists strain and the resultant accumulation of damage
| Biomechanical Factors | Biological Factors |
|---|---|
| Training patterns and loads | Athletic/physical activity history |
| Biomechanics | Medical history |
| Footwear | Energy availability/ RED-S |
| Harder training surface | Bone health |
| Calcium and Vit D status | |
| Sleep | |
| stress |
1. Biomechanical Factors[edit | edit source]
While overall in the research paper the relationship between the onset of running-related injuries and biomechanics is poor. Runner’s gait and their biomechanics could alter bone strain magnitudes, and loading rates and hence can influence the risk of a BSI.
The study has validated the following as increasing the bone stress injury risk through altering the magnitude and/or direction of bone loading:
- pes cavus and pes planus feet
- leg length discrepancies
- smaller calf girth
- greater external rotation at the hip.[10]
Dynamic biomechanical loading patterns associated with BSI risk include:
- Greater average vertical loading
- Higher peak acceleration
- Grater peak free mass
- Higher peak adduction, knee internal rotation, tibial internal rotation, rearfoot eversion during gait.[11]
References[edit | edit source]
- ↑ Song SH, Koo JH. Bone Stress Injuries in Runners: a Review for Raising Interest in Stress Fractures in Korea. Journal of Korean medical science. 2020 Mar 2;35(8).
- ↑ Pegrum J, Crisp T, Padhiar N. Diagnosis and management of bone stress injuries of the lower limb in athletes. Bmj. 2012 Apr 24;344.
- ↑ Spitz DJ, Newberg AH. Imaging of stress fractures in the athlete. Radiologic Clinics. 2002 Mar 1;40(2):313-31.
- ↑ Robertson GA, Wood AM. Lower limb stress fractures in sport: optimising their management and outcome. World journal of orthopedics. 2017 Mar 18;8(3):242.
- ↑ Warden SJ, Burr DB. Bone Stress Injuries. Primer on the Metabolic Bone Diseases and Disorders of Mineral Metabolism. 2018 Sep 25:450.
- ↑ Kiuru MJ, Pihlajamäki HK, Ahovuo JA. Bone stress injuries. Acta Radiologica. 2004 May;45(3):000-.
- ↑ Tenforde AS, Kraus E, Fredericson M. Bone stress injuries in runners. Physical Medicine and Rehabilitation Clinics. 2016 Feb 1;27(1):139-49.
- ↑ Roche M, Fredericson M, Kraus E. Bone Stress Injuries. InClinical Care of the Runner 2020 Jan 1 (pp. 141-151). Elsevier.
- ↑ Warden SJ, Burr DB, Brukner PD. Stress fractures: pathophysiology, epidemiology, and risk factors. Current osteoporosis reports. 2006 Sep;4(3):103-9.
- ↑ Harrast MA, editor. Clinical Care of the Runner E-Book: Assessment, Biomechanical Principles, and Injury Management. Elsevier Health Sciences; 2019 Nov 22.
- ↑ Tenforde AS, Parziale AL, Popp KL, Ackerman KE. Low bone mineral density in male athletes is associated with bone stress injuries at anatomic sites with greater trabecular composition. The American journal of sports medicine. 2018 Jan;46(1):30-6.
- ↑ Hreljac A. Etiology, prevention, and early intervention of overuse injuries in runners: a biomechanical perspective. Physical Medicine and Rehabilitation Clinics. 2005 Aug 1;16(3):651-67.
