Context:Stress fractures are common injuries in athletes, often difficult to diagnose. A stress fracture is a fatigue-induced fracture of bone caused by repeated applications of stress over time.Evidence Acquisition:PubMed articles published from 1974 to January 2012.Results:Intrinsic and extrinsic factors may predict the risk of stress fractures in athletes, including bone health, training, nutrition, and biomechanical factors. Based on their location, stress fractures may be categorized as low- or high-risk, depending on the likelihood of the injury developing into a complete fracture. Treatment for these injuries varies substantially and must account for the risk level of the fractured bone, the stage of fracture development, and the needs of the patient. High-risk fractures include the anterior tibia, lateral femoral neck, patella, medial malleolus, and femoral head. Low-risk fractures include the posteromedial tibia, fibula, medial femoral shaft, and pelvis. Magnetic resonance is the imaging test of choice for diagnosis.Conclusions:These injuries can lead to substantial lost time from participation. Treatment will vary by fracture location, but most stress fractures will heal with rest and modified weightbearing. Some may require more aggressive intervention, such as prolonged nonweightbearing movement or surgery. Contributing factors should also be addressed prior to return to sports.

Background The current health care system requires a substantial amount of documentation by physicians, potentially limiting time spent on patient care. Objective We sought to explore trainees' perceptions of their clinical documentation requirements and the relationship between time spent on clinical documentation versus time available for patient care. Methods An anonymous, online survey was sent to trainees in all postgraduate years of training and specialties in Accreditation Council for Graduate Medical Education–accredited programs. Results Over a 2-month time frame, 1515 trainees in 24 specialties completed the survey. Most (92%) reported that documentation obligations are excessive, that time spent with patients has been compromised by this (90%), and that the amount of clinical documentation has had a negative effect on patient care (73%). Most residents and fellows reported feeling rushed and frustrated because of these documentation demands. They also reported that time spent on these tasks decreased their time available for teaching others and reduced the quality of their education. Respondents reported spending more time on clinical documentation than on direct patient care (P < .001). Conclusions Trainees' current clinical documentation workload may be a barrier to optimal patient care and to resident and fellow education. Residents and fellows report that clinical documentation duties are onerous, and there is a perceived negative effect on time spent with patients, overall quality of patient care, physician well-being, time available for teaching, and quality of resident education.

SUMMARYThe material properties of a tendon affect its ability to store and return elastic energy, resist damage, provide mechanical feedback and amplify or attenuate muscle power. While the structural properties of a tendon are known to respond to a variety of stimuli, the extent to which material properties vary among individual muscles remains unclear. We studied the tendons of six different muscles in the hindlimb of Eastern wild turkeys to determine whether there was variation in elastic modulus, ultimate tensile strength and resilience. A hydraulic testing machine was used to measure tendon force during quasi-static lengthening, and a stress-strain curve was constructed. There was substantial variation in tendon material properties among different muscles. Average elastic modulus differed significantly between some tendons, and values for the six different tendons varied nearly twofold, from 829±140 to 1479±106MPa. Tendons were stretched to failure, and the stress at failure, or ultimate tensile stress, was taken as a lower-limit estimate of tendon strength. Breaking tests for four of the tendons revealed significant variation in ultimate tensile stress, ranging from 66.83±14.34 to 112.37±9.39MPa. Resilience, or the fraction of energy returned in cyclic length changes was generally high, and one of the four tendons tested was significantly different in resilience from the other tendons (range: 90.65±0.83 to 94.02±0.71%). An analysis of correlation between material properties revealed a positive relationship between ultimate tensile strength and elastic modulus (r 2 0.79). Specifically, stiffer tendons were stronger, and we suggest that this correlation results from a constrained value of breaking strain, which did not vary significantly among tendons. This finding suggests an interdependence of material properties that may have a structural basis and may explain some adaptive responses observed in studies of tendon plasticity.