Fatigue fractures in sports

Fatigue fractures in sports

Frac­tures from fati­gue in sports are com­mon inju­ries in ath­le­tes and can have a major impact on the rhythm of trai­ning and com­pe­ti­ti­ons. The lower extre­mi­ty is one of the most fre­quent­ly affec­ted, with ove­r­use dama­ge to the bone due to repea­ted and one-sided stress. 

In gene­ral, a distinc­tion is made bet­ween two types of fati­gue frac­tures, tho­se in which the healt­hy bone is over­loa­ded and tho­se in which a fati­gue frac­tu­re occurs under nor­mal stress but with a wea­k­en­ed bone structure. 

The grea­test influence on the deve­lo­p­ment of fati­gue frac­tures is cau­sed by trai­ning stress and strain. Sym­ptoms are most­ly unspe­ci­fic, typi­cal­ly appear during exer­cise and can lead to the dis­con­ti­nua­tion of phy­si­cal acti­vi­ty. Soft tis­sue swel­ling or cal­lus for­ma­ti­on can occur in the late stages. 

Radio­lo­gi­cal­ly, chan­ges are only visi­ble late. The MRT exami­na­ti­on has estab­lished its­elf as the gold stan­dard for ear­ly detec­tion and sta­ging appro­pria­te to the stage. The type and dura­ti­on of tre­at­ment and reha­bi­li­ta­ti­on can be deter­mi­ned accordingly. 

The cen­tral pil­lar of the tre­at­ment of fati­gue frac­tures is the reduc­tion of the (trai­ning) strain to a level below the pain thres­hold. In prin­ci­ple, sur­gi­cal the­ra­py is rare­ly indi­ca­ted, but the­re are spe­ci­fic fati­gue frac­tures in which con­ser­va­ti­ve manage­ment can be frustrating.


Fati­gue frac­tures are com­mon inju­ries among ath­le­tes and occur pre­do­mi­nant­ly in the feet and legs. The tibia, navicu­lar bone, meta­tar­sal bone, and fibu­la are pre­dis­po­sed.1 This most­ly affects run­ners or ath­le­tes, but games such as soc­cer, vol­ley­ball or bas­ket­ball can also pro­vo­ke fati­gue frac­tures. Fati­gue frac­tures are also obser­ved in the upper extre­mi­ties, e.g. stress frac­tures of the car­pal bones in ten­nis or squash play­ers. The fre­quen­cy of fati­gue frac­tures is very varia­ble depen­ding on the sport and can reach up to 47%. 2, 3

Fati­gue frac­tures (= stress frac­tures) are dama­ge to the bone due to repea­ted, one-sided stress, which overta­xes the bone due to its uni­for­mi­ty and dura­bi­li­ty. This leads to chan­ges in the arran­ge­ment of tra­be­cu­lae (which repre­sent the sup­port­ing lines of the bone) and sub­se­quent­ly to a reac­tion of the peri­o­s­te­um in the form of flu­id accu­mu­la­ti­on (ede­ma). The accu­mu­la­ti­on of flu­id (bone mar­row ede­ma) is usual­ly the point in time at which pain occurs for the first time.

A basic distinc­tion is made bet­ween two types of fati­gue frac­tures, tho­se in which the healt­hy bone is over­loa­ded and tho­se in which a fati­gue frac­tu­re occurs under nor­mal stress but with a wea­k­en­ed bone struc­tu­re. The grea­test influence on the occur­rence of fati­gue frac­tures is cau­sed by trai­ning stress and strain, which is why the ana­ly­sis of stress, trai­ning con­di­ti­ons and risk fac­tors is necessary.


The sym­ptoms of fati­gue frac­tures are most­ly non-spe­ci­fic. The main sym­ptom is pain which is often descri­bed as dull and typi­cal­ly occurs during exer­cise. In the initi­al stage, exer­tio­nal pain only occurs towards the end of the sport­ing acti­vi­ty, in the advan­ced stage the onset of pain shifts ste­adi­ly to an ear­lier point in time and can ulti­m­ate­ly even lead to the dis­con­ti­nua­tion of the sport­ing acti­vi­ty. Recent chan­ges in trai­ning (increase in inten­si­ty, dura­ti­on) or extrin­sic fac­tors (chan­ge of foot­wear or sur­face) should be inqui­red about based on anamnesis.

In the late stages, soft tis­sue swel­ling or cal­lus for­ma­ti­on can be seen on cli­ni­cal exami­na­ti­on. Pro­vo­ca­ti­on tests (with com­pres­si­on / fle­xi­on) can pro­vi­de evi­dence of the pre­sence of a fati­gue frac­tu­re. The mobi­li­ty of the adja­cent joints is usual­ly not rest­ric­ted and pain­less. The search for ana­to­mic­al mis­a­lignments that can favor a stress frac­tu­re (e.g. genu varum, flat or hol­low feet, leg length dif­fe­ren­ces) must be car­ri­ed out.


Ima­ging methods are requi­red for a relia­ble dia­gno­sis and sta­ging appro­pria­te to the stage.

In con­ven­tio­nal X‑rays, chan­ges in the bone struc­tu­re in fati­gue frac­tures beco­me visi­ble late or not at all. Typi­cal signs here are the ele­va­ti­on of the peri­o­s­te­um, thi­c­ke­ning of the cor­tex, cal­lus for­ma­ti­on or, final­ly, the mar­king of a frac­tu­re line.4 If the x‑ray image is nor­mal but the cli­ni­cal sus­pi­ci­on of a fati­gue frac­tu­re, the dia­gno­sis with magne­tic reso­nan­ce ima­ging (MRI) or bone scin­ti­gra­phy should be escala­ted.5–7 Seve­ral stu­dies have shown that MRI is equi­va­lent to bone scin­ti­gra­phy in terms of sen­si­ti­vi­ty, but has an even hig­her spe­ci­fi­ci­ty. 5–7

The MRI exami­na­ti­on is used to clas­si­fy the seve­ri­ty accor­ding to Are­ndt et al.6, which clas­si­fy gra­des 1 and 2 as “low gra­de” and gra­des 3 and 4 as “high gra­de”. Fre­de­ric­son et al.7 also dif­fe­ren­tia­te in their clas­si­fi­ca­ti­on bet­ween peri­o­s­te­al and bone mar­row reac­tions. This sta­ging shows a good cor­re­la­ti­on bet­ween radio­lo­gi­cal fin­dings and cli­ni­cal sym­ptoms in ever­y­day cli­ni­cal prac­ti­ce. Based on this clas­si­fi­ca­ti­on, fur­ther pro­ce­du­res and dura­ti­on of tre­at­ment can be deter­mi­ned. Ano­ther advan­ta­ge of MRI is the low radia­ti­on expo­sure, which enables fol­low-up exami­na­ti­ons at intervals.

Pos­si­ble dif­fe­ren­ti­al dia­gno­ses for a fati­gue frac­tu­re — in addi­ti­on to osteo­mye­li­tis and oste­on corps — are bone con­tus­i­on with a so-cal­led “bone brui­se”. The dif­fe­ren­tia­ti­on in the MRI is often dif­fi­cult, poin­ting the way here are trau­ma histo­ry (direct trau­ma during con­tus­i­on) and occur­rence near the joint.


A detail­ed ana­mne­sis is cru­cial for the suc­cess of the the­ra­py when dia­gno­sing a fati­gue frac­tu­re. Inqui­ring about and iden­ti­fy­ing pos­si­ble trai­ning errors, chan­ges in trai­ning inten­si­ty, fail­ure to take account of chan­ges in extrin­sic fac­tors (sur­face, foot­wear), lack of rest breaks or other inju­ries are key fac­tors here.

The main pil­lar of the­ra­py is redu­cing phy­si­cal acti­vi­ty to a level below the pain­ful level and modi­fy­ing trai­ning. In the cli­ni­cal cour­se, pain has pro­ven to be the best indi­ca­tor for the start of the­ra­py / the heal­ing pro­cess. The doc­tor-pati­ent rela­ti­onship is ano­ther key point. Detail­ed infor­ma­ti­on about the cli­ni­cal pic­tu­re and cour­se and the neces­sa­ry com­pli­ance of the ath­le­te are neces­sa­ry in order to avo­id the risk of the fati­gue frac­tu­re pro­gres­sing to the next stage or to a com­ple­te fracture.

Con­ser­va­ti­ve the­ra­py com­pri­ses three pha­ses as sum­ma­ri­zed by Albrecht et al.1:

  1. Pain con­trol by means of coo­ling, phy­sio­the­ra­peu­tic mea­su­res, trai­ning breaks or modi­fied trai­ning breaks.
    The (par­ti­al) reli­ef on fore­arm crut­ches is neces­sa­ry if pain is alre­a­dy pre­sent when wal­king in ever­y­day life. The later increase in load should be deci­ded on the basis of the pain pro­gres­si­on. If the­re is no pain, the load can be increased in a con­trol­led man­ner, with a day of rest for rege­ne­ra­ti­on after exer­cise. Pha­se (2) beg­ins after 3–5 pain­less days.
  1. Exer­ci­s­es with loads, but wit­hout impacts (e.g. step­pers) and sport-spe­ci­fic mus­cle trai­ning. Mus­cu­lar imba­lan­ces should be cor­rec­ted during this pha­se. Endu­rance trai­ning such as swim­ming, aqua jog­ging or cycling can be done if it can be car­ri­ed out painlessly.
  2. The last pha­se pro­vi­des for the dosed, con­ti­nuous return to sport-spe­ci­fic activities.

Basi­cal­ly, most fati­gue frac­tures respond to a con­ser­va­ti­ve the­ra­py regi­men; sur­gi­cal the­ra­py is rare­ly indi­ca­ted. Howe­ver, the­re are fati­gue frac­tures that show an increased risk of delay­ed bone heal­ing, deve­lo­p­ment of pseud­arthro­ses or the for­ma­ti­on of a com­ple­te frac­tu­re. An exam­p­le of this is the ante­rior tibi­al stress frac­tu­re. The sur­gi­cal the­ra­py opti­ons available are intra­me­dul­la­ry nai­ling, dril­ling of the pseud­arthro­sis and debri­de­ment with spon­gio­sa­plasty. 3, 8, 9


Fati­gue frac­tures are com­mon inju­ries among ath­le­tes. In the case of dif­fu­se stress pain in the area of the bone during sport­ing acti­vi­ties, a stress frac­tu­re should be con­side­red, all the more if the­re has recent­ly been a histo­ry of a chan­ge in trai­ning habits. If the dia­gno­sis is con­firm­ed at an ear­ly stage, a few weeks of reha­bi­li­ta­ti­on time are usual­ly suf­fi­ci­ent to return to fami­li­ar trai­ning and com­pe­ti­ti­on con­di­ti­ons. In the event of a cli­ni­cal sus­pi­ci­on of a fati­gue frac­tu­re, the dia­gno­sis should the­r­e­fo­re be escala­ted with an MRI (= gold stan­dard) at an ear­ly stage. Most fati­gue frac­tures respond to con­ser­va­ti­ve the­ra­py manage­ment, but sur­gi­cal the­ra­py is rare­ly indicated.

Aut­hors: Univ.-Prof. Dr. med. Ulrich Stöck­le and Priv.-Doz. Dr. med. Luc­ca Lacheta

Cor­re­spon­dence address:

Univ.-Prof. Dr. med. Ulrich Stoeck­le
Cha­ri­té — Uni­ver­si­ty Medi­ci­ne Ber­lin
Augus­ten­bur­ger­platz 1, 13353 Ber­lin
Email: ulrich.stoeckle@charite.de


1. Albrecht SB, R.M. Stress­frak­tu­ren. Switz­er­land. Zeit­schrift für Sport­me­di­zin und Sport­trau­ma­to­lo­gie. 2004;52:27–30.

2. Ben­nell KL, Mal­colm SA, Tho­mas SA, Wark JD, Bru­kner PD. The inci­dence and dis­tri­bu­ti­on of stress frac­tures in com­pe­ti­ti­ve track and field ath­le­tes. A twel­ve-month pro­s­pec­ti­ve stu­dy. Am J Sports Med. 1996;24:211–217.

3. Chang PS, Har­ris RM. Intra­me­dul­la­ry nai­ling for chro­nic tibi­al stress frac­tures. A review of five cases. Am J Sports Med. 1996;24:688–692.

4. Har­rast MA, Colon­no D. Stress frac­tures in run­ners. Clin Sports Med. 2010;29:399–416.

5. Deutsch AL, Coel MN, Mink JH. Ima­ging of stress inju­ries to bone. Radio­gra­phy, scin­ti­gra­phy, and MR ima­ging. Clin Sports Med. 1997;16:275–290.

6. Are­ndt EAG, H.J. The use of MR ima­ging in the assess­ment and cli­ni­cal manage­ment of stress reac­tions of bone in high-per­for­mance ath­le­tes. Clin. Sports Med. . 1997;16:191–306.

7. Fre­de­ric­son M, Berg­man AG, Hoff­man KL, Dil­ling­ham MS. Tibi­al stress reac­tion in run­ners. Cor­re­la­ti­on of cli­ni­cal sym­ptoms and scin­ti­gra­phy with a new magne­tic reso­nan­ce ima­ging gra­ding sys­tem. Am J Sports Med. 1995;23:472–481.

8. Green NE, Rogers RA, Lips­comb AB. Non­uni­ons of stress frac­tures of the tibia. Am J Sports Med. 1985;13:171–176.

9. Ora­va S, Kar­pak­ka J, Hulk­ko A, et al. Dia­gno­sis and tre­at­ment of stress frac­tures loca­ted at the mid-tibi­al shaft in ath­le­tes. Int J Sports Med. 1991;12:419–422.

Leave a Reply