Lower extremity and pelvic stress fractures in athletes

Abstract

Stress fractures occur following excessive use and are commonly seen in athletes, in whom the lower limbs are frequently involved. Delayed diagnosis and management of these injuries can result in significant long-term damage and athlete morbidity. A high index of suspicion may facilitate diagnosis, but clinical presentation may be non-specific. In this regard, imaging in the form of plain radiograph, CT, MRI and bone scintigraphy may be of value. This article reviews the incidence, presentation, radiological findings and management options for athletes with stress fractures of the lower limb.

Figures

Figure 1

Incomplete chronic fatigue fracture (white arrow) of the anterior tibia in a male with pyknodysostosis.

Figure 2

Fatigue pre-fracture in a middle-aged female with breast cancer on bisphosphonate therapy. Plain radiograph (a) demonstrates focal cortical thickening on the lateral mid-shaft (white arrow). MRI axial short tau inversion–recovery image (b) shows endosteal and periosteal high signal around the focal cortical thickening.

Figure 3

Second metatarsal stress fracture. Initial plain radiograph (a) showed normal appearances apart from an incidental sessile exostosis on the first metatarsal shaft. Sagittal short tau inversion–recovery MR image (b) obtained the following day depicted marrow and periosseous soft-tissue oedema around the second metatarsal with a subtle cortical break superiorly (white arrow). Plain radiograph after 2 months (c) revealed a minimally displaced healing fracture.

Figure 4

Jones’ fracture of the fifth metatarsal. Plain radiograph depicting a narrow fracture line distal to the tubercle without adjacent sclerosis.

Figure 5

Calcaneal stress fracture. Plain radiograph (a) depicts a sclerotic line traversing the posterosuperior calcaneum (black arrow), paralleling the posterior cortex. Sagittal short tau inversion–recovery magnetic resonance image (b) of the same patient demonstrates a hypointense sclerotic line (white arrow), surrounded by hyperintense marrow oedema.

Figure 6

Bilateral navicular stress fractures seen on CT (a, white arrows). In the acute phase, marrow oedema is evident on MRI (b). Courtesy of Dr J Healy, Chelsea and Westminster Hospital, London, UK.

Figure 7

Posterior tibial stress fracture. Plain radiographs (a) were reported as normal. Sagittal magnetic resonance image (b) depicts a transverse hypointense line of the posterior tibia with adjacent marrow oedema.

Figure 8

Distal fibular stress fracture in a runner. Initial plain radiographs (a) depict subtle sclerosis and cortical break (white arrows) of the distal fibula. Subsequent plain radiograph obtained weeks later (b) depicts callus at the fracture site.

Figure 9

Compression side femoral stress fracture in a long-distance runner. Subtle periosteal reaction and fracture line of the inferomedial femoral neck are evident on plain radiograph (a). Coronal T1 weighted MRI (b) confirms the finding of a fracture line and adjacent marrow oedema. Courtesy of Dr C Oh, Royal Preston Hospital, Preston, UK.

Figure 10

L5 pars interarticularis defect (spondylolysis) seen on sagittal T2 weighted image in an adolescent. Courtesy of Dr C Soh, Salford Royal Hospital, Salford, UK.

Figure 11

Avulsion fracture of the anterior inferior iliac spine (AIIS) in an adolescent athlete. Plain radiograph (a) demonstrates subtle avulsion fracture of the AIIS. Coronal and sagittal short tau inversion–recovery images (b) depict marrow oedema of the AIIS. Courtesy of Dr R Mehan, Royal Bolton Hospital, Bolton, UK.