Femoral stress fracture: Difference between revisions

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'''Original Editors ''' - [[User:Matthias Verstraelen|Matthias Verstraelen]] as part of the [[Vrije Universiteit Brussel Evidence-based Practice Project|Vrije Universiteit Brussel's Evidence-based Practice project]]
<p><b>Original Editors </b> - <a href="User:Matthias Verstraelen">Matthias Verstraelen</a> as part of the <a href="Vrije Universiteit Brussel Evidence-based Practice Project">Vrije Universiteit Brussel's Evidence-based Practice project</a>
 
</p><p><b>Top Contributors</b> - <span class="fck_mw_template">{{Special:Contributors/{{FULLPAGENAME}}}}</span> &nbsp;  
'''Top Contributors''' - {{Special:Contributors/{{FULLPAGENAME}}}} &nbsp;  
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== Definition/Description  ==
<h2> Definition/Description  </h2>
 
<p><b>Stress fractures</b> are injuries who occur when repetitive and excessive stress on the <a href="Bone">bone</a> is combined with limited rest. This leads to muscle weakness and a lower shock absorbing capacity of the leg<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Stress">Stress Fractures, information from your family doctor. Americain Family Physician Jan. 2011. Level of evidence: 5</span><span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Zadpoor">Zadpoor A, Nikooyan A. The relationship between lower-extremity stress fractures and the ground reaction force: a systematic review. Clinical Biomechanics 2011; 26: 23 -28. Level of evidence: 1B</span><span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Niva">Niva M, Mattila V, Kiuru M, Pihlajamäki H. Bone stress Injuries are common in female military trainees. Clin Orthop Relat Res (2009) 467: 2962-2969. Level of evidence: 3A</span><span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Schultz">Schultz, Houglum, Perrin. Third edition, examination of musculoskeletal injuries p.401. Human Kinetics. Level of evidence: 5</span><span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Houglum">Houglum P. Second edition, therapeutic exercise for musculoskeletal injuries p.80-81, p. 811-812. Human Kinetics. Level of evidence: 5</span>. At the begin there is only pain during activity, in the next phase the pain is shown after activity and during the night. There is a grading system of 5 grades based on MRI results but this system is not yet validated. Grades I to III are the low grades<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Niva" />. It begins with endosteal edema followed by periosteal edema to muscle edema. When the injury is at level IV there is a fracture line seen on the image. A grade V refers to callus formation in the cortical bone <span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Niva" /><span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Fredericson">Fredericson M, Jang K, Bergman G, Gold G. Femoral diaphyseal stress fractures: results of a systematic bone scan and magnetic resonance evaluation in 25 runners. Physical Therapy in Sport 5 (2004): 188-193. Level of evidence: 2B</span>.  
'''Stress fractures''' are injuries who occur when repetitive and excessive stress on the [[Bone|bone]] is combined with limited rest. This leads to muscle weakness and a lower shock absorbing capacity of the leg<ref name="Stress">Stress Fractures, information from your family doctor. Americain Family Physician Jan. 2011. Level of evidence: 5</ref><ref name="Zadpoor">Zadpoor A, Nikooyan A. The relationship between lower-extremity stress fractures and the ground reaction force: a systematic review. Clinical Biomechanics 2011; 26: 23 -28. Level of evidence: 1B</ref><ref name="Niva">Niva M, Mattila V, Kiuru M, Pihlajamäki H. Bone stress Injuries are common in female military trainees. Clin Orthop Relat Res (2009) 467: 2962-2969. Level of evidence: 3A</ref><ref name="Schultz">Schultz, Houglum, Perrin. Third edition, examination of musculoskeletal injuries p.401. Human Kinetics. Level of evidence: 5</ref><ref name="Houglum">Houglum P. Second edition, therapeutic exercise for musculoskeletal injuries p.80-81, p. 811-812. Human Kinetics. Level of evidence: 5</ref>. At the begin there is only pain during activity, in the next phase the pain is shown after activity and during the night. There is a grading system of 5 grades based on MRI results but this system is not yet validated. Grades I to III are the low grades<ref name="Niva" />. It begins with endosteal edema followed by periosteal edema to muscle edema. When the injury is at level IV there is a fracture line seen on the image. A grade V refers to callus formation in the cortical bone <ref name="Niva" /><ref name="Fredericson">Fredericson M, Jang K, Bergman G, Gold G. Femoral diaphyseal stress fractures: results of a systematic bone scan and magnetic resonance evaluation in 25 runners. Physical Therapy in Sport 5 (2004): 188-193. Level of evidence: 2B</ref>.  
</p>
 
<h2> Clinically Relevant Anatomy  </h2>
== Clinically Relevant Anatomy  ==
<p>Stress fractures of the femur can occur in the whole bone like the neck, shaft and the condyles. The highest incidence is seen at the femoral neck. When the patient doesn’t adapt his training, certain stress fractures could lead to complications even to complete <a href="Femoral Fractures">femoral fractures</a> of the head or shaft <span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref">Patel D, Roth M, Kapil N. Stress fractures: diagnosis, treatment and prevention. American Family fckLRPhysician Jan. 2011; 83: 39-46. Level of evidence: 1A</span><span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref">Zadpoor A, Nikooyan A. The relationship between lower-extremity stress fractures and the ground reaction force: a systematic review. Clinical Biomechanics 2011; 26: 23 -28. Level of evidence: 1B</span>.  
 
</p>
Stress fractures of the femur can occur in the whole bone like the neck, shaft and the condyles. The highest incidence is seen at the femoral neck. When the patient doesn’t adapt his training, certain stress fractures could lead to complications even to complete [[Femoral_Fractures|femoral fractures]] of the head or shaft <ref>Patel D, Roth M, Kapil N. Stress fractures: diagnosis, treatment and prevention. American Family fckLRPhysician Jan. 2011; 83: 39-46. Level of evidence: 1A</ref><ref>Zadpoor A, Nikooyan A. The relationship between lower-extremity stress fractures and the ground reaction force: a systematic review. Clinical Biomechanics 2011; 26: 23 -28. Level of evidence: 1B</ref>.  
<h2> Epidemiology /Etiology  </h2>
 
<p>Stress fractures are presented in athletes with the main focus on running or in military trainees<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Niva" />. The femoral ones are at a level 6% to 7% of all the stress injuries. Femoral stress fractures are seen in overtrainers but also in undertrainers <span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Kang">Kang L, Belcher D, Hulstyn M. Stress fractures of the femoral shaft in women’s college lacrosse: a report of seven cases and a review of the literature. Br J Sports Med 2005; 39: 902-906. Level of evidence: 2B</span>. With the decreased physical level of the population, it is possible that the incidence of femoral stress fractures will increase in the future <span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Fredericson" />.  
== Epidemiology /Etiology  ==
</p>
 
<h2> Characteristics/Clinical Presentation  </h2>
Stress fractures are presented in athletes with the main focus on running or in military trainees<ref name="Niva" />. The femoral ones are at a level 6% to 7% of all the stress injuries. Femoral stress fractures are seen in overtrainers but also in undertrainers <ref name="Kang">Kang L, Belcher D, Hulstyn M. Stress fractures of the femoral shaft in women’s college lacrosse: a report of seven cases and a review of the literature. Br J Sports Med 2005; 39: 902-906. Level of evidence: 2B</ref>. With the decreased physical level of the population, it is possible that the incidence of femoral stress fractures will increase in the future <ref name="Fredericson" />.  
<p>The risk factors are presented in liste: <span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Patel">Patel D, Roth M, Kapil N. Stress fractures: diagnosis, treatment and prevention. American Family fckLRPhysician Jan. 2011; 83: 39-46. Level of evidence: 1A</span><span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Stress" /><span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Zadpoor" /><span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Anand">Anand A, Raviraj A, Kodikal G. Subchondral stress fractures of femoral head in healthy adult. Indian J Orthop. 2010 Oct-Dec; 44(4): 458-460. Level of evidence: 3B</span>  
 
</p>
== Characteristics/Clinical Presentation  ==
<ul><li>High-intensity training  
 
</li><li>Recreational runners  
The risk factors are presented in liste: <ref name="Patel">Patel D, Roth M, Kapil N. Stress fractures: diagnosis, treatment and prevention. American Family fckLRPhysician Jan. 2011; 83: 39-46. Level of evidence: 1A</ref><ref name="Stress" /><ref name="Zadpoor" /><ref name="Anand">Anand A, Raviraj A, Kodikal G. Subchondral stress fractures of femoral head in healthy adult. Indian J Orthop. 2010 Oct-Dec; 44(4): 458-460. Level of evidence: 3B</ref>  
</li><li>Track and field, basketball, soccer, dance  
 
</li><li>Women  
*High-intensity training  
</li><li>Poor nutrition and lifestyle activities  
*Recreational runners  
</li><li>Lower 25-hydroxyvitamin D  
*Track and field, basketball, soccer, dance  
</li><li>Female athlete triad  
*Women  
</li><li>(history of) smoking  
*Poor nutrition and lifestyle activities  
</li><li>&lt; 3 times exercising/week  
*Lower 25-hydroxyvitamin D  
</li><li>&gt; 10 alcoholic drinks/week  
*Female athlete triad  
</li><li>Genetic factors&nbsp;<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Korvola">Korvala J, Hartikka H, Pihlajamäki H, Solovieva S, Ruohola J-P, Sahi T, Barral S, Ott J, Ala-Kokko L, Männikkö M. Genetic predisposition for femoral neck stress fractures in military conscripts. BMC Genetics 2010, 11: 95. Level of evidence: 2B</span>&nbsp;(CTR C allele, VDR C-A haplotype, LRP5 A-G-G-C, VDR C-A haplotype)  
*(history of) smoking  
</li><li>Change of surfaces (indoor track, frozen field)  
*&lt; 3 times exercising/week  
</li><li>Biomechanical imbalance (leg length, foot arch, forefoot varus, stance of foot and ankle)
*&gt; 10 alcoholic drinks/week  
</li></ul>
*Genetic factors&nbsp;<ref name="Korvola">Korvala J, Hartikka H, Pihlajamäki H, Solovieva S, Ruohola J-P, Sahi T, Barral S, Ott J, Ala-Kokko L, Männikkö M. Genetic predisposition for femoral neck stress fractures in military conscripts. BMC Genetics 2010, 11: 95. Level of evidence: 2B</ref>&nbsp;(CTR C allele, VDR C-A haplotype, LRP5 A-G-G-C, VDR C-A haplotype)  
<p><br />There is a trend to significance for energy expenditure (kcal/day) with lower limb stress fractures (p=0.06). This effect could be explained as a sequence that more active people have also a higher expenditure level <span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Cline">Cline A, Jansen R, Melby C. Stress fractures in female army recruits: implications of bone density, calcium intake and exercise. Journal of the American College of Nutrition, Vol. 17; No. 2: 128-135 (1998). Level of evidence: 3A</span>.<br />No significant effect is found of the ground reaction force on the incidence of lower-limb stress fractures (p&gt;0.05) <span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Zadpoor" />.<br />The incidence of femoral stress fractures is reduced with 14% (p=0.013) when a semi rigid insole is used <span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Snyder">Snyder R, De Angelis J, Koester M., Spindler K, Dunn W. Does shoe insole modification prevent stress fractures? A systematic review. HSSJ (2009) 5: 92-98. Level of evidence: 2B</span>.<br />Alana et al. concluded that there’s no effect on lower limb stress fractures and calcium intake (p=0.55) or bone density <span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Cline" />.<br />There is a trend to significance for energy expenditure (kcal/day) with lower limb stress fractures (p=0.06). This effect could be explained as a sequence that more active people have also a higher expenditure level <span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Cline" />.<br />  
*Change of surfaces (indoor track, frozen field)  
</p>
*Biomechanical imbalance (leg length, foot arch, forefoot varus, stance of foot and ankle)
<h2> Diagnostic Procedures  </h2>
 
<p>First of all we describe the possible symptoms: <span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Anand" /><span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Niva" /><span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Ivkovic">Ivkovic A, Bojanic I, Pecina M. Stress fractures of the femoral shaft in athletes: a new treatment algorithm. Br J Sports Med 2006; 40: 518-520. Level of evidence: 2A</span><span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Schultz" />  
<br>There is a trend to significance for energy expenditure (kcal/day) with lower limb stress fractures (p=0.06). This effect could be explained as a sequence that more active people have also a higher expenditure level <ref name="Cline">Cline A, Jansen R, Melby C. Stress fractures in female army recruits: implications of bone density, calcium intake and exercise. Journal of the American College of Nutrition, Vol. 17; No. 2: 128-135 (1998). Level of evidence: 3A</ref>.<br>No significant effect is found of the ground reaction force on the incidence of lower-limb stress fractures (p&gt;0.05) <ref name="Zadpoor" />.<br>The incidence of femoral stress fractures is reduced with 14% (p=0.013) when a semi rigid insole is used <ref name="Snyder">Snyder R, De Angelis J, Koester M., Spindler K, Dunn W. Does shoe insole modification prevent stress fractures? A systematic review. HSSJ (2009) 5: 92-98. Level of evidence: 2B</ref>.<br>Alana et al. concluded that there’s no effect on lower limb stress fractures and calcium intake (p=0.55) or bone density <ref name="Cline" />.<br>There is a trend to significance for energy expenditure (kcal/day) with lower limb stress fractures (p=0.06). This effect could be explained as a sequence that more active people have also a higher expenditure level <ref name="Cline" />.<br>  
</p>
 
<ul><li>Locale pain and edema  
== Diagnostic Procedures  ==
</li><li>Point tenderness on <a href="Palpation techniques">palpation</a>
 
</li><li>Local swelling  
First of all we describe the possible symptoms: <ref name="Anand" /><ref name="Niva" /><ref name="Ivkovic">Ivkovic A, Bojanic I, Pecina M. Stress fractures of the femoral shaft in athletes: a new treatment algorithm. Br J Sports Med 2006; 40: 518-520. Level of evidence: 2A</ref><ref name="Schultz" />  
</li><li>Antalgic gait  
 
</li><li>Painful and limited passive and active ROM of hip and/or knee (flexion, internal rotation, extension)  
*Locale pain and edema  
</li><li>Pain increases during activity  
*Point tenderness on [[Palpation_techniques|palpation]]
</li><li>Groin pain  
*Local swelling  
</li><li>Bone marrow edema
*Antalgic gait  
</li></ul>
*Painful and limited passive and active ROM of hip and/or knee (flexion, internal rotation, extension)  
<p>Therapists have to pay attention to misdiagnose a femoral stress fracture as <a href="Muscle Strain">muscle strainof</a> the quadriceps or illiopsoas tendinopathy because of the similar symptoms <span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Nguyen">Nguyen J, Peterson J, Biswal S, Beaulieu C, Fredericson M. Stress-related injuries around the lesser trochanter in long-distance runners. AJR 2008; 190: 1616-1620. Level of evidence: 3B</span>.<br />To present femoral stress fractures on images. We can use 4 modalities: plain radiography, bone scintigrapy, MRI and ultrasonography with the highest sensitivity and specificity for MRI <span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Patel" />. These techniques can be used in different phases of diagnosis and treatment <span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Patel" /><span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Korvala" />.<br />  
*Pain increases during activity  
</p>
*Groin pain  
<h2> Examination<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref">Casterline M, Osowski S, Ulrich G. Femoral stress fracture. Journal of Athletic Training March 1996; 31: 53-56. Level of evidence: 4</span>  </h2>
*Bone marrow edema
<p><span class="fck_mw_template">{{#ev:youtube|8Dw3fNd5Szc|300}}</span> <span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref">BJSM Videos. Stress fracture (fulcrum) test, with Mike Reiman. Available from: http://www.youtube.com/watch?v=8Dw3fNd5Szc [last accessed 25/01/14]</span>  
 
</p><p><br /> The hop test and tuning fork test could be used as diagnostic test but there is a lack of recent evidence for their validity. Another test is the “fist” test, the therapist create a bilateral pressure on the anterior side of the femur starting at the distal part and moving to the proximal one. The most valid test for the diagnosis is the <a href="Fulcrum Test">fulcrum-test</a>, while the therapist pushes to the dorsum of the knee&nbsp;<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Ivkovic" />.<br />  
Therapists have to pay attention to misdiagnose a femoral stress fracture as [[Muscle_Strain|muscle strain]]of the quadriceps or illiopsoas tendinopathy because of the similar symptoms <ref name="Nguyen">Nguyen J, Peterson J, Biswal S, Beaulieu C, Fredericson M. Stress-related injuries around the lesser trochanter in long-distance runners. AJR 2008; 190: 1616-1620. Level of evidence: 3B</ref>.<br>To present femoral stress fractures on images. We can use 4 modalities: plain radiography, bone scintigrapy, MRI and ultrasonography with the highest sensitivity and specificity for MRI <ref name="Patel" />. These techniques can be used in different phases of diagnosis and treatment <ref name="Patel" /><ref name="Korvala" />.<br>  
</p>
 
<h2> Physical Therapy Management <br />  </h2>
== Examination<ref>Casterline M, Osowski S, Ulrich G. Femoral stress fracture. Journal of Athletic Training March 1996; 31: 53-56. Level of evidence: 4</ref>  ==
<p>Initial treatment is based on the reduction of activities to a pain-free level. During this “relative rest”-period of 4 to 12 weeks, the patient can use pneumatic compression walking boots to reduce his pain level. Also physical therapy and cross-training which contains of flexibility, strength and cardiovascular training is permitted for example swimming and biking. After that restriction period the activities can be increased in a slow, graduated way <span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Snyder" />. Ivkovic et al. designed a new treatment algorithm for femoral shaft stress injuries. Four phases has to be fulfilled to start normal training and each phase is evaluated by a hop or fulcrum test. The first phase is called symptomatic, where the patient has to walk with crutches. The second phase is the asymptomatic one where patient are allowed to walk normally and to start swimming and exercises the upper extremity. During the third ‘basic’ phase the patient can perform exercises of lower and upper extremities. During the last ‘resuming phase’, the athlete is allowed to gradually start normal training <span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Ivkovic" />. No recurrence of injury after treatment and follow-up for 48-96 months <span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Ivkovic" />.<br />The treatment algorithm is free available in the article from Ivkovic et al.: "Stress fractures of the femoral shaft in athletes: a new treatment algorithm."<br /><br />To prevent femoral stress fractures, people could modify their training schedules and wear shock-absorbing shoe inserts. Insoles lowers the incidence because the improves biomechanics, less fatigue and limit the impact on the ground. The size of these insoles can range in different types to support the forefoot and/or the toes <span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Zadpoor" /><span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Snyder" />. Also calcium and vitamin D supplementation could play a role in the prevention but their data are controversial <span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Snyder" />. Leg muscle stretching during warm-up has no significant effect on prevention for femoral stress fractures<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Patel" />.<br />  
 
</p>
{{#ev:youtube|8Dw3fNd5Szc|300}} <ref>BJSM Videos. Stress fracture (fulcrum) test, with Mike Reiman. Available from: http://www.youtube.com/watch?v=8Dw3fNd5Szc [last accessed 25/01/14]</ref>  
<h2> Resources <br />  </h2>
 
<p>- Pubmed, Web of Knowledge, Pedro<br />- Third edition, Examination of musculoskeletal injuries<br />- Second edition, Therapeutic exercise for musculoskeletal injuries<br />  
<br> The hop test and tuning fork test could be used as diagnostic test but there is a lack of recent evidence for their validity. Another test is the “fist” test, the therapist create a bilateral pressure on the anterior side of the femur starting at the distal part and moving to the proximal one. The most valid test for the diagnosis is the [[Fulcrum_Test|fulcrum-test]], while the therapist pushes to the dorsum of the knee&nbsp;<ref name="Ivkovic" />.<br>  
</p>
 
<h2> Recent Related Research (from <a href="http://www.ncbi.nlm.nih.gov/pubmed/">Pubmed</a>)  </h2>
== Physical Therapy Management <br>  ==
<div class="researchbox"><span class="fck_mw_special" _fck_mw_customtag="true" _fck_mw_tagname="rss">https://www.ncbi.nlm.nih.gov/entrez/eutils/erss.cgi?rss_guid=1z7zlNEMzQey5ho5ycqHgyGE-zzZ0V9IYjL5nVIB9cE6ZW-kIK|charset=UTF-8|short|max=10</span></div>  
 
<h2> References  </h2>
Initial treatment is based on the reduction of activities to a pain-free level. During this “relative rest”-period of 4 to 12 weeks, the patient can use pneumatic compression walking boots to reduce his pain level. Also physical therapy and cross-training which contains of flexibility, strength and cardiovascular training is permitted for example swimming and biking. After that restriction period the activities can be increased in a slow, graduated way <ref name="Snyder" />. Ivkovic et al. designed a new treatment algorithm for femoral shaft stress injuries. Four phases has to be fulfilled to start normal training and each phase is evaluated by a hop or fulcrum test. The first phase is called symptomatic, where the patient has to walk with crutches. The second phase is the asymptomatic one where patient are allowed to walk normally and to start swimming and exercises the upper extremity. During the third ‘basic’ phase the patient can perform exercises of lower and upper extremities. During the last ‘resuming phase’, the athlete is allowed to gradually start normal training <ref name="Ivkovic" />. No recurrence of injury after treatment and follow-up for 48-96 months <ref name="Ivkovic" />.<br>The treatment algorithm is free available in the article from Ivkovic et al.: "Stress fractures of the femoral shaft in athletes: a new treatment algorithm."<br><br>To prevent femoral stress fractures, people could modify their training schedules and wear shock-absorbing shoe inserts. Insoles lowers the incidence because the improves biomechanics, less fatigue and limit the impact on the ground. The size of these insoles can range in different types to support the forefoot and/or the toes <ref name="Zadpoor" /><ref name="Snyder" />. Also calcium and vitamin D supplementation could play a role in the prevention but their data are controversial <ref name="Snyder" />. Leg muscle stretching during warm-up has no significant effect on prevention for femoral stress fractures<ref name="Patel" />.<br>  
<p><span class="fck_mw_references" _fck_mw_customtag="true" _fck_mw_tagname="references" />
 
</p><p><u>1.</u> Patel D, Roth M, Kapil N. Stress fractures: diagnosis, treatment and prevention. American Family <br />Physician Jan. 2011; 83: 39-46. Level of evidence: 1A<br /><u>2.</u> Stress Fractures, information from your family doctor. Americain Family Physician Jan. 2011. Level of evidence: 5<br /><u>3.</u> Zadpoor A, Nikooyan A. The relationship between lower-extremity stress fractures and the ground reaction force: a systematic review. Clinical Biomechanics 2011; 26: 23 -28. Level of evidence: 1B<br /><u>4.</u> Korvala J, Hartikka H, Pihlajamäki H, Solovieva S, Ruohola J-P, Sahi T, Barral S, Ott J, Ala-Kokko L, Männikkö M. Genetic predisposition for femoral neck stress fractures in military conscripts. BMC Genetics 2010, 11: 95. Level of evidence: 2B<br /><u>5.</u> Anand A, Raviraj A, Kodikal G. Subchondral stress fractures of femoral head in healthy adult. Indian J Orthop. 2010 Oct-Dec; 44(4): 458-460. Level of evidence: 3B<br /><u>6.</u> Snyder R, De Angelis J, Koester M., Spindler K, Dunn W. Does shoe insole modification prevent stress fractures? A systematic review. HSSJ (2009) 5: 92-98. Level of evidence: 2B<br /><u>7.</u> Niva M, Mattila V, Kiuru M, Pihlajamäki H. Bone stress Injuries are common in female military trainees. Clin Orthop Relat Res (2009) 467: 2962-2969. Level of evidence: 3A<br /><u>8.</u> Nguyen J, Peterson J, Biswal S, Beaulieu C, Fredericson M. Stress-related injuries around the lesser trochanter in long-distance runners. AJR 2008; 190: 1616-1620. Level of evidence: 3B<br /><u>9.</u> Ivkovic A, Bojanic I, Pecina M. Stress fractures of the femoral shaft in athletes: a new treatment algorithm. Br J Sports Med 2006; 40: 518-520. Level of evidence: 2A<br /><u>10.</u> Cline A, Jansen R, Melby C. Stress fractures in female army recruits: implications of bone density, calcium intake and exercise. Journal of the American College of Nutrition, Vol. 17; No. 2: 128-135 (1998). Level of evidence: 3A<br /><u>11.</u> Casterline M, Osowski S, Ulrich G. Femoral stress fracture. Journal of Athletic Training March 1996; 31: 53-56. Level of evidence: 4<br /><u>12.</u> Fredericson M, Jang K, Bergman G, Gold G. Femoral diaphyseal stress fractures: results of a systematic bone scan and magnetic resonance evaluation in 25 runners. Physical Therapy in Sport 5 (2004): 188-193. Level of evidence: 2B<br /><u>13.</u> Lynch S, Renström P. Groin injuries in sport- treatment strategies. Sports Med 1999 Aug; 28 (2): 137-144. Level of evidence: 4<br /><u>14.</u> Kang L, Belcher D, Hulstyn M. Stress fractures of the femoral shaft in women’s college lacrosse: a report of seven cases and a review of the literature. Br J Sports Med 2005; 39: 902-906. Level of evidence: 2B<br /><u>15.</u> Schultz, Houglum, Perrin. Third edition, examination of musculoskeletal injuries p.401. Human Kinetics. Level of evidence: 5<br /><u>16.</u> Houglum P. Second edition, therapeutic exercise for musculoskeletal injuries p.80-81, p. 811-812. Human Kinetics. Level of evidence: 5<br />
== Resources <br>  ==
</p><a _fcknotitle="true" href="Category:Condition">Condition</a> <a _fcknotitle="true" href="Category:Hip">Hip</a> <a _fcknotitle="true" href="Category:Knee">Knee</a> <a href="Category:Musculoskeletal/Orthopaedics">Orthopaedics</a> <a _fcknotitle="true" href="Category:Sports_Injuries">Sports_Injuries</a>
 
- Pubmed, Web of Knowledge, Pedro<br>- Third edition, Examination of musculoskeletal injuries<br>- Second edition, Therapeutic exercise for musculoskeletal injuries<br>  
 
== Recent Related Research (from [http://www.ncbi.nlm.nih.gov/pubmed/ Pubmed])  ==
<div class="researchbox"><rss>https://www.ncbi.nlm.nih.gov/entrez/eutils/erss.cgi?rss_guid=1z7zlNEMzQey5ho5ycqHgyGE-zzZ0V9IYjL5nVIB9cE6ZW-kIK|charset=UTF-8|short|max=10</rss></div>  
== References  ==
 
<u>1.</u> Patel D, Roth M, Kapil N. Stress fractures: diagnosis, treatment and prevention. American Family <br>Physician Jan. 2011; 83: 39-46. Level of evidence: 1A<br><u>2.</u> Stress Fractures, information from your family doctor. Americain Family Physician Jan. 2011. Level of evidence: 5<br><u>3.</u> Zadpoor A, Nikooyan A. The relationship between lower-extremity stress fractures and the ground reaction force: a systematic review. Clinical Biomechanics 2011; 26: 23 -28. Level of evidence: 1B<br><u>4.</u> Korvala J, Hartikka H, Pihlajamäki H, Solovieva S, Ruohola J-P, Sahi T, Barral S, Ott J, Ala-Kokko L, Männikkö M. Genetic predisposition for femoral neck stress fractures in military conscripts. BMC Genetics 2010, 11: 95. Level of evidence: 2B<br><u>5.</u> Anand A, Raviraj A, Kodikal G. Subchondral stress fractures of femoral head in healthy adult. Indian J Orthop. 2010 Oct-Dec; 44(4): 458-460. Level of evidence: 3B<br><u>6.</u> Snyder R, De Angelis J, Koester M., Spindler K, Dunn W. Does shoe insole modification prevent stress fractures? A systematic review. HSSJ (2009) 5: 92-98. Level of evidence: 2B<br><u>7.</u> Niva M, Mattila V, Kiuru M, Pihlajamäki H. Bone stress Injuries are common in female military trainees. Clin Orthop Relat Res (2009) 467: 2962-2969. Level of evidence: 3A<br><u>8.</u> Nguyen J, Peterson J, Biswal S, Beaulieu C, Fredericson M. Stress-related injuries around the lesser trochanter in long-distance runners. AJR 2008; 190: 1616-1620. Level of evidence: 3B<br><u>9.</u> Ivkovic A, Bojanic I, Pecina M. Stress fractures of the femoral shaft in athletes: a new treatment algorithm. Br J Sports Med 2006; 40: 518-520. Level of evidence: 2A<br><u>10.</u> Cline A, Jansen R, Melby C. Stress fractures in female army recruits: implications of bone density, calcium intake and exercise. Journal of the American College of Nutrition, Vol. 17; No. 2: 128-135 (1998). Level of evidence: 3A<br><u>11.</u> Casterline M, Osowski S, Ulrich G. Femoral stress fracture. Journal of Athletic Training March 1996; 31: 53-56. Level of evidence: 4<br><u>12.</u> Fredericson M, Jang K, Bergman G, Gold G. Femoral diaphyseal stress fractures: results of a systematic bone scan and magnetic resonance evaluation in 25 runners. Physical Therapy in Sport 5 (2004): 188-193. Level of evidence: 2B<br><u>13.</u> Lynch S, Renström P. Groin injuries in sport- treatment strategies. Sports Med 1999 Aug; 28 (2): 137-144. Level of evidence: 4<br><u>14.</u> Kang L, Belcher D, Hulstyn M. Stress fractures of the femoral shaft in women’s college lacrosse: a report of seven cases and a review of the literature. Br J Sports Med 2005; 39: 902-906. Level of evidence: 2B<br><u>15.</u> Schultz, Houglum, Perrin. Third edition, examination of musculoskeletal injuries p.401. Human Kinetics. Level of evidence: 5<br><u>16.</u> Houglum P. Second edition, therapeutic exercise for musculoskeletal injuries p.80-81, p. 811-812. Human Kinetics. Level of evidence: 5<br>  
 
[[Category:Condition]] [[Category:Hip]] [[Category:Knee]] [[Category:Musculoskeletal/Orthopaedics|Orthopaedics]] [[Category:Sports_Injuries]]

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Definition/Description

Stress fractures are injuries who occur when repetitive and excessive stress on the <a href="Bone">bone</a> is combined with limited rest. This leads to muscle weakness and a lower shock absorbing capacity of the legStress Fractures, information from your family doctor. Americain Family Physician Jan. 2011. Level of evidence: 5Zadpoor A, Nikooyan A. The relationship between lower-extremity stress fractures and the ground reaction force: a systematic review. Clinical Biomechanics 2011; 26: 23 -28. Level of evidence: 1BNiva M, Mattila V, Kiuru M, Pihlajamäki H. Bone stress Injuries are common in female military trainees. Clin Orthop Relat Res (2009) 467: 2962-2969. Level of evidence: 3ASchultz, Houglum, Perrin. Third edition, examination of musculoskeletal injuries p.401. Human Kinetics. Level of evidence: 5Houglum P. Second edition, therapeutic exercise for musculoskeletal injuries p.80-81, p. 811-812. Human Kinetics. Level of evidence: 5. At the begin there is only pain during activity, in the next phase the pain is shown after activity and during the night. There is a grading system of 5 grades based on MRI results but this system is not yet validated. Grades I to III are the low grades. It begins with endosteal edema followed by periosteal edema to muscle edema. When the injury is at level IV there is a fracture line seen on the image. A grade V refers to callus formation in the cortical bone Fredericson M, Jang K, Bergman G, Gold G. Femoral diaphyseal stress fractures: results of a systematic bone scan and magnetic resonance evaluation in 25 runners. Physical Therapy in Sport 5 (2004): 188-193. Level of evidence: 2B.

Clinically Relevant Anatomy

Stress fractures of the femur can occur in the whole bone like the neck, shaft and the condyles. The highest incidence is seen at the femoral neck. When the patient doesn’t adapt his training, certain stress fractures could lead to complications even to complete <a href="Femoral Fractures">femoral fractures</a> of the head or shaft Patel D, Roth M, Kapil N. Stress fractures: diagnosis, treatment and prevention. American Family fckLRPhysician Jan. 2011; 83: 39-46. Level of evidence: 1AZadpoor A, Nikooyan A. The relationship between lower-extremity stress fractures and the ground reaction force: a systematic review. Clinical Biomechanics 2011; 26: 23 -28. Level of evidence: 1B.

Epidemiology /Etiology

Stress fractures are presented in athletes with the main focus on running or in military trainees. The femoral ones are at a level 6% to 7% of all the stress injuries. Femoral stress fractures are seen in overtrainers but also in undertrainers Kang L, Belcher D, Hulstyn M. Stress fractures of the femoral shaft in women’s college lacrosse: a report of seven cases and a review of the literature. Br J Sports Med 2005; 39: 902-906. Level of evidence: 2B. With the decreased physical level of the population, it is possible that the incidence of femoral stress fractures will increase in the future .

Characteristics/Clinical Presentation

The risk factors are presented in liste: Patel D, Roth M, Kapil N. Stress fractures: diagnosis, treatment and prevention. American Family fckLRPhysician Jan. 2011; 83: 39-46. Level of evidence: 1AAnand A, Raviraj A, Kodikal G. Subchondral stress fractures of femoral head in healthy adult. Indian J Orthop. 2010 Oct-Dec; 44(4): 458-460. Level of evidence: 3B

  • High-intensity training
  • Recreational runners
  • Track and field, basketball, soccer, dance
  • Women
  • Poor nutrition and lifestyle activities
  • Lower 25-hydroxyvitamin D
  • Female athlete triad
  • (history of) smoking
  • < 3 times exercising/week
  • > 10 alcoholic drinks/week
  • Genetic factors Korvala J, Hartikka H, Pihlajamäki H, Solovieva S, Ruohola J-P, Sahi T, Barral S, Ott J, Ala-Kokko L, Männikkö M. Genetic predisposition for femoral neck stress fractures in military conscripts. BMC Genetics 2010, 11: 95. Level of evidence: 2B (CTR C allele, VDR C-A haplotype, LRP5 A-G-G-C, VDR C-A haplotype)
  • Change of surfaces (indoor track, frozen field)
  • Biomechanical imbalance (leg length, foot arch, forefoot varus, stance of foot and ankle)


There is a trend to significance for energy expenditure (kcal/day) with lower limb stress fractures (p=0.06). This effect could be explained as a sequence that more active people have also a higher expenditure level Cline A, Jansen R, Melby C. Stress fractures in female army recruits: implications of bone density, calcium intake and exercise. Journal of the American College of Nutrition, Vol. 17; No. 2: 128-135 (1998). Level of evidence: 3A.
No significant effect is found of the ground reaction force on the incidence of lower-limb stress fractures (p>0.05) .
The incidence of femoral stress fractures is reduced with 14% (p=0.013) when a semi rigid insole is used Snyder R, De Angelis J, Koester M., Spindler K, Dunn W. Does shoe insole modification prevent stress fractures? A systematic review. HSSJ (2009) 5: 92-98. Level of evidence: 2B.
Alana et al. concluded that there’s no effect on lower limb stress fractures and calcium intake (p=0.55) or bone density .
There is a trend to significance for energy expenditure (kcal/day) with lower limb stress fractures (p=0.06). This effect could be explained as a sequence that more active people have also a higher expenditure level .

Diagnostic Procedures

First of all we describe the possible symptoms: Ivkovic A, Bojanic I, Pecina M. Stress fractures of the femoral shaft in athletes: a new treatment algorithm. Br J Sports Med 2006; 40: 518-520. Level of evidence: 2A

  • Locale pain and edema
  • Point tenderness on <a href="Palpation techniques">palpation</a>
  • Local swelling
  • Antalgic gait
  • Painful and limited passive and active ROM of hip and/or knee (flexion, internal rotation, extension)
  • Pain increases during activity
  • Groin pain
  • Bone marrow edema

Therapists have to pay attention to misdiagnose a femoral stress fracture as <a href="Muscle Strain">muscle strainof</a> the quadriceps or illiopsoas tendinopathy because of the similar symptoms Nguyen J, Peterson J, Biswal S, Beaulieu C, Fredericson M. Stress-related injuries around the lesser trochanter in long-distance runners. AJR 2008; 190: 1616-1620. Level of evidence: 3B.
To present femoral stress fractures on images. We can use 4 modalities: plain radiography, bone scintigrapy, MRI and ultrasonography with the highest sensitivity and specificity for MRI . These techniques can be used in different phases of diagnosis and treatment .

ExaminationCasterline M, Osowski S, Ulrich G. Femoral stress fracture. Journal of Athletic Training March 1996; 31: 53-56. Level of evidence: 4

BJSM Videos. Stress fracture (fulcrum) test, with Mike Reiman. Available from: http://www.youtube.com/watch?v=8Dw3fNd5Szc [last accessed 25/01/14]


The hop test and tuning fork test could be used as diagnostic test but there is a lack of recent evidence for their validity. Another test is the “fist” test, the therapist create a bilateral pressure on the anterior side of the femur starting at the distal part and moving to the proximal one. The most valid test for the diagnosis is the <a href="Fulcrum Test">fulcrum-test</a>, while the therapist pushes to the dorsum of the knee .

Physical Therapy Management

Initial treatment is based on the reduction of activities to a pain-free level. During this “relative rest”-period of 4 to 12 weeks, the patient can use pneumatic compression walking boots to reduce his pain level. Also physical therapy and cross-training which contains of flexibility, strength and cardiovascular training is permitted for example swimming and biking. After that restriction period the activities can be increased in a slow, graduated way . Ivkovic et al. designed a new treatment algorithm for femoral shaft stress injuries. Four phases has to be fulfilled to start normal training and each phase is evaluated by a hop or fulcrum test. The first phase is called symptomatic, where the patient has to walk with crutches. The second phase is the asymptomatic one where patient are allowed to walk normally and to start swimming and exercises the upper extremity. During the third ‘basic’ phase the patient can perform exercises of lower and upper extremities. During the last ‘resuming phase’, the athlete is allowed to gradually start normal training . No recurrence of injury after treatment and follow-up for 48-96 months .
The treatment algorithm is free available in the article from Ivkovic et al.: "Stress fractures of the femoral shaft in athletes: a new treatment algorithm."

To prevent femoral stress fractures, people could modify their training schedules and wear shock-absorbing shoe inserts. Insoles lowers the incidence because the improves biomechanics, less fatigue and limit the impact on the ground. The size of these insoles can range in different types to support the forefoot and/or the toes . Also calcium and vitamin D supplementation could play a role in the prevention but their data are controversial . Leg muscle stretching during warm-up has no significant effect on prevention for femoral stress fractures.

Resources

- Pubmed, Web of Knowledge, Pedro
- Third edition, Examination of musculoskeletal injuries
- Second edition, Therapeutic exercise for musculoskeletal injuries

Recent Related Research (from <a href="http://www.ncbi.nlm.nih.gov/pubmed/">Pubmed</a>)

https://www.ncbi.nlm.nih.gov/entrez/eutils/erss.cgi?rss_guid=1z7zlNEMzQey5ho5ycqHgyGE-zzZ0V9IYjL5nVIB9cE6ZW-kIK%7Ccharset=UTF-8%7Cshort%7Cmax=10

References

1. Patel D, Roth M, Kapil N. Stress fractures: diagnosis, treatment and prevention. American Family
Physician Jan. 2011; 83: 39-46. Level of evidence: 1A
2. Stress Fractures, information from your family doctor. Americain Family Physician Jan. 2011. Level of evidence: 5
3. Zadpoor A, Nikooyan A. The relationship between lower-extremity stress fractures and the ground reaction force: a systematic review. Clinical Biomechanics 2011; 26: 23 -28. Level of evidence: 1B
4. Korvala J, Hartikka H, Pihlajamäki H, Solovieva S, Ruohola J-P, Sahi T, Barral S, Ott J, Ala-Kokko L, Männikkö M. Genetic predisposition for femoral neck stress fractures in military conscripts. BMC Genetics 2010, 11: 95. Level of evidence: 2B
5. Anand A, Raviraj A, Kodikal G. Subchondral stress fractures of femoral head in healthy adult. Indian J Orthop. 2010 Oct-Dec; 44(4): 458-460. Level of evidence: 3B
6. Snyder R, De Angelis J, Koester M., Spindler K, Dunn W. Does shoe insole modification prevent stress fractures? A systematic review. HSSJ (2009) 5: 92-98. Level of evidence: 2B
7. Niva M, Mattila V, Kiuru M, Pihlajamäki H. Bone stress Injuries are common in female military trainees. Clin Orthop Relat Res (2009) 467: 2962-2969. Level of evidence: 3A
8. Nguyen J, Peterson J, Biswal S, Beaulieu C, Fredericson M. Stress-related injuries around the lesser trochanter in long-distance runners. AJR 2008; 190: 1616-1620. Level of evidence: 3B
9. Ivkovic A, Bojanic I, Pecina M. Stress fractures of the femoral shaft in athletes: a new treatment algorithm. Br J Sports Med 2006; 40: 518-520. Level of evidence: 2A
10. Cline A, Jansen R, Melby C. Stress fractures in female army recruits: implications of bone density, calcium intake and exercise. Journal of the American College of Nutrition, Vol. 17; No. 2: 128-135 (1998). Level of evidence: 3A
11. Casterline M, Osowski S, Ulrich G. Femoral stress fracture. Journal of Athletic Training March 1996; 31: 53-56. Level of evidence: 4
12. Fredericson M, Jang K, Bergman G, Gold G. Femoral diaphyseal stress fractures: results of a systematic bone scan and magnetic resonance evaluation in 25 runners. Physical Therapy in Sport 5 (2004): 188-193. Level of evidence: 2B
13. Lynch S, Renström P. Groin injuries in sport- treatment strategies. Sports Med 1999 Aug; 28 (2): 137-144. Level of evidence: 4
14. Kang L, Belcher D, Hulstyn M. Stress fractures of the femoral shaft in women’s college lacrosse: a report of seven cases and a review of the literature. Br J Sports Med 2005; 39: 902-906. Level of evidence: 2B
15. Schultz, Houglum, Perrin. Third edition, examination of musculoskeletal injuries p.401. Human Kinetics. Level of evidence: 5
16. Houglum P. Second edition, therapeutic exercise for musculoskeletal injuries p.80-81, p. 811-812. Human Kinetics. Level of evidence: 5

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