Premature Return After Bone Stress Injury in Endurance Athletes: A Review of Recurrence Risk and Return-to-Running Criteria
DOI:
https://doi.org/10.5281/zenodo.22548495Keywords:
Bone stress injury, Stress fracture, Return to running, Recurrence, Relative Energy Deficiency in Sport, Endurance athletesAbstract
Bone stress injury recurs in a substantial minority of endurance athletes, and recurrence risk is not
evenly distributed: high-risk anatomical sites, Relative Energy Deficiency in Sport (RED-S) risk factors,
and a prior bone stress injury history each independently raise reported recurrence rates well above the
average for a first injury. MRI grading systems correlate imperfectly, but usefully, with time to healing,
and graduated return-to-running protocols built around symptom-limited progression rather than a fixed
calendar interval are the consensus response to that imperfect correlation. This review synthesises the
grading, risk-factor, and return-to-running literature to set out what a defensible, recurrence-aware
return-to-running decision after bone stress injury should weigh, and where premature return most often
originates.
References
Nattiv A, Kennedy G, Barrack MT, et al. "Correlation of MRI grading of bone stress injuries with clinical risk factors and return to play: a 5-year prospective study in collegiate track and field athletes". Am J Sports Med 41(2013):1930-1941.
Hoenig T, Tenforde AS, Strahl A, Rolvien T, Hollander K. "Does magnetic resonance imaging grading correlate with return to sports after bone stress injuries? A systematic review and meta-analysis". Am J Sports Med 50(2022):834-844.
Fredericson M, Bergman AG, Hoffman KL, Dillingham MS. "Tibial stress reaction in runners: correlation of clinical symptoms with scintigraphy and magnetic resonance imaging grading". Am J Sports Med 23(1995):472-481.
Warden SJ, Davis IS, Fredericson M. "Management and prevention of bone stress injuries in long-distance runners". J Orthop Sports Phys Ther 44(2014):749-765.
Mountjoy M, Sundgot-Borgen J, Burke L, et al. "The IOC consensus statement: beyond the Female Athlete Triad -- Relative Energy Deficiency in Sport (RED-S)". Br J Sports Med 48(2014):491-497.
Mountjoy M, Sundgot-Borgen JK, Burke LM, et al. "IOC consensus statement on relative energy deficiency in sport (RED-S): 2018 update". Br J Sports Med 52(2018):687-697.
Nattiv A, Loucks AB, Manore MM, Sanborn CF, Sundgot-Borgen J, Warren MP. "American College of Sports Medicine position stand: the female athlete triad". Med Sci Sports Exerc 39(2007):1867-1882.
Barrack MT, Gibbs JC, De Souza MJ, et al. "Higher incidence of bone stress injuries with increasing female athlete triad-related risk factors: a prospective multisite study of exercising girls and women". Am J Sports Med 42(2014):949-958.
Tenforde AS, Sayres LC, McCurdy ML, Collado H, Sainani KL, Fredericson M. "Overuse injuries in high school runners: lifetime prevalence and prevention strategies". PM R 3(2011):125-131.
Tenforde AS, Sayres LC, Sainani KL, Fredericson M. "Evaluating the relationship of calcium and vitamin D in the prevention of stress fracture injuries in the young athlete: a review of the literature". PM R 2(2010):945-949.
Rauh MJ, Nichols JF, Barrack MT. "Relationships among injury and disordered eating, menstrual dysfunction, and low bone mineral density in high school athletes: a prospective study". J Athl Train 45(2010):243-252.
Kraus E, Tenforde AS, Nattiv A, et al. "Bone stress injuries in male distance runners: higher modified Female Athlete Triad Cumulative Risk Assessment scores predict increased rates of injury". Br J Sports Med 53(2019):237-242.
Miller TL, Jamieson M, Everson S, Siegel C. "Expected time to return to athletic participation after stress fracture in Division I collegiate athletes". Sports Health 10(2018):340-344.
Wright AA, Taylor JB, Ford KR, Siska L, Smoliga JM. "Risk factors associated with lower extremity stress fractures in runners: a systematic review with meta-analysis". Br J Sports Med 49(2015):1517-1523.
Bennell KL, Malcolm SA, Thomas SA, et al. "Risk factors for stress fractures in track and field athletes: a twelve-month prospective study". Am J Sports Med 24(1996):810-818.
Tenforde AS, Kraus E, Fredericson M. "Bone stress injuries in runners". Phys Med Rehabil Clin N Am 27(2016):139-149.
Changstrom BG, Brou L, Khodaee M, Braund C, Comstock RD. "Epidemiology of stress fracture injuries among US high school athletes, 2005-2006 through 2012-2013". Am J Sports Med 43(2015):26-33.
Wentz L, Liu PY, Haymes E, Ilich JZ. "Females have a greater incidence of stress fractures than males in both military and athletic populations: a systemic review". Mil Med 176(2011):420-430.
Popp KL, Hughes JM, Smock AJ, et al. "Bone geometry, strength, and muscle size in runners with a history of stress fracture". Med Sci Sports Exerc 41(2009):2145-2150.
Milgrom C, Giladi M, Chisin R, Dizian R. "The long-term followup of soldiers with stress fractures". Am J Sports Med 13(1985):398-400.
Meardon SA, Willson JD, Gries SR, Kernozek TW, Derrick TR. "Bone stress in runners with tibial stress fracture". Clin Biomech 30(2015):895-902.
Diehl JJ, Best TM, Kaeding CC. "Classification and return-to-play considerations for stress fractures". Clin Sports Med 25(2006):17-28.
Boden BP, Osbahr DC. "High-risk stress fractures: evaluation and treatment". J Am Acad Orthop Surg 8(2000):344-353.
Kaeding CC, Miller T. "The comprehensive description of stress fractures: a new classification system". J Bone Joint Surg Am 95(2013):1214-1220.
Robertson GAJ, Wood AM. "Return to sport following stress fractures in track and field athletes: a systematic review". Br Med Bull 123(2017):61-81.
Nattiv A. "Stress fractures and bone health in track and field athletes". J Sci Med Sport 3(2000):268-279.
Bergman AG, Fredericson M. "MR imaging of stress reactions, muscle injuries, and other overuse injuries in runners". Magn Reson Imaging Clin N Am 7(1999):151-174.
Wright AA, Hegedus EJ, Lenchik L, Kuhn KJ, Santiago L, Smoliga JM. "Diagnostic accuracy of various imaging modalities for suspected lower extremity stress fractures: a systematic review with evidence-based recommendations for clinical practice". Am J Sports Med 44(2016):255-263.
Beck BR, Bergman AG, Miner M, et al. "Tibial stress injury: relationship of radiographic, nuclear medicine bone scanning, MR imaging, and CT severity grades to clinical severity and time to healing". Radiology 263(2012):811-818.
Feldman DS, Singh N, Madan S, Koval KJ. "Stress fractures in athletes: evaluation, treatment, and return to play considerations". Curr Sports Med Rep 12(2013):1-9.
