Epidemiology of Stress Fractures
Section snippets
Methods
To ensure a comprehensive review of available studies, a literature search was conducted using the MEDLINE database. The terms “stress fracture,” “athletes,” “epidemiology,” and “incidence” were searched from 1966 through May 2005. The references of all retrieved articles also were reviewed. Prospective studies were searched for initially, but the inclusion criteria were expanded after only three such studies were identified [1], [2], [3]. Retrospective medical record reviews were then
Injury Exposure
Epidemiology is the study of diseases in populations, including the relationship between exposures and outcomes. For the purpose of this discussion, the term “exposure” is defined as athletic activity, and the occurrence of a stress fracture is the outcome of interest. One of the major challenges in sports injury epidemiology is the process of defining and collecting meaningful exposure data [4]. A quantitative measure of injury exposure is often not accounted for in studies, and data are
Results
Fourteen cohort studies were identified that provided a measure of either the proportion or cumulative incidence of stress fractures among athletic populations (Table 1). Each study that was reviewed observed different athlete populations, including recreational and competitive athletes, collegiate athletes, track and field athletes, gymnasts, and basketball players. Because of the variety in sport, frequency, and intensity of activity, caution should be exercised in comparing results across
Age
The role of age as an independent risk factor for developing a stress fracture cannot be determined from the available literature. No study has controlled for activity level; thus, the distribution of fractures among age groups is more likely to be associated with training volume and intensity rather than the ages of the participants. There are no studies in athletes that suggest an independent effect of age on the occurrence of stress fractures. Studies in military recruits have had
Stress fracture characteristics
Fifteen studies provided sufficient details to allow a review of anatomic fracture sites, but the studies are of limited value in assessing fracture occurrence by sport. Few inferences can be made regarding specific injury patterns because of the heterogeneity of the study populations and inconsistent methodology. Variations in exposure will affect fracture patterns. In addition to the volume of activity, other potentially confounding variables include sports or activities, climate, and
Morbidity and outcomes
The available literature offers few data in regard to outcomes and recurrence rates following a stress fracture. Sullivan and colleagues [27] have reported that seven of 51 athletes who had a stress fracture had suffered a radiologically proven fracture before study enrollment. Bennell and colleagues [1] have found that 60% of athletes with a stress fracture over their prospective 12-month observation period had experienced a previous stress fracture. There was a strong recruitment bias in this
Summary
The pathophysiology of stress fractures is well understood, but a lack of quality epidemiologic data remains. Injuries to the tibia and metatarsals are the most frequent stress fractures reported in the literature. There is a clear association between increasing training volumes and increased risk of stress fracture, but little is known beyond this association. There is a pressing need for large prospective studies to better establish the risks of stress fracture by sport, age, and gender. Such
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