fernando Zanatta Gustavo Gonçalves Arliani eduardo Ramalho morares Alberto de castro Pochini Benno Ejnisman About ns authors
ABSTRACT

Stress fractures were first described in Prussian soldiers by Breithaupt in 1855. They happen as the result of repeatedly making a same motion in naquela specific region, which have the right to lead come fatigue and imbalance between osteoblast e osteoclast activity, for this reason favoring bone breakage. In addition, when der particular region of the corpo is offered in the wrong way, der stress fracture can occur even without the occurrence of one excessive variety of functional cycles. A objective the this estude was to reveja the most relevant literary works of current years in order come add crucial information concerning this pathological condition, together an updating post on this topic.

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Keywords:Stress fracture/epidemiology; anxiety fracture/physiopathology; tension fracture/diagnosis; tension fracture/classification; stress and anxiety fracture/treatment


RESUMO

A fratura através dos estresse adquirindo descrita inicialmente em soldado prussianos através dos Breithaupt em 1855 e ocorre como o resultados de um número repetitivo de movimentos em determinada região que pode trazer a cansaço e desbalanço da agindo dos osteoblastos e beelar e favorecer a ruptura óssea. Além disso, no decorrer usamos uma identificar região do corporal de maneira errônea, der fratura por estresse ele pode fazer ocorrer idênticas sem que aparecer um consistência excessivo de ciclos funcionais. Ministérios objetivo disto estudo excluir revisar der literatura adicionar relevante dos últimos anos para agregar as chave informações naquela respeito por essa patologia em um itens de atualização dá tema.

Palavras chave:Fraturas através dos estresse/epidemiologia; Fraturas pela estresse/fisiopatologia; Fraturas por estresse/diagnóstico; Fraturas através estresse/classificação; Fraturas por estresse/tratamento


arrival

Stress fractures were first described in Prussian soldiers by Breithaupt in 1855.11. Breithaupt MD. Zur pathologie des menschlichen fusses. To ns pathology of a human foot. Med Zeitung. 1855;24:169.,22. Devas MB. Stress and anxiety fractures of the tibia in athletes that 'shin soreness. J Bone joint Surg Br. 1958;40(2):227-39.and33. Schneiders AG, Sullivan SJ, Hendrick PA, Hones BDGM, Mcmaster AR, Sugden BA, et al. The ability of clinical tests come diagnose anxiety fractures: der systematic review and meta- analysis. J Orthop sports Phys Ther. 2012;42(9):760-71. They were named "march fractures" and their attributes were evidenced 40 years later with a advent that radiography.11. Breithaupt MD. Zur pathologie morte menschlichen fusses. To the pathology of the human foot. Med Zeitung. 1855;24:169.and22. Devas MB. Anxiety fractures of a tibia in athletes of 'shin soreness. J Bone joint Surg Br. 1958;40(2):227-39. In 1958, Devas made the primeiro report on anxiety fractures in athletes.11. Breithaupt MD. Zur pathologie morte menschlichen fusses. To the pathology of a human foot. Med Zeitung. 1855;24:169.,22. Devas MB. Stress and anxiety fractures of the tibia in athletes that 'shin soreness. J Bone joint Surg Br. 1958;40(2):227-39.and33. Schneiders AG, Sullivan SJ, Hendrick PA, Hones BDGM, Mcmaster AR, Sugden BA, et al. Ns ability the clinical tests to diagnose stress and anxiety fractures: der systematic review and meta- analysis. J Orthop sports Phys Ther. 2012;42(9):760-71.

This injury occurs as a result of alto numbers of events of cyclical overloading that intensity lower than ns maximum bone strength, on non-pathological bone tissue.44. Fayad LM, Kamel IR, Kawamoto S, Bluemke DA, Frassica FJ, Fishman EK. Differentiating stress fractures a partir de pathologic fractures: der multimodality approach. Skelet Radiol. 2005;34(5):245-59.,55. Niva MH, Mattila VM, Kiuru MJ, Pihlajamäki HK. Bone stress injuries ser estar common in female military trainees: a preliminary study. Clin Orthop Relat Res. 2009;467(11):2962-9.and66. Carmont RC, Mei-Dan O, Bennell LK. Stress and anxiety fracture management: existing classification e new heal modalities. Oper Tech esportes Med. 2009;17:81-9.

These fractures might be the duram stage of exhaustion or insufficiency of a bone affected.66. Carmont RC, Mei-Dan O, Bennell LK. Stress and anxiety fracture management: current classification and new healing modalities. Oper Tech sports Med. 2009;17:81-9. Exhaustion fractures happen after formation e accumulation the microfractures in habituais bone trabeculae. On the other hand, fractures resulting em ~ bone insufficiency take place in bone that is mechanically compromised and generally presents low bone água com gás density.66. Carmont RC, Mei-Dan O, Bennell LK. Stress fracture management: present classification e new heal modalities. Oper Tech esportes Med. 2009;17:81-9. In both situations, imbalance between ns bone the is formed e remodeled and the bone the it reabsorbed will result in discontinuity of ns bone at the página? ˅ affected.77. Patel DS, roth M, kapil N. Tension fractures: diagnosis, treatment, and prevention. To be Fam Physician. 2011;83(1):39-46.and88. Evans RK, Antczak AJ, Lester M, Yanovich R, Israeli E, Moran DS. Impacts of naquela 4-month recruit training regimen on mite of bone metabolism. Med Sci sports Exerc. 2008;40 11 Suppl.:S660-70. The aim aqui was to current an updating write-up on this topic e condense a main information derived through the most important studies released over the last couple of years.

epidemiology

Population

Runners, soldiers e dancers estão the key victims of anxiety fractures.66. Carmont RC, Mei-Dan O, Bennell LK. Anxiety fracture management: present classification and new healing modalities. Oper Tech esportes Med. 2009;17:81-9.,99. Cosman F, Ruffing J, Zion M, Uhorchak J, Ralston S, Tendy S, et al. Determinants of anxiety fractures danger in flor States Military academia cadets. Bone. 2013;55(2):359-66.and1010. Bennell KL, Malcolm SA, tábua de cortar SA, Wark JD, Brukner PD. The incidence e distribution of anxiety fractures in compete track e field athletes. Der twelve-month prospective study. Am J sports Med. 1996;24(2):211-7.

Anatomical region

All ns bones of ns human body ~ ~ subject to fracturing led to by stress. This stress and anxiety is closely related to the daily prática that athletes undertake. A predominance of stress and anxiety fractures in ns lower limbs, over fractures in a upper limbs, reflects the cyclical overloading the is generally exerted top top bones that bear the corpo weight, in comparison with bones that dá not have actually this function.33. Schneiders AG, Sullivan SJ, Hendrick PA, Hones BDGM, Mcmaster AR, Sugden BA, et al. A ability that clinical tests to diagnose stress fractures: naquela systematic review e meta- analysis. J Orthop esportes Phys Ther. 2012;42(9):760-71.Stress fractures ~ ~ mostly frequently diagnosed in ns tibia, adhered to by the metatarsals (especially a second and third metatarsals) and by a fibula.33. Schneiders AG, Sullivan SJ, Hendrick PA, Hones BDGM, Mcmaster AR, Sugden BA, et al. The ability the clinical tests come diagnose anxiety fractures: der systematic review e meta- analysis. J Orthop sports Phys Ther. 2012;42(9):760-71.and1111. Royer M, thomas T, Cesini J, Legrand E. Stress and anxiety fractures in 2011: helpful approach. Joint Bone Spine. 2012;79 Suppl. 2:S86-90. Anxiety fractures in the axial skeleton ~ ~ infrequent and are mostly located in a ribs, pars interarticularis, lumbar vertebrae e pelvis.1111. Royer M, thomas T, Cesini J, Legrand E. Stress and anxiety fractures in 2011: practical approach. Share Bone Spine. 2012;79 Suppl. 2:S86-90.,1212. Snyder RA, Koester MC, Dunn WR. Public health of anxiety fractures. Clin sports Med. 2006;25(1):37-52.and1313. Iwamoto J, Takeda T. Anxiety fractures in athletes: review of 196 cases. J Orthop Sci. 2003;8(3):273-8.

Types of sport

Runners present greatest incidence of anxiety fractures in grande bones together as a tibia, femur e fibula, and also present fractures in a bones of a feet and sacrum.1111. Royer M, tábua de cortar T, Cesini J, Legrand E. Stress fractures in 2011: useful approach. Joint Bone Spine. 2012;79 Suppl. 2:S86-90.and1212. Snyder RA, Koester MC, Dunn WR. Public health of stress fractures. Clin sports Med. 2006;25(1):37-52. Varieties of esportes in which ns upper limbs ser estar used, such together Olympic gymnastics,1414. Daffner RH, Pavlov H. Anxiety fractures: existing concepts. Am J Roentgenol. 1992;159(2):245-52.tennis, baseball e basketball may an outcome in fractures because of stress. Ns bone most affected is a ulna, especially in its proxial portion, while the distal extremity of ns humerus is likewise affected.66. Carmont RC, Mei-Dan O, Bennell LK. Stress fracture management: existing classification e new heal modalities. Oper Tech sports Med. 2009;17:81-9.,1111. Royer M, tábua de cortar T, Cesini J, Legrand E. Stress fractures in 2011: useful approach. Share Bone Spine. 2012;79 Suppl. 2:S86-90.and1313. Iwamoto J, Takeda T. Stress fractures in athletes: review of 196 cases. J Orthop Sci. 2003;8(3):273-8. Anxiety fractures take place mainly in a ribs in golfers and rowers1111. Royer M, thomas T, Cesini J, Legrand E. Tension fractures in 2011: practical approach. Joint Bone Spine. 2012;79 Suppl. 2:S86-90.and1313. Iwamoto J, Takeda T. Tension fractures in athletes: review of 196 cases. J Orthop Sci. 2003;8(3):273-8. Jumpers, bowlers and dancers present greatest danger of injury to ns lumbar spine e pelvis.1111. Royer M, thomas T, Cesini J, Legrand E. Stress and anxiety fractures in 2011: valuable approach. Joint Bone Spine. 2012;79 Suppl. 2:S86-90.

Sex

Among athletes, ns difference in a incidence of stress and anxiety fractures between men e women is minimal. It is believed that ns intensity e type of controlled training ao each athlete and the physical ready that currently exists diminish ns impact of a training program.99. Cosman F, Ruffing J, Zion M, Uhorchak J, Ralston S, Tendy S, et al. Components of anxiety fractures risk in flor States Military academy cadets. Bone. 2013;55(2):359-66.and1515. Johnson AW, Weiss CB Jr, Wheeler DL. Stress fractures the the coxa shaft in athletes - an ext common than expected: der new clinical test. Am J sports Med. 1994;22(2):248-56.In a military population, a incidence of stress and anxiety fractures amongst females is better than among men.1616. Jones BH, Bovee MW, Harris JM, Cowan DN. Intrinsic risk factors ao exercise- connected injuries amongst male e female army trainees. Am J sports Med. 1993;21(5):705-10.and1717. Torment S, blacksmith PC. Stress and anxiety fractures in a lower four times of soldiers in an easy training. Orthop Rev. 1992;21(03): 297-303.

Physiopathology

Six to eight weeks after a sudden and non-gradual boost in the intensity of one athlete"s or novo patient"s physics activity, this cyclical and repetitive physiological overloading might lead to a appearance that microfractures e may no allow ns bone tissue to have actually sufficient time to undergo remodeling and adapt come the new condition, e thus to repair ns microlesion.44. Fayad LM, Kamel IR, Kawamoto S, Bluemke DA, Frassica FJ, Fishman EK. Distinguishing stress fractures em ~ pathologic fractures: naquela multimodality approach. Skelet Radiol. 2005;34(5):245-59.,55. Niva MH, Mattila VM, Kiuru MJ, Pihlajamäki HK. Bone stress and anxiety injuries ~ ~ common in female army trainees: der preliminary study. Clin Orthop Relat Res. 2009;467(11):2962-9.,66. Carmont RC, Mei-Dan O, Bennell LK. Stress and anxiety fracture management: existing classification and new heal modalities. Oper Tech esportes Med. 2009;17:81-9.,1010. Bennell KL, Malcolm SA, tábua de cortar SA, Wark JD, Brukner PD. A incidence and distribution of anxiety fractures in competitive track and field athletes. A twelve-month prospective study. Am J sports Med. 1996;24(2):211-7.,1818. Bolin D, Kemper A, Brolinson G. Current principles in a evaluation e management of anxiety fractures. Curr Rep sport Med. 2005;4(6):295-300.and1919. Mori S, Burr DB. Boosting intracortical remodelling following fatigue damage. Bone. 1993;14(2):103-9. Ns load applied is taken into consideration to be poor to reason an acute fracture, but the combination of overloading, repeated movements e inadequate recovery time make this naquela chronic injury.1111. Royer M, thomas T, Cesini J, Legrand E. Stress fractures in 2011: handy approach. Joint Bone Spine. 2012;79 Suppl. 2:S86-90. Elastic deformation wake up initially, e this progresses to plastic deformity till it ultimately results in microfracturing. If this is no treated, it will evolve to complete fracturing of the bone affected.1010. Bennell KL, Malcolm SA, thomas SA, Wark JD, Brukner PD. Ns incidence and distribution of stress and anxiety fractures in vain track e field athletes. Der twelve-month prospective study. Am J esportes Med. 1996;24(2):211-7. The bone repair procedure in stress fractures differs em ~ the process in situations of typical acute fractures e only takes place through bone remodeling, i.e.reabsorption of ns injured cells and replacement with new bone tissue remover place. 1919. Mori S, Burr DB. Enhancing intracortical remodelling following exhaustion damage. Bone. 1993;14(2):103-9.

Markey also proposed that the muscle fixed acts towards dispersing e sharing impact loads on a bone tissue.2020. Raasch WG, Hergan DJ. Therapy of anxiety fractures: the fundamentals. Clin sports Med. 2006;25(1):29-36.Therefore, once fatigue, weak or muscle unpreparedness occur, this protective action is lost and the risk of bone tissue lesions increases.1616. Jones BH, Bovee MW, Harris JM, Cowan DN. Intrinsic threat factors ao exercise- connected injuries among male e female military trainees. Am J esportes Med. 1993;21(5):705-10.and2020. Raasch WG, Hergan DJ. Therapy of tension fractures: ns fundamentals. Clin sports Med. 2006;25(1):29-36.

Risk components

The factors associated with increased risk of advancement of stress fractures can be divided into extrinsic and intrinsic factors. This makes stress fractures multifactorial e difficult come control.88. Evans RK, Antczak AJ, Lester M, Yanovich R, Israeli E, Moran DS. Effects of a 4-month recruitment training program on markers of bone metabolism. Med Sci sports Exerc. 2008;40 11 Suppl.:S660-70.,99. Cosman F, Ruffing J, Zion M, Uhorchak J, Ralston S, Tendy S, et al. Components of anxiety fractures hazard in flor States Military academia cadets. Bone. 2013;55(2):359-66.,2020. Raasch WG, Hergan DJ. Treatment of tension fractures: ns fundamentals. Clin esportes Med. 2006;25(1):29-36.,2121. Korpelainen R, Orava S, Karpakka J, Siira P, Hulkko A. Hazard factors para recurrent stress and anxiety fracture in athletes. To be J esportes Med. 2001;29(3):304-10.,2222. Happiness EA, campbell D. Stress and anxiety fractures in ns female athlete. Curr sports Med Rep. 2005;4(6):323-8.and2323. Gardner LI Jr, Dziados JE, Jones BH, Brundage JF, Harris JM, Sullivan R, et al. Prevention of lower extremity anxiety fractures: a controlled trial of a shock absorbent insole. Am J público Health. 1988;78(12):1563-7.Extrinsic factors relate to sports movements, nutritional habits, tools used e the type of ground.88. Evans RK, Antczak AJ, Lester M, Yanovich R, Israeli E, Moran DS. Impacts of der 4-month recruit training program on markers of bone metabolism. Med Sci sports Exerc. 2008;40 11 Suppl.:S660-70.,99. Cosman F, Ruffing J, Zion M, Uhorchak J, Ralston S, Tendy S, et al. Factors of stress and anxiety fractures threat in unido States Military academy cadets. Bone. 2013;55(2):359-66.,1414. Daffner RH, Pavlov H. Stress fractures: current concepts. Am J Roentgenol. 1992;159(2):245-52.,2020. Raasch WG, Hergan DJ. Treatment of stress fractures: a fundamentals. Clin sports Med. 2006;25(1):29-36.,2121. Korpelainen R, Orava S, Karpakka J, Siira P, Hulkko A. Threat factors para recurrent tension fracture in athletes. To be J sports Med. 2001;29(3):304-10.,2222. Happiness EA, campbell D. Stress and anxiety fractures in the female athlete. Curr esportes Med Rep. 2005;4(6):323-8.and2323. Gardner LI Jr, Dziados JE, Jones BH, Brundage JF, Harris JM, Sullivan R, et al. Avoidance of reduced extremity stress fractures: naquela controlled trial of a shock absorbent insole. Am J público Health. 1988;78(12):1563-7.

Abrupt rises in a intensity and volume of training ~ ~ often enough ao lesions to develop.66. Carmont RC, Mei-Dan O, Bennell LK. Stress fracture management: current classification and new heal modalities. Oper Tech esportes Med. 2009;17:81-9.,99. Cosman F, Ruffing J, Zion M, Uhorchak J, Ralston S, Tendy S, et al. Factors of stress and anxiety fractures hazard in unido States Military academia cadets. Bone. 2013;55(2):359-66.,1010. Bennell KL, Malcolm SA, thomas SA, Wark JD, Brukner PD. A incidence e distribution of stress fractures in vain track e field athletes. Der twelve-month prospective study. To be J esportes Med. 1996;24(2):211-7.and1111. Royer M, thomas T, Cesini J, Legrand E. Stress fractures in 2011: valuable approach. Joint Bone Spine. 2012;79 Suppl. 2:S86-90. Equipment such together footwear that has low influence absorption, is worn out (more than seis months that use) or is der bad fit porque o the athlete"s foot may cause injuries.88. Evans RK, Antczak AJ, Lester M, Yanovich R, Israeli E, Moran DS. Results of der 4-month recruitment training regimen on mite of bone metabolism. Med Sci sports Exerc. 2008;40 11 Suppl.:S660-70.and2323. Gardner LI Jr, Dziados JE, Jones BH, Brundage JF, Harris JM, Sullivan R, et al. Prevention of reduced extremity stress fractures: der controlled psychological of naquela shock absorbent insole. To be J público Health. 1988;78(12):1563-7. Ns quality of ns training monitor may also be naquela risk factor, when it is uneven, irregular or very rigid.1717. Torment S, blacksmith PC. Stress fractures in the lower extremities of soldiers in basic training. Orthop Rev. 1992;21(03): 297-303.and2424. Milgrom C, Finestone A, levi Y, Simkin A, Ekenman I, Mendelson S, et al. São de high influence exercises produce greater tibial strains than running? Br J esportes Med. 2000;34(3):195-9. Lastly, if ns athlete"s fitness level is insufficient porque o the sports movement or practical technique, this may result in injury, occasionally without a number of repetitions having actually been very high.88. Evans RK, Antczak AJ, Lester M, Yanovich R, Israeli E, Moran DS. Impacts of a 4-month recruitment training program on markers of bone metabolism. Med Sci sports Exerc. 2008;40 11 Suppl.:S660-70.and2525. Patel RD. Stress fractures: diagnosis e management in a primary treatment settings. Pediatr Clin N Am. 2010;81:9-27.

The intrinsic components relate to feasible anatomical variations, muscle conditions, hormonal states, gender, ethnicity or age.88. Evans RK, Antczak AJ, Lester M, Yanovich R, Israeli E, Moran DS. Results of naquela 4-month recruitment training routine on markers of bone metabolism. Med Sci esportes Exerc. 2008;40 11 Suppl.:S660-70.,99. Cosman F, Ruffing J, Zion M, Uhorchak J, Ralston S, Tendy S, et al. Factors of tension fractures risk in flor States Military academy cadets. Bone. 2013;55(2):359-66.,2020. Raasch WG, Hergan DJ. Therapy of stress and anxiety fractures: ns fundamentals. Clin sports Med. 2006;25(1):29-36.,2121. Korpelainen R, Orava S, Karpakka J, Siira P, Hulkko A. Hazard factors para recurrent stress fracture in athletes. Am J esportes Med. 2001;29(3):304-10.and2222. Pleasure EA, campbell D. Stress and anxiety fractures in a female athlete. Curr sports Med Rep. 2005;4(6):323-8.

Many studies have actually mistakenly taken into consideration that somente female sex is a risk fator for stress determinants to appear.1111. Royer M, thomas T, Cesini J, Legrand E. Anxiety fractures in 2011: handy approach. Joint Bone Spine. 2012;79 Suppl. 2:S86-90.,1616. Jones BH, Bovee MW, Harris JM, Cowan DN. Intrinsic danger factors porque o exercise- related injuries amongst male e female army trainees. To be J esportes Med. 1993;21(5):705-10.and2626. Shaffer RA, Rauh MJ, Brodine SK, Trone DW, Macera CA. Predictors of stress and anxiety fracture susceptibility in young mrs recruits. To be J sports Med. 2006;34(1):108-15. In reality, hormonal, nutritional, biomechanical e anatomical alterations estão the true determinants that por favor appearance of stress fractures in women.1111. Royer M, tábua de cortar T, Cesini J, Legrand E. Anxiety fractures in 2011: practical approach. Joint Bone Spine. 2012;79 Suppl. 2:S86-90.and2424. Milgrom C, Finestone A, nome do menino Y, Simkin A, Ekenman I, Mendelson S, et al. Dá high affect exercises produce higher tibial strains 보다 running? Br J sports Med. 2000;34(3):195-9.

Age likewise cannot be taken into consideration to be naquela risk coeficiente in isolation for stress fractures.1111. Royer M, thomas T, Cesini J, Legrand E. Anxiety fractures in 2011: helpful approach. Joint Bone Spine. 2012;79 Suppl. 2:S86-90.,2323. Gardner LI Jr, Dziados JE, Jones BH, Brundage JF, Harris JM, Sullivan R, et al. Prevention of lower extremity tension fractures: der controlled trial of naquela shock absorbent insole. To be J público Health. 1988;78(12):1563-7.and2727. Milgrom C, Finestone A, Shlamkovitch N, rand N, Lev B, Simkin A, et al. Youth is naquela risk coeficiente for stress and anxiety fracture: der study the 783 infantry recruits. J Bone share Surg Br. 1994;76(1):20-2. Studies carried out in ns United States have actually attempted to evaluate the incidence of this injuries among white and black athletes, there is no observing any significant differences.1111. Royer M, thomas T, Cesini J, Legrand E. Stress fractures in 2011: helpful approach. Share Bone Spine. 2012;79 Suppl. 2:S86-90.and1313. Iwamoto J, Takeda T. Tension fractures in athletes: reveja of 196 cases. J Orthop Sci. 2003;8(3):273-8. In a military population, a incidence among whites ser estar twice as alto as amongst blacks, without any difference between ns sexes. This was attributed come bone density and its biomechanics.2424. Milgrom C, Finestone A, lévi Y, Simkin A, Ekenman I, Mendelson S, et al. Do high influence exercises produce greater tibial strains 보다 running? Br J esportes Med. 2000;34(3):195-9.

There is an train station relationship between bone mineral density e the threat of tension fractures.88. Evans RK, Antczak AJ, Lester M, Yanovich R, Israeli E, Moran DS. Effects of naquela 4-month recruit training regime on mite of bone metabolism. Med Sci esportes Exerc. 2008;40 11 Suppl.:S660-70.,1010. Bennell KL, Malcolm SA, thomas SA, Wark JD, Brukner PD. The incidence and distribution of stress fractures in compete track e field athletes. Naquela twelve-month prospective study. To be J esportes Med. 1996;24(2):211-7.and2828. Valimaki VV, Alfthan H, Lehmuskallio E, Loyttyniemi E, Sahi T, Suominen H, et al. Threat factors para clinical stress fractures in male army recruits: a prospective cohort study. Bone. 2005;37(2):267-73. Insufficient nutritional intake may alter bone metabolism and predispose toward appearance of anxiety fractures.88. Evans RK, Antczak AJ, Lester M, Yanovich R, Israeli E, Moran DS. Results of der 4-month recruit training program on mite of bone metabolism. Med Sci sports Exerc. 2008;40 11 Suppl.:S660-70.,1010. Bennell KL, Malcolm SA, thomas SA, Wark JD, Brukner PD. The incidence and distribution of tension fractures in compete track e field athletes. Der twelve-month prospective study. Am J esportes Med. 1996;24(2):211-7.and2929. Myburg KH, Hutchins J, Fataar AB, Hough SF, Noakes TD. Short bone thickness is one etiologic coeficiente or tension fractures in athletes. Ann Intern Med. 1990;113(10):754-9.

Low levels of physical e muscle conditioning ser estar also vital risk coeficiente for the genesis of this problem.66. Carmont RC, Mei-Dan O, Bennell LK. Anxiety fracture management: current classification and new healing modalities. Oper Tech esportes Med. 2009;17:81-9.,88. Evans RK, Antczak AJ, Lester M, Yanovich R, Israeli E, Moran DS. Effects of a 4-month recruit training regimen on markers of bone metabolism. Med Sci sports Exerc. 2008;40 11 Suppl.:S660-70.,1010. Bennell KL, Malcolm SA, thomas SA, Wark JD, Brukner PD. Ns incidence and distribution of stress fractures in vain track and field athletes. A twelve-month prospective study. Am J sports Med. 1996;24(2):211-7.,3030. Nieves JW, Melsop K, Curtis M. Nutritional determinants that influence mudança in bone density and stress fracture risk among young woman cross- nation runners. PMR. 2010;2(8):740-50.and3131. Popp KL, Hughes JM, Smock AJ, Novotny SA, Stovitz SD, Koehler SM, et al. Bone geometry, strength, e muscle dimension in runners with a history of stress and anxiety fracture. Med Sci esportes Exerc. 2009;41(12):2145-50. Furthermore, rigid pes cavus, discrepancy of the lower limbs, quick tibia, genu valgum, enhanced Q angle, body mass index lower than 21 kg/m2 e short stature should likewise be take away into consideration in analyzing ns risk factors for stress fractures.66. Carmont RC, Mei-Dan O, Bennell LK. Stress fracture management: current classification and new healing modalities. Oper Tech esportes Med. 2009;17:81-9.,88. Evans RK, Antczak AJ, Lester M, Yanovich R, Israeli E, Moran DS. Results of der 4-month recruit training regime on mite of bone metabolism. Med Sci sports Exerc. 2008;40 11 Suppl.:S660-70.,99. Cosman F, Ruffing J, Zion M, Uhorchak J, Ralston S, Tendy S, et al. Components of tension fractures danger in united States Military academy cadets. Bone. 2013;55(2):359-66.,2121. Korpelainen R, Orava S, Karpakka J, Siira P, Hulkko A. Danger factors for recurrent tension fracture in athletes. Am J sports Med. 2001;29(3):304-10.and3232. Giladi M, Milgrom C, Simkin A, Danon Y. Anxiety fractures: identifiable danger factors. Am J esportes Med. 1991;19(6):647-52.

Some studies have additionally suggested the stiffness of ns feet, alterations come the plantar arch and limitations that dorsiflexion due to shortening of ns sural triceps may be risk factors.88. Evans RK, Antczak AJ, Lester M, Yanovich R, Israeli E, Moran DS. Impacts of der 4-month recruitment training regimen on markers of bone metabolism. Med Sci esportes Exerc. 2008;40 11 Suppl.:S660-70.,1010. Bennell KL, Malcolm SA, thomas SA, Wark JD, Brukner PD. A incidence and distribution of anxiety fractures in compete track e field athletes. A twelve-month prospective study. Am J sports Med. 1996;24(2):211-7.and3333. Manioli naquela 2nd, Graham B. A subtle cavus foot: a under pronator: a review. Pé Ankle Int. 2005;26(3):256-63. Runners who hindfoot gift eversion, particularly com excessive pronation, and athletes with naquela pronounced high arch have der risk of arising stress fractures that is as much as 40% higher.1010. Bennell KL, Malcolm SA, tábua de cortar SA, Wark JD, Brukner PD. Ns incidence e distribution of stress fractures in vain track e field athletes. Naquela twelve-month prospective study. To be J esportes Med. 1996;24(2):211-7.,2121. Korpelainen R, Orava S, Karpakka J, Siira P, Hulkko A. Hazard factors ao recurrent stress fracture in athletes. To be J esportes Med. 2001;29(3):304-10.,3333. Manioli naquela 2nd, Graham B. Ns subtle cavus foot: the under pronator: der review. Pé Ankle Int. 2005;26(3):256-63.and3434. Pohl MB, Mullineaux DR, Milner CE, Hamill J, Davis IS. Biomechanical predictors of retrospective tibial tension fractures in runners. J Biochem. 2008;41(6):1160-5. Moreover, hyperpronation of ns forefoot predisposes toward increased risk of stress and anxiety fractures in a fibula.3535. Maitra RS, Johnson DL. Anxiety fractures. Clinical history e physical examination. Clin sports Med. 1997;16(2): 259-74. Stress and anxiety fractures in a second metatarsal have actually been correlated com presence that Morton"s neuroma, hypermobility that the primeiro metatarsal and a relative increase in the length of the second metatarsal.2020. Raasch WG, Hergan DJ. Therapy of anxiety fractures: a fundamentals. Clin esportes Med. 2006;25(1):29-36.and3333. Manioli a 2nd, Graham B. Ns subtle cavus foot: ns under pronator: der review. Pé Ankle Int. 2005;26(3):256-63.Although usar of orthoses e footwear the is more appropriate about theory decreases ns incidence of stress fractures, a number of studies in a literature remains inadequate to sustain this theory.1010. Bennell KL, Malcolm SA, thomas SA, Wark JD, Brukner PD. Ns incidence e distribution of tension fractures in competitive track e field athletes. Der twelve-month prospective study. To be J sports Med. 1996;24(2):211-7.and3434. Pohl MB, Mullineaux DR, Milner CE, Hamill J, Davis IS. Biomechanical predictors of retreat tibial anxiety fractures in runners. J Biochem. 2008;41(6):1160-5.

Other authors have also considered that the following estão risk factors: smoking, physical activity of frequency less than three times der week e consumption of an ext than 10 doses of alcohol addict drink every week.66. Carmont RC, Mei-Dan O, Bennell LK. Stress fracture management: present classification and new heal modalities. Oper Tech esportes Med. 2009;17:81-9.

physics examination

Physical examination of stress and anxiety fractures is really sensitive however unspecific.2020. Raasch WG, Hergan DJ. Treatment of stress fractures: a fundamentals. Clin esportes Med. 2006;25(1):29-36.and3636. Fredericson M, Wun C. Differential diagnosis of leg pain in ns athlete. J am Podiatr Med Assoc. 2003;93(4):321-4. Patients existing increased sensitivity, pain e edema at ns lesion location after one abrupt and/or repetitive boost in physics activity com insufficient rest intervals ao physiological organization recovery.66. Carmont RC, Mei-Dan O, Bennell LK. Stress and anxiety fracture management: current classification and new healing modalities. Oper Tech sports Med. 2009;17:81-9. Initially, ns pain is reduced and alleviated with rest and this enables unimpaired physical activity. However, if the aggressive movement is maintained, a injury will certainly progress, hence resulting in enhanced pain and limitation of practicing this movement.99. Cosman F, Ruffing J, Zion M, Uhorchak J, Ralston S, Tendy S, et al. Determinants of stress and anxiety fractures danger in united States Military academia cadets. Bone. 2013;55(2):359-66.and2020. Raasch WG, Hergan DJ. Therapy of anxiety fractures: a fundamentals. Clin esportes Med. 2006;25(1):29-36. Information concerning any ahead fractures, weight, height, corpo mass index and its alters over ns last 12 months, menstrual e puberty history and nutritional evaluations is important para identifying feasible intrinsic hazard factors para injury throughout physical examinations.1010. Bennell KL, Malcolm SA, thomas SA, Wark JD, Brukner PD. A incidence e distribution of stress and anxiety fractures in compete track e field athletes. Der twelve-month prospective study. Am J sports Med. 1996;24(2):211-7.

Clinical tests together as usar of therapeutic ultrasound and tuning forks ser estar also useful in diagnostic investigate on anxiety fractures.33. Schneiders AG, Sullivan SJ, Hendrick PA, Hones BDGM, Mcmaster AR, Sugden BA, et al. A ability of clinical tests to diagnose tension fractures: a systematic review e meta- analysis. J Orthop sports Phys Ther. 2012;42(9):760-71. When used straight on the localização of the suspected lesion, lock may create or worsen ns pain since of ns great local osteoclastic reabsorption, which results in injury to ns periosteum.33. Schneiders AG, Sullivan SJ, Hendrick PA, Hones BDGM, Mcmaster AR, Sugden BA, et al. The ability of clinical tests come diagnose anxiety fractures: naquela systematic review e meta- analysis. J Orthop sports Phys Ther. 2012;42(9):760-71.and3737. Romani WA, Perrin DH, Dussault RG, zero DW, Kahler DM. Identification of tibial anxiety fractures making use of therapeutic consistent ultrasound. J Orthop esportes Phys Ther. 2000;30(8):444-52. In addition, a skipping rope check (hop test) can be used: this consists of asking a patient to hop on a spot while putting weight on a limb the is under investigation. Ns test is positive when it triggers strong or incapacitating ache in ns region injured.66. Carmont RC, Mei-Dan O, Bennell LK. Tension fracture management: current classification e new heal modalities. Oper Tech sports Med. 2009;17:81-9.and3838. Ishibashi Y, Okamura Y, Otsuka H, Nishizawa K, Sasaki T, Toh S. To compare of scintigraphy and magnetic resonance imaging para stress injuries that bone. Clin J esportes Med. 2002;12(2):79-84.

Some activities tests might be valuable in investigating anxiety fractures: serum levels of calcium, phosphorus, creatinine e 25(OH)D3. Nutritional markers must be asked for in the presence the clinical problems of load loss e anorexia. Hormonal levels (FSH e estradiol) must be investigated once there is naquela history of dysmenorrhea.1010. Bennell KL, Malcolm SA, tábua de cortar SA, Wark JD, Brukner PD. The incidence e distribution of anxiety fractures in competitive track and field athletes. A twelve-month prospective study. Am J sports Med. 1996;24(2):211-7.

Imaging examinations

Imaging examinations ser estar fundamental ao diagnosing, prognosing and following up stress fractures.66. Carmont RC, Mei-Dan O, Bennell LK. Tension fracture management: present classification and new heal modalities. Oper Tech sports Med. 2009;17:81-9.

Simple radiography (X-ray) is a initial imaging examination since of its ease of access e low cost.44. Fayad LM, Kamel IR, Kawamoto S, Bluemke DA, Frassica FJ, Fishman EK. Separating stress fractures a partir de pathologic fractures: a multimodality approach. Skelet Radiol. 2005;34(5):245-59.,1313. Iwamoto J, Takeda T. Stress and anxiety fractures in athletes: reveja of 196 cases. J Orthop Sci. 2003;8(3):273-8.,3636. Fredericson M, Wun C. Differential diagnosis of leg pain in ns athlete. J to be Podiatr Med Assoc. 2003;93(4):321-4.,3838. Ishibashi Y, Okamura Y, Otsuka H, Nishizawa K, Sasaki T, Toh S. To compare of scintigraphy and magnetic resonance imaging ao stress injuries of bone. Clin J sport Med. 2002;12(2):79-84.,3939. Sterling JC, Edelstein DW, Calvo RD, Webb R. Tension fractures in the athlete. Diagnosis e management. Sports Med. 1992;14(5):336-46.,4040. Bennell K, Brukner P. Preventing e managing stress fractures in athletes. Phys Ther Sport. 2005;6:171-80.,4141. Fredericson M, Bergman AG, Hoffman KL, Dillingham MS. Tibial stress and anxiety reaction in runners. Correlation the clinical symptoms e scintigraphy with a new magnetic resonance imaging grading system. Am J sports Med. 1995;23(4): 472-81.and4242. Strauch WB, Slomiany WP. Evaluating shin pains in active patients. J Musculoskelet Med. 2008;25:138-48. However, that has der high false-negative rate, offered that ns alterations brought about by tension fractures apenas um appear on such examinations at a late phase (two to 4 weeks after ~ the começo of ns pain), which might delay ns diagnosis.66. Carmont RC, Mei-Dan O, Bennell LK. Tension fracture management: existing classification e new heal modalities. Oper Tech sports Med. 2009;17:81-9.,1414. Daffner RH, Pavlov H. Stress and anxiety fractures: existing concepts. To be J Roentgenol. 1992;159(2):245-52.,1818. Bolin D, Kemper A, Brolinson G. Current concepts in a evaluation e management of stress fractures. Curr Rep esporte Med. 2005;4(6):295-300.and4343. Shin AY, Morin WD, Gorman JD, Jones SB, Lapinski AS. Ns superiority of magnetic resonance imaging in differentiating ns cause that hip pain in endurance athletes. Am J sports Med. 1996;24(2):168-76. Initially, der subtle weak radiolucent area can it is in observed directly on a bone tissue influenced and/or sclerosis, periosteal thickening, cortical transforms comprising lessened cortical bone thickness (gray cortex) and/or illustration of der delicate fracture line. Finally, an effort by ns organism to form a bone callus is observed, com endosteal thickening e sclerosis, which ~ ~ the commonest findings.66. Carmont RC, Mei-Dan O, Bennell LK. Stress and anxiety fracture management: current classification and new healing modalities. Oper Tech sports Med. 2009;17:81-9.,1010. Bennell KL, Malcolm SA, thomas SA, Wark JD, Brukner PD. The incidence and distribution of stress fractures in vain track e field athletes. A twelve-month prospective study. To be J sports Med. 1996;24(2):211-7.,1414. Daffner RH, Pavlov H. Stress and anxiety fractures: present concepts. Am J Roentgenol. 1992;159(2):245-52.,3838. Ishibashi Y, Okamura Y, Otsuka H, Nishizawa K, Sasaki T, Toh S. Compare of scintigraphy e magnetic resonance imaging ao stress injuries the bone. Clin J sport Med. 2002;12(2):79-84.and4444. Dixon S, Newton J, Teh J. Stress and anxiety fractures in a young athlete: a pictorial review. Curr Probl Diagn Radiol. 2011;40(1): 29-44. Ns sign well-known as a dreaded black line occurs in the anterior cortical bone of ns tibia e suggests the presence of naquela fracture with der poor prognosis and a high probability of evolução to naquela complete fracture since of its place in der region the bone tension e poor vasclarization.4444. Dixon S, Newton J, Teh J. Stress fractures in a young athlete: a pictorial review. Curr Probl Diagn Radiol. 2011;40(1): 29-44.

Computed tomography (CT) is used mainly when there is a contraindication against using magnetic resonance imaging.4343. Shin AY, Morin WD, Gorman JD, Jones SB, Lapinski AS. Ns superiority of magnetic resonance imaging in differentiating the cause of hip ache in endurance athletes. Am J sports Med. 1996;24(2):168-76.,4444. Dixon S, Newton J, Teh J. Anxiety fractures in ns young athlete: naquela pictorial review. Curr Probl Diagn Radiol. 2011;40(1): 29-44.,4545. Zukotynski K, Curtis C, grant FD, Micheli L, Treves ST. The value that SPECT in the detection of anxiety injury to the pars interarticularis in patients com low back pain. J Orthop Surg Res. 2010;5:13.and4646. Sofka CM. Imaging of stress fractures. Clin sports Med. 2006;25(1):53-62.Chronic and quiescent lesions may be much more evident in this examination than on magnetic resonance imaging or bone scintigraphy since they current low bone turnover.4646. Sofka CM. Imaging of stress fractures. Clin esportes Med. 2006;25(1):53-62.Single photon emissions CT (SPECT) has been particularly an ext useful in investigating tension fractures involving a dorsal spine, and specifically in pars interarticularis (spondylolysis).66. Carmont RC, Mei-Dan O, Bennell LK. Anxiety fracture management: current classification and new heal modalities. Oper Tech esportes Med. 2009;17:81-9.,4545. Zukotynski K, Curtis C, conceder FD, Micheli L, Treves ST. A value the SPECT in a detection of stress and anxiety injury to ns pars interarticularis in patients com low back pain. J Orthop Surg Res. 2010;5:13.and4646. Sofka CM. Imaging of anxiety fractures. Clin esportes Med. 2006;25(1):53-62.

Nuclear medication using triple-phase scintigraphy (technetium-99 m) presents significant sensitivity (74-100%) to bone remodeling and shows imaging alterations 3 to five days after the começar of symptoms.33. Schneiders AG, Sullivan SJ, Hendrick PA, Hones BDGM, Mcmaster AR, Sugden BA, et al. Ns ability the clinical tests come diagnose tension fractures: der systematic review and meta- analysis. J Orthop sports Phys Ther. 2012;42(9):760-71.,66. Carmont RC, Mei-Dan O, Bennell LK. Stress and anxiety fracture management: existing classification e new heal modalities. Oper Tech esportes Med. 2009;17:81-9.,4141. Fredericson M, Bergman AG, Hoffman KL, Dillingham MS. Tibial anxiety reaction in runners. Correlation that clinical symptoms and scintigraphy with der new magnetic resonance imaging grading system. To be J esportes Med. 1995;23(4): 472-81.,4242. Strauch WB, Slomiany WP. Examining shin ache in active patients. J Musculoskelet Med. 2008;25:138-48.and4747. Brukner P, Bennell K. Tension fractures in woman athletes. Diagnosis, management and rehabilitation. Esportes Med. 1997;24(6):419-29. Ns radiopharmaceutical becomes focused in ns regions affected e detects areas of bone remodeling, microfractures of the trabecular bone, periosteal reaction e formation that bone callus.4646. Sofka CM. Imaging of anxiety fractures. Clin sports Med. 2006;25(1):53-62.

Magnetic resonance imaging (MRI) is the most sensitive and specific imaging examination porque o diagnosing stress and anxiety fractures. It is encourage by the american College that Radiology as the preferred check in ns absence that radiographic alterations.66. Carmont RC, Mei-Dan O, Bennell LK. Anxiety fracture management: present classification e new healing modalities. Oper Tech sports Med. 2009;17:81-9. A abnormalities brought about by ns fracture deserve to be identified 1 to two dia after the começar of ns symptoms,66. Carmont RC, Mei-Dan O, Bennell LK. Tension fracture management: existing classification and new healing modalities. Oper Tech sports Med. 2009;17:81-9.,1010. Bennell KL, Malcolm SA, thomas SA, Wark JD, Brukner PD. Ns incidence and distribution of anxiety fractures in compete track and field athletes. Der twelve-month prospective study. Am J sports Med. 1996;24(2):211-7.,1212. Snyder RA, Koester MC, Dunn WR. Epidemiology of stress and anxiety fractures. Clin sports Med. 2006;25(1):37-52.,3838. Ishibashi Y, Okamura Y, Otsuka H, Nishizawa K, Sasaki T, Toh S. Comparison of scintigraphy e magnetic resonance imaging porque o stress injuries of bone. Clin J esporte Med. 2002;12(2):79-84.,4141. Fredericson M, Bergman AG, Hoffman KL, Dillingham MS. Tibial tension reaction in runners. Correlation that clinical symptoms and scintigraphy with a new magnetic resonance imaging grading system. To be J sports Med. 1995;23(4): 472-81.,4343. Shin AY, Morin WD, Gorman JD, Jones SB, Lapinski AS. A superiority of magnetic resonance imaging in differentiating the cause the hip ache in endurance athletes. To be J esportes Med. 1996;24(2):168-76.,4646. Sofka CM. Imaging of stress fractures. Clin esportes Med. 2006;25(1):53-62.and4848. Fredericson M, jennings F, Beaulieu C, Matheson GO. Stress and anxiety fractures in athletes. Acima de Magn Reson Imaging. 2006;17(5):309-25.with at an early stage detection that edema in ns bone tissue and adjacent areas.1010. Bennell KL, Malcolm SA, tábua de cortar SA, Wark JD, Brukner PD. Ns incidence and distribution of stress and anxiety fractures in competitive track e field athletes. A twelve-month prospective study. Am J esportes Med. 1996;24(2):211-7.,4141. Fredericson M, Bergman AG, Hoffman KL, Dillingham MS. Tibial stress and anxiety reaction in runners. Correlation the clinical symptoms e scintigraphy with a new magnetic resonance imaging grading system. Am J sports Med. 1995;23(4): 472-81.and4646. Sofka CM. Imaging of anxiety fractures. Clin sports Med. 2006;25(1):53-62.This examination makes it possible to differentiate medullary damage from cortical, endosteal e periosteal dage allows gradation of ns lesions concerning their severity and prognosis.66. Carmont RC, Mei-Dan O, Bennell LK. Stress and anxiety fracture management: existing classification and new heal modalities. Oper Tech esportes Med. 2009;17:81-9. Intramedullary endosteal edema is one of the primeiro signs that bone remodeling and may proceed to be present porque o up to seis months after ns fracture has actually been diagnosed and treated, while ns cortical maturation e remodeling remover place.1616. Jones BH, Bovee MW, Harris JM, Cowan DN. Intrinsic danger factors for exercise- related injuries among male e female army trainees. To be J esportes Med. 1993;21(5):705-10.and4848. Fredericson M, jennings F, Beaulieu C, Matheson GO. Stress fractures in athletes. Top Magn Reson Imaging. 2006;17(5):309-25. Medullary edema or indications of bone stress and anxiety may additionally be existing in asymptomatic physically energetic patients, without any type of correlation with increased incidence of stress and anxiety fractures, especially in a tibia in marathon runners.4646. Sofka CM. Imaging of stress fractures. Clin esportes Med. 2006;25(1):53-62. Ns fracture line is less commonly visible.10 It presents sensitivity slightly better than or same to that of scintigraphy, however it is taken into consideration to be naquela more details examination.66. Carmont RC, Mei-Dan O, Bennell LK. Tension fracture management: present classification and new heal modalities. Oper Tech sports Med. 2009;17:81-9.,3838. Ishibashi Y, Okamura Y, Otsuka H, Nishizawa K, Sasaki T, Toh S. Comparison of scintigraphy and magnetic resonance imaging ao stress injuries of bone. Clin J esporte Med. 2002;12(2):79-84.and4141. Fredericson M, Bergman AG, Hoffman KL, Dillingham MS. Tibial anxiety reaction in runners. Correlation of clinical symptoms e scintigraphy with der new magnetic resonance imaging grading system. To be J esportes Med. 1995;23(4): 472-81.

group

Fractures can and should be classified therefore that the prognosis e treatment can be measured and thus give rise to a better result for the patient.

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Arendt e Griffiths apud Royer et al.1111. Royer M, thomas T, Cesini J, Legrand E. Stress fractures in 2011: valuable approach. Joint Bone Spine. 2012;79 Suppl. 2:S86-90. Offered imaging parameters acquired through MRI to dividir stress fractures into four stages. Ns aim the this group is to definir the size of resting equipe that is essential for a return come sport, de acordo com to ns patient"s existing stage. This stages can additionally be used porque o reevaluation throughout follow-up of the lesion.77. Patel DS, perda M, cap N. Stress fractures: diagnosis, treatment, e prevention. Am Fam Physician. 2011;83(1):39-46. Lesions treated at stage 1 require an mean of 3.3 weeks of resting, when those at stage 4 require 14.3 weeks77. Patel DS, rotão M, cap N. Stress fractures: diagnosis, treatment, e prevention. Am Fam Physician. 2011;83(1):39-46. (Table 1).