Return to sport following low-risk and high-risk bone stress injuries: a systematic review and meta-analysis

Abstract

ObjectiveBone 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.DesignSystematic review and meta-analysis.Data sourcesPubMed, Web of Science, Cochrane CENTRAL and Google Scholar databases were searched from database inception to December 2021.Eligibility criteria for selecting studiesPeer-reviewed studies that reported site-specific RTS of BSIs in athletes.ResultsSeventy-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.ConclusionThis 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 numberCRD42021232351.

Images in sports medicine: bone stress injury

“…Bone stress injury is common in athletics, especially for distance runners and those diagnosed with REDs in whom there is a larger chance of recurrence 5. Repetitive stress injuries in the lower extremities are common in endurance athletes involved in weight-bearing sports.…”

“…The findings were consistent with a Nattiv grade 3 bone stress injury (table 1). 2–6 Comparative imaging for the left tibia was normal.…”

Outcomes Using Focused Shockwave for Treatment of Bone Stress Injury in Runners

“…As anticipated, a longer return to running time was observed in runners with delayed and non-union BSI. The time for a return to running was similar in low and high-grade BSI using MRI criteria, although a larger sample size may be needed in order to distinguish this difference given the variability in time for the return of sport based on MRI grades and location of injuries [ 5 , 8 ]. Biological risk factors of the Female and Male Athlete Triad did not influence the time for return to run.…”

“…Low energy availability may contribute to reduced sex hormones (estradiol and testosterone) and lower bone density, resulting in prolonged healing times [ 2 ]. The anatomical location of injury can be divided into low-risk and high-risk categories based on the risk of delayed/non-union, complete or re-fracture, or prolonged time for healing [ 8 ]. While over 90% of athletes return to sport, some injuries progress to non-union, which can require surgery or result in discontinuation of sport [ 5 ].…”

Bone Stress Injuries in Runners Using Carbon Fiber Plate Footwear

“…Navicular BSIs are classified as a high-risk location for injury as some of these injuries may not effectively heal with non-surgical measures [14]. While navicular BSIs are described in older populations of collegiate and professional athletes [15], these injuries have also been observed in youth athletes [16][17][18].…”