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.

Ergogenic drugs are substances that are used to enhance athletic performance. These drugs include illicit substances as well as compounds that are marketed as nutritional supplements. Many such drugs have been used widely by professional and elite athletes for several decades. However, in recent years, research indicates that younger athletes are increasingly experimenting with these drugs to improve both appearance and athletic abilities. Ergogenic drugs that are commonly used by youths today include anabolic-androgenic steroids, steroid precursors (androstenedione and dehydroepiandrosterone), growth hormone, creatine, and ephedra alkaloids. Reviewing the literature to date, it is clear that children are exposed to these substances at younger ages than in years past, with use starting as early as middle school. Anabolic steroids and creatine do offer potential gains in body mass and strength but risk adverse effects to multiple organ systems. Steroid precursors, growth hormone, and ephedra alkaloids have not been proven to enhance any athletic measures, whereas they do impart many risks to their users. To combat this drug abuse, there have been recent changes in the legal status of several substances, changes in the rules of youth athletics including drug testing of high school students, and educational initiatives designed for the young athlete. This article summarizes the current literature regarding these ergogenic substances and details their use, effects, risks, and legal standing.www.pediatrics.org/cgi

Background The initial graft tension applied at the time of anterior cruciate ligament (ACL) reconstruction alters joint contact and may influence cartilage health. The objective was to compare outcomes between two commonly used “laxity-based” initial graft tension protocols. Hypothesis We hypothesized that; 1) the high-tension group would have less knee laxity, improved clinical and patient-oriented outcomes, and less cartilage damage than the low-tension group after 36-months of healing, and 2) the outcomes of the high-tension group would be equivalent to those of a matched control group. Study Design Randomized controlled clinical trial. Methods Ninety patients with isolated unilateral ACL injuries were randomized to undergo ACL reconstruction using one of two initial graft tension protocols; 1) autografts tensioned to restore normal anteroposterior (AP) laxity at the time of surgery (i.e., “low-tension”; n=46) and 2) autografts tensioned to over-constrain AP laxity by 2 mm (i.e., “high-tension”; n=44). Sixty matched healthy subjects formed the control group. Outcomes were assessed pre-operatively, intra-operatively, and at 6-, 12- and 36-months after surgery. Results No significant differences were found between the two initial graft tension protocols for any of the outcome measures at 36-months. However, there were differences when comparing the two treatment groups to the control group. On average, AP laxity was 2 mm greater in the ACL reconstructed groups than in the control group (p<.007). IKDC knee evaluation scores (p<0.001), peak isokinetic knee extension torques (p<.027), and 4 out of 5 of the Knee Osteoarthritis Outcome Scores (KOOS; p<.05) were significantly worse than the control group. SF-36 scores and re-injury rates were similar between groups at 36-months. Although there were significant radiographic and MRI changes present in the ACL reconstructed knees of both treatment groups, the magnitude was relatively small and likely clinically insignificant at 36-months. Conclusions Both laxity-based initial graft tension protocols produced similar outcomes without fully restoring joint function and KOOS scores when compared to the control group. There was minimal evidence of cartilage damage 36-months after surgery.