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Bone stress injuries

Nature Reviews Disease Primers volume 8, Article number: 26 (2022) Cite this article

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Abstract

Bone stress injuries, including stress fractures, are overuse injuries that lead to substantial morbidity in active individuals. These injuries occur when excessive repetitive loads are introduced to a generally normal skeleton. Although the precise mechanisms for bone stress injuries are not completely understood, the prevailing theory is that an imbalance in bone metabolism favours microdamage accumulation over its removal and replacement with new bone via targeted remodelling. Diagnosis is achieved by a combination of patient history and physical examination, with imaging used for confirmation. Management of bone stress injuries is guided by their location and consequent risk of healing complications. Bone stress injuries at low-risk sites typically heal with activity modification followed by progressive loading and return to activity. Additional treatment approaches include non-weight-bearing immobilization, medications or surgery, but these approaches are usually limited to managing bone stress injuries that occur at high-risk sites. A comprehensive strategy that integrates anatomical, biomechanical and biological risk factors has the potential to improve the understanding of these injuries and aid in their prevention and management.

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Fig. 1: Incidence of bone stress injuries in different college sports.
Fig. 2: Common anatomical sites for bone stress injuries.
Fig. 3: Hierarchy of bone structural organization.
Fig. 4: Pathogenesis of bone stress injuries.
Fig. 5: Molecular aspects of bone stress injury pathophysiology.
Fig. 6: Imaging modalities for exemplary bone stress injuries.
Fig. 7: Overview of commonly used MRI-based classification systems for bone stress injuries.
Fig. 8: Protocol for return to running after a bone stress injury.

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Acknowledgements

S.J.W.: contribution was facilitated by support from the National Institutes of Health (NIH/NIAMS P30 AR072581) and National Basketball Association–General Electric Healthcare Orthopedics and Sports Medicine Collaboration. K.L.P.: the opinions or assertions contained herein are the private views of the authors and are not to be construed as official or reflecting the views of the U.S. Army or the Department of Defense. Any citations of commercial organizations and trade names in this report do not constitute an official U.S. Army or Department of Defense endorsement or approval of the products or services of these organizations.

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Author notes

  1. These authors jointly supervised this work: Adam S. Tenforde, Stuart J. Warden.

Authors and Affiliations

  1. Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany

    Tim Hoenig & Tim Rolvien

  2. Wu Tsai Female Athlete Program, Boston Children’s Hospital, Boston, MA, USA

    Kathryn E. Ackerman

  3. Endocrine Unit, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA

    Kathryn E. Ackerman, Mary L. Bouxsein & Kristin L. Popp

  4. School of Health Sciences & Social Work, Griffith University, Gold Coast, Queensland, Australia

    Belinda R. Beck

  5. Menzies Health Institute Queensland, Gold Coast, Queensland, Australia

    Belinda R. Beck

  6. The Bone Clinic, Brisbane, Queensland, Australia

    Belinda R. Beck

  7. Department of Orthopedic Surgery, Harvard Medical School and Center for Advanced Orthopedic Studies, Beth Israel Deaconess Medical Center, Boston, MA, USA

    Mary L. Bouxsein

  8. Department of Anatomy, Cell Biology, and Physiology, Indiana University School of Medicine, Indiana University, Indianapolis, IN, USA

    David B. Burr

  9. Indiana Center for Musculoskeletal Health, Indiana University School of Medicine, Indiana University, Indianapolis, IN, USA

    David B. Burr & Stuart J. Warden

  10. Institute of Interdisciplinary Exercise Science and Sports Medicine, MSH Medical School Hamburg, Hamburg, Germany

    Karsten Hollander

  11. U.S. Army Research Institute of Environmental Medicine, Natick, MA, USA

    Kristin L. Popp

  12. Spaulding Rehabilitation Hospital, Department of Physical Medicine and Rehabilitation, Harvard Medical School, Charlestown, MA, USA

    Adam S. Tenforde

  13. Department of Physical Therapy, School of Health & Human Sciences, Indiana University, Indianapolis, IN, USA

    Stuart J. Warden

  14. La Trobe Sport and Exercise Medicine Research Centre, La Trobe University, Bundoora, Victoria, Australia

    Stuart J. Warden

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Contributions

Introduction (T.H.); Epidemiology (K.H.); Risk factors (K.L.P., K.E.A. and T.R.); Pathophysiology (T.R., D.B.B. and M.L.B.); Diagnosis (B.R.B.); Treatment (S.J.W. and A.S.T.); Quality of life (T.H.); Outlook (T.H.). All authors critically revised all aspects of the article. T.H., A.S.T. and S.J.W. were responsible for overall handling of the manuscript.

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Correspondence to Tim Hoenig, Adam S. Tenforde or Stuart J. Warden.

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Nature Reviews Disease Primers thanks M. Baggaley, who co-reviewed with B. Edwards; G. Robertson, who co-reviewed with N. Maffulli; A. Kemper; M. Schaffler; and the other, anonymous, reviewer(s) for their contribution to the peer review of this work.

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Glossary

Stress fractures

Bone stress injuries with radiologically visible sclerosis or fracture line.

Stress reactions

Bone stress injuries without radiologically visible sclerosis or fracture line.

Bone stress injury

Focal failure of bone tissue to repeated loading that results in localized pain and/or an increased risk of complete bone fracture to typically tolerable loads.

Stress

The amount of force experienced per unit area of tissue when an external force is applied.

Strain

The change in the dimensions of bone tissue when stress is applied.

Material fatigue

The formation and propagation of cracks in a material due to repeated loading.

Microdamage

Microscopic damage in bone tissue, often in the form of small cracks, in response to repeated stress, which stimulates targeted remodelling.

Targeted remodelling

The coordinated and sequential action of bone-resorbing osteoclasts and bone-forming osteoblasts to remove bone microdamage and replace it with new bone.

Insufficiency fracture

A bone injury due to loads within the normal range being applied to an abnormal bone or a bone with abnormal biology.

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Hoenig, T., Ackerman, K.E., Beck, B.R. et al. Bone stress injuries. Nat Rev Dis Primers 8, 26 (2022). https://doi.org/10.1038/s41572-022-00352-y

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