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Return to sport following low-risk and high-risk bone stress injuries: a systematic review and meta-analysis
  1. Tim Hoenig1,
  2. Julian Eissele1,
  3. André Strahl1,
  4. Kristin L Popp2,3,4,
  5. Julian Stürznickel1,
  6. Kathryn E Ackerman2,5,
  7. Karsten Hollander6,
  8. Stuart J Warden7,8,
  9. Karl-Heinz Frosch1,
  10. Adam S Tenforde9,
  11. Tim Rolvien1
  1. 1 Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
  2. 2 Endocrine Unit, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
  3. 3 U.S. Army Research Institute of Environmental Medicine, Natick, Massachusetts, USA
  4. 4 TRIA Orthopedic Center, Bloomington, Minnesota, USA
  5. 5 Division of Sports Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
  6. 6 Institute of Interdisciplinary Exercise Science and Sports Medicine, MSH Medical School Hamburg, Hamburg, Germany
  7. 7 Department of Physical Therapy, School of Health & Human Sciences, Indiana University, Indianapolis, Indiana, USA
  8. 8 Indiana Center for Musculoskeletal Health, Indiana University, Indianapolis, Indiana, USA
  9. 9 Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Harvard Medical School, Cambridge, Massachusetts, USA
  1. Correspondence to Dr Tim Hoenig, Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany; t.hoenig{at}


Objective Bone stress injuries (BSIs) are classified in clinical practice as being at low- or high-risk for complication based on the injury location. However, this dichotomous approach has not been sufficiently validated. The purpose of this systematic review was to examine the prognostic role of injury location on return-to-sport (RTS) and treatment complications after BSI of the lower extremity and pelvis.

Design Systematic review and meta-analysis.

Data sources PubMed, Web of Science, Cochrane CENTRAL and Google Scholar databases were searched from database inception to December 2021.

Eligibility criteria for selecting studies Peer-reviewed studies that reported site-specific RTS of BSIs in athletes.

Results Seventy-six studies reporting on 2974 BSIs were included. Sixteen studies compared multiple injury sites, and most of these studies (n=11) described the anatomical site of injury as being prognostic for RTS or the rate of treatment complication. Pooled data revealed the longest time to RTS for BSIs of the tarsal navicular (127 days; 95% CI 102 to 151 days) and femoral neck (107 days; 95% CI 79 to 135 days) and shortest duration of time for BSIs of the posteromedial tibial shaft (44 days, 95% CI 27 to 61 days) and fibula (56 days; 95% CI 13 to 100 days). Overall, more than 90% of athletes successfully returned to sport. Treatment complication rate was highest in BSIs of the femoral neck, tarsal navicular, anterior tibial shaft and fifth metatarsal; and lowest in the fibula, pubic bone and posteromedial tibial shaft.

Conclusion This systematic review supports that the anatomical site of BSIs influences RTS timelines and the risk of complication. BSIs of the femoral neck, anterior tibial shaft and tarsal navicular are associated with increased rates of complications and more challenging RTS.

PROSPERO registration number CRD42021232351.

  • rehabilitation
  • fractures, stress

Data availability statement

Data are available on reasonable request. Further data available on request.

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Data availability statement

Data are available on reasonable request. Further data available on request.

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  • Twitter @hoenig_tim, @kristypopp, @drkateackerman, @k_hollander_, @StuartJWarden, @AdamTenfordeMD, @TimRolvien

  • Contributors Protocol design: TH. Study selection, data extraction, data analysis: TH, JE, TR, KH and JS. Drafting and revising manuscript: TH, JE, AS, KLP, JS, KEA, KH, SJW, K-HF, AT and TR. Guarantor: TH.

  • Funding Work on this contribution by SJW was supported by the National Institutes of Health (NIH/NIAMS P30 AR072581)

  • Competing interests KEA: KEA is a deputy editor of BJSM.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Author note Social media statement: How serious is a bone stress injury? A systematic review identifies injury sites at risk for treatment complications and failure to (timely) return to sport.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.