STRESS FRACTURES IN ATHLETES : diagnosis and management.

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