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Semin Musculoskelet Radiol 2023; 27(01): 054-072
DOI: 10.1055/s-0043-1761613
Review Article

Bone Marrow Lesions in Athletic Stress Injuries: An Overview

Ana Navas
1   Department of Radiology, Division of Musculoskeletal Radiology, Leiden University Medical Center, Leiden, The Netherlands
,
Ara Kassarjian
2   Department of Radiology, Division of Musculoskeletal Radiology, Olympia Medical Center, Elite Sports Imaging, Madrid, Spain
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Erratum: Bone Marrow Lesions in Athletic Stress Injuries: An OverviewSemin Musculoskelet Radiol 2023; 27(01): e1-e1
DOI: 10.1055/s-0043-1768228

Abstract

This article discusses the presumed pathophysiology of osseous sport-related stress changes, the optimal imaging strategy for detecting the lesions, and the progression of the lesions as seen on magnetic resonance imaging. It also describes some of the most common stress-related injuries in athletes by anatomical location and introduces some new concepts in the field.

Keywords

bone - stress - sports - magnetic resonance imaging - fracture


Publication History

Article published online:
03 March 2023

© 2023. Thieme. All rights reserved.

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  • References

  • 1 Gorbachova T, Amber I, Beckmann NM. et al. Nomenclature of subchondral nonneoplastic bone lesions. AJR Am J Roentgenol 2019; 213 (05) 963-982
    CrossrefPubMedGoogle Scholar
  • 2 Palmer W, Bancroft L, Bonar F. et al. Glossary of terms for musculoskeletal radiology. Skeletal Radiol 2020; 49 (Suppl. 01) 1-33
    CrossrefPubMedGoogle Scholar
  • 3 Kornaat PR, de Jonge MC, Maas M. Bone marrow edema-like signal in the athlete. Eur J Radiol 2008; 67 (01) 49-53
    CrossrefPubMedGoogle Scholar
  • 4 Pathria MN, Chung CB, Resnick DL. Acute and stress-related injuries of bone and cartilage: pertinent anatomy, basic biomechanics, and imaging perspective. Radiology 2016; 280 (01) 21-38
    CrossrefPubMedGoogle Scholar
  • 5 Aicale R, Tarantino D, Maffulli N. Overuse injuries in sport: a comprehensive overview. J Orthop Surg Res 2018; 13 (01) 309
    CrossrefPubMedGoogle Scholar
  • 6 Vanhoenacker FM, Snoeckx A. Bone marrow edema in sports: general concepts. Eur J Radiol 2007; 62 (01) 6-15
    CrossrefPubMedGoogle Scholar
  • 7 Kozoriz MG, Grebenyuk J, Andrews G, Forster BB. Evaluating bone marrow oedema patterns in musculoskeletal injury. Br J Sports Med 2012; 46 (13) 946-953
    CrossrefPubMedGoogle Scholar
  • 8 Matheny JB, Goff MG, Pownder SL. et al. An in vivo model of a mechanically-induced bone marrow lesion. J Biomech 2017; 64: 258-261
    CrossrefPubMedGoogle Scholar
  • 9 Tarantino U, Greggi C, Cariati I. et al. Reviewing bone marrow edema in athletes: a difficult diagnostic and clinical approach. Medicina (Kaunas) 2021; 57 (11) 1143
    CrossrefPubMedGoogle Scholar
  • 10 Fredericson M, Jennings F, Beaulieu C, Matheson GO. Stress fractures in athletes. Top Magn Reson Imaging 2006; 17 (05) 309-325
    CrossrefPubMedGoogle Scholar
  • 11 Mountjoy M, Sundgot Borgen J, Burke L. et al. 2014 Female Athlete Triad Coalition Consensus Statement on Treatment and Return to Play of the Female Athlete Triad. Br J Sports Med 2014; 48: 491-497
    CrossrefPubMedGoogle Scholar
  • 12 De Souza MJ, Nattiv A, Joy E. et al; Expert Panel. 2014 Female Athlete Triad Coalition Consensus Statement on Treatment and Return to Play of the Female Athlete Triad: 1st International Conference held in San Francisco, California, May 2012 and 2nd International Conference held in Indianapolis, Indiana, May 2013. Br J Sports Med 2014; 48 (04) 289
    CrossrefPubMedGoogle Scholar
  • 13 Winter EM, Ireland A, Butterfield NC. et al. Pregnancy and lactation, a challenge for the skeleton. Endocr Connect 2020; 9 (06) R143-R157
    CrossrefPubMedGoogle Scholar
  • 14 Niemeyer P, Weinberg A, Schmitt H, Kreuz PC, Ewerbeck V, Kasten P. Stress fractures in the juvenile skeletal system. Int J Sports Med 2006; 27 (03) 242-249
    Article in Thieme ConnectPubMedGoogle Scholar
  • 15 Walker RN, Green NE, Spindler KP. Stress fractures in skeletally immature patients. J Pediatr Orthop 1996; 16 (05) 578-584
    CrossrefPubMedGoogle Scholar
  • 16 Mandalia V, Williams C, Kosy J. et al. Bone marrow oedema in the knees of asymptomatic high-level athletes: prevalence and associated factors. Indian J Orthop 2020; 54 (03) 324-331
    CrossrefPubMedGoogle Scholar
  • 17 Taylor J, Saw AE, Saw R, Sims K, Kountouris A. Presence of bone marrow oedema in asymptomatic elite fast bowlers: implications for management. Bone 2021; 143: 115626
    CrossrefPubMedGoogle Scholar
  • 18 Zhang Y, Shu D, Yao W. et al. MRI study of changes in knee bone marrow edema-like signal in asymptomatic amateur marathon runners before and after half-marathon running. Clin Imaging 2021; 80: 150-157
    CrossrefPubMedGoogle Scholar
  • 19 Kornaat PR, Van de Velde SK. Bone marrow edema lesions in the professional runner. Am J Sports Med 2014; 42 (05) 1242-1246
    CrossrefPubMedGoogle Scholar
  • 20 Laor T, Jaramillo D. MR imaging insights into skeletal maturation: what is normal?. Radiology 2009; 250 (01) 28-38
    CrossrefPubMedGoogle Scholar
  • 21 Chan BY, Gill KG, Rebsamen SL, Nguyen JC. MR imaging of pediatric bone marrow. Radiographics 2016; 36 (06) 1911-1930
    CrossrefPubMedGoogle Scholar
  • 22 Zbojniewicz AM, Laor T. Focal periphyseal edema (FOPE) zone on MRI of the adolescent knee: a potentially painful manifestation of physiologic physeal fusion?. AJR Am J Roentgenol 2011; 197 (04) 998-1004
    CrossrefPubMedGoogle Scholar
  • 23 Kiuru MJ, Pihlajamäki HK, Ahovuo JA. Bone stress injuries. Acta Radiol 2004; 45 (03) 317-326
    CrossrefPubMedGoogle Scholar
  • 24 Mulligan ME. The “gray cortex ”: an early sign of stress fracture. Skeletal Radiol 1995; 24 (03) 201-203
    CrossrefPubMedGoogle Scholar
  • 25 Gosangi B, Mandell JC, Weaver MJ. et al. Bone marrow edema at dual-energy CT: a game changer in the emergency department. Radiographics 2020; 40 (03) 859-874
    CrossrefPubMedGoogle Scholar
  • 26 Ghazi Sherbaf F, Sair HI, Shakoor D. et al. DECT in detection of vertebral fracture-associated bone marrow edema: a systematic review and meta-analysis with emphasis on technical and imaging interpretation parameters. Radiology 2021; 300 (01) 110-119
    CrossrefPubMedGoogle Scholar
  • 27 Foti G, Serra G, Iacono V, Zorzi C. Identification of traumatic bone marrow oedema: the pearls and pitfalls of dual-energy CT (DECT). Tomography 2021; 7 (03) 424-433
    CrossrefPubMedGoogle Scholar
  • 28 Navas A, Kassarjian A. Bone marrow changes in stress injuries. Semin Musculoskelet Radiol 2011; 15 (03) 183-197
    Article in Thieme ConnectPubMedGoogle Scholar
  • 29 Matheson GO, Clement DB, McKenzie DC, Taunton JE, Lloyd-Smith DR, MacIntyre JG. Stress fractures in athletes. A study of 320 cases. Am J Sports Med 1987; 15 (01) 46-58
    CrossrefPubMedGoogle Scholar
  • 30 Iwamoto J, Takeda T. Stress fractures in athletes: review of 196 cases. J Orthop Sci 2003; 8 (03) 273-278
    CrossrefPubMedGoogle Scholar
  • 31 Sinha AK, Kaeding CC, Wadley GM. Upper extremity stress fractures in athletes: clinical features of 44 cases. Clin J Sport Med 1999; 9 (04) 199-202
    CrossrefPubMedGoogle Scholar
  • 32 Baker JC, Demertzis JL. Manubrial stress fractures diagnosed on MRI: report of two cases and review of the literature. Skeletal Radiol 2016; 45 (06) 833-837
    CrossrefPubMedGoogle Scholar
  • 33 Pujol-Marzo M, Balius R. Stress fracture of the sternum. JOSPT Cases Published Online 2021; 1 (04) 240-241
    PubMedGoogle Scholar
  • 34 D'Ailly PN, Sluiter JK, Kuijer PP. Rib stress fractures among rowers: a systematic review on return to sports, risk factors and prevention. J Sports Med Phys Fitness 2016; 56 (06) 744-753
    PubMedGoogle Scholar
  • 35 Sakata T, Kimura Y, Hida T. First rib stress fracture in a sidearm baseball pitcher: a case report. J Sports Sci Med 2005; 4 (02) 201-207
    PubMedGoogle Scholar
  • 36 Kawashima K, Terabayashi N, Asano H, Akiyama H. Classification of stress fractures of the first rib in adolescent athletes. J Pediatr Orthop B 2020; 29 (04) 409-411
    CrossrefPubMedGoogle Scholar
  • 37 Rodrigues C, Claro R. Unusual stress fracture in a CrossFit athlete: a case report. JBJS Case Connect 2021; 11 (01) 00135
    CrossrefPubMedGoogle Scholar
  • 38 Yusuf BS, Segaren N, Segaren N, Di Mascio L. Barista's fracture: a new occupational hazard. JRSM Open 2020; 11 (05) 2054270420918493
    CrossrefPubMedGoogle Scholar
  • 39 Kassarjian A, Llopis E, Palmer WE. Distal clavicular osteolysis: MR evidence for subchondral fracture. Skeletal Radiol 2007; 36 (01) 17-22
    CrossrefPubMedGoogle Scholar
  • 40 Branch T, Partin C, Chamberland P, Emeterio E, Sabetelle M. Spontaneous fractures of the humerus during pitching. A series of 12 cases. Am J Sports Med 1992; 20 (04) 468-470
    CrossrefPubMedGoogle Scholar
  • 41 Horwitz BR, DiStefano V. Stress fracture of the humerus in a weight lifter. Orthopedics 1995; 18 (02) 185-187
    CrossrefPubMedGoogle Scholar
  • 42 McBride AP, Brais G, Wood T, Ek ET, Hoy G. Stress reactions and fractures around the elbow in athletes. J Sci Med Sport 2021; 24 (05) 425-429
    CrossrefPubMedGoogle Scholar
  • 43 DeFroda S, McGlone P, Levins J, O'Donnell R, Cruz AI, Kriz PK. Shoulder and elbow injuries in the adolescent throwing athlete. R I Med J (2013) 2020; 103 (07) 21-29
    PubMedGoogle Scholar
  • 44 Brucker J, Sahu N, Sandella B. Olecranon stress injury in an adolescent overhand pitcher: a case report and analysis of the literature. Sports Health 2015; 7 (04) 308-311
    CrossrefPubMedGoogle Scholar
  • 45 Cain Jr EL, Dugas JR, Wolf RS, Andrews JR. Elbow injuries in throwing athletes: a current concepts review. Am J Sports Med 2003; 31 (04) 621-635
    CrossrefPubMedGoogle Scholar
  • 46 Santelli J, McCambridge TM, Valasek AE, Standiford K. Proximal radial head fractures in young gymnasts: a case series of newly described overuse injuries. Clin J Sport Med 2019; 29 (01) e1-e3
    CrossrefPubMedGoogle Scholar
  • 47 Kajiwara T, Ogawa T, Mamizuka N, Michinobu R, Irie T, Hirano A. High-definition magnetic resonance images on medial elbow injuries in preadolescent Little Leaguers. J Orthop Sci 2022:S0949-2658(21)00398-5
    PubMedGoogle Scholar
  • 48 Hodge C, Schroeder JD. et al. Medial Epicondyle Apophysitis (Little League Elbow). Treasure Island, FL: StatPearls Publishing; 2022
    Google Scholar
  • 49 Adams JE. Little league elbow. Calif Med 1973; 118 (03) 34-35
    PubMedGoogle Scholar
  • 50 Benjamin HJ, Engel SC, Chudzik D. Wrist pain in gymnasts: a review of common overuse wrist pathology in the gymnastics athlete. Curr Sports Med Rep 2017; 16 (05) 322-329
    CrossrefPubMedGoogle Scholar
  • 51 Mauck B, Kelly D, Sheffer B, Rambo A, Calandruccio JH. Gymnast's wrist (distal radial physeal stress syndrome). Orthop Clin North Am 2020; 51 (04) 493-497
    CrossrefPubMedGoogle Scholar
  • 52 Sochacki KR, Liberman SR, Mehlhoff TL, Jones JM, Lintner DM, McCulloch PC. Progression of hamate hook stress reactions in elite baseball players. Orthop J Sports Med 2020; 8 (05) 2325967120919389
    CrossrefPubMedGoogle Scholar
  • 53 Kohyama S, Kanamori A, Tanaka T, Hara Y, Yamazaki M. Stress fracture of the scaphoid in an elite junior tennis player: a case report and review of the literature. J Med Case Reports 2016; 10 (01) 8
    CrossrefPubMedGoogle Scholar
  • 54 Nishikawa K, Kimura Y, Chiba D. et al. Metacarpal stress fracture is not an uncommon condition in adolescent racket athletes. Case Rep Orthop 2020; 2020: 5840925
    PubMedGoogle Scholar
  • 55 Bärtschi N, Scheibler A, Schweizer A. Symptomatic epiphyseal sprains and stress fractures of the finger phalanges in adolescent sport climbers. Hand Surg Rehabil 2019; 38 (04) 251-256
    CrossrefPubMedGoogle Scholar
  • 56 Halsey T, Johnson MI, Jones G. Epiphyseal stress fractures of the fingers in an adolescent climber: a potential “Maslow's hammer” in terms of clinical reasoning. Curr Sports Med Rep 2019; 18 (12) 431-433
    CrossrefPubMedGoogle Scholar
  • 57 Quinlan E, Reinke T, Bogar WC. Spinous process apophysitis: a cause of low back pain following repetitive hyperextension in an adolescent female dancer. J Dance Med Sci 2013; 17 (04) 170-174
    CrossrefPubMedGoogle Scholar
  • 58 Koehler SM, Rosario-Quinones F, Mayer J. et al. Understanding acute apophyseal spinous process avulsion injuries. Orthopedics 2014; 37 (03) e317-e321
    CrossrefPubMedGoogle Scholar
  • 59 Beit Ner E, Rabau O, Dosani S, Hazan U, Anekstein Y, Smorgick Y. Sacral stress fractures in athletes. Eur Spine J 2022; 31 (01) 1-9
    CrossrefPubMedGoogle Scholar
  • 60 Weir A, Brukner P, Delahunt E. et al. Doha agreement meeting on terminology and definitions in groin pain in athletes. Br J Sports Med 2015; 49 (12) 768-774
    CrossrefPubMedGoogle Scholar
  • 61 Chen YT, Tenforde AS, Fredericson M. Update on stress fractures in female athletes: epidemiology, treatment, and prevention. Curr Rev Musculoskelet Med 2013; 6 (02) 173-181
    CrossrefPubMedGoogle Scholar
  • 62 Patel DS, Roth M, Kapil N. Stress fractures: diagnosis, treatment, and prevention. Am Fam Physician 2011; 83 (01) 39-46
    PubMedGoogle Scholar
  • 63 Tyburski MD, Saint-Phard D, Laker S, Van Dorsten B, McCarty E. Femoral stress fractures in a team of elite cross-country runners: a retrospective study of related factors. Med Sci Sports Exerc 2006; 38 (05) s350
    CrossrefPubMedGoogle Scholar
  • 64 Clough TM. Femoral neck stress fracture: the importance of clinical suspicion and early review. Br J Sports Med 2002; 36 (04) 308-309
    CrossrefPubMedGoogle Scholar
  • 65 Anand A, Raviraj A, Kodikal G. Subchondral stress fracture of femoral head in a healthy adult. Indian J Orthop 2010; 44 (04) 458-460
    CrossrefPubMedGoogle Scholar
  • 66 Lee CH, Huang GS, Chao KH, Jean JL, Wu SS. Surgical treatment of displaced stress fractures of the femoral neck in military recruits: a report of 42 cases. Arch Orthop Trauma Surg 2003; 123 (10) 527-533
    CrossrefPubMedGoogle Scholar
  • 67 Tshering-Vogel D, Waldherr C, Schindera ST, Steinbach LS, Stauffer E, Anderson SE. Adductor insertion avulsion syndrome, “thigh splints”: relevance of radiological follow-up. Skeletal Radiol 2005; 34 (06) 355-358
    CrossrefPubMedGoogle Scholar
  • 68 Johansson C, Ekenman I, Törnkvist H, Eriksson E. Stress fractures of the femoral neck in athletes. The consequence of a delay in diagnosis. Am J Sports Med 1990; 18 (05) 524-528
    CrossrefPubMedGoogle Scholar
  • 69 Visuri T. Stress osteopathy of the femoral head. 10 military recruits followed for 5-11 years. Acta Orthop Scand 1997; 68 (02) 138-141
    CrossrefPubMedGoogle Scholar
  • 70 Baker S, Seales J, Newcomer S, Bruce J. A case report: bilateral patella stress fractures in a collegiate gymnast. J Orthop Case Rep 2018; 8 (04) 45-48
    PubMedGoogle Scholar
  • 71 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 2011; 176 (04) 420-430
    CrossrefPubMedGoogle Scholar
  • 72 McClure CJ, Oh R. Medial Tibial Stress Syndrome. Treasure Island, FL: StatPearls Publishing; 2022
    Google Scholar
  • 73 Liong SY, Whitehouse RW. Lower extremity and pelvic stress fractures in athletes. Br J Radiol 2012; 85 (1016): 1148-1156
    CrossrefPubMedGoogle Scholar
  • 74 Gmachowska AM, Żabicka M, Pacho R, Pacho S, Majek A, Feldman B. Tibial stress injuries—location, severity, and classification in magnetic resonance imaging examination. Pol J Radiol 2018; 83: e471-e481
    CrossrefPubMedGoogle Scholar
  • 75 Devas MB, Sweetnam R. Stress fractures of the fibula; a review of fifty cases in athletes. J Bone Joint Surg Br 1956; 38-B (04) 818-829
    CrossrefPubMedGoogle Scholar
  • 76 Boden BP, Osbahr DC, Jimenez C. Low-risk stress fractures. Am J Sports Med 2001; 29 (01) 100-111
    CrossrefPubMedGoogle Scholar
  • 77 Sormaala MJ, Niva MH, Kiuru MJ, Mattila VM, Pihlajamäki HK. Outcomes of stress fractures of the talus. Am J Sports Med 2006; 34 (11) 1809-1814
    CrossrefPubMedGoogle Scholar
  • 78 Towne LC, Blazina ME, Cozen LN. Fatigue fracture of the tarsal navicular. J Bone Joint Surg Am 1970; 52 (02) 376-378
    CrossrefPubMedGoogle Scholar
  • 79 Khan KM, Brukner PD, Kearney C, Fuller PJ, Bradshaw CJ, Kiss ZS. Tarsal navicular stress fracture in athletes. Sports Med 1994; 17 (01) 65-76
    CrossrefPubMedGoogle Scholar
  • 80 Patel KA, Christopher ZK, Drakos MC, O'Malley MJ. Navicular stress fractures. J Am Acad Orthop Surg 2021; 29 (04) 148-157
    CrossrefPubMedGoogle Scholar
  • 81 Saxena A, Fullem B, Hannaford D. Results of treatment of 22 navicular stress fractures and a new proposed radiographic classification system. J Foot Ankle Surg 2000; 39 (02) 96-103
    CrossrefPubMedGoogle Scholar
  • 82 Saxena A, Fullem B, Torg JS. Letter to the editor. Am J Sports Med 2010; 38: NP3-NP5
    CrossrefPubMedGoogle Scholar
  • 83 Rosenberg GA, Sferra JJ. Treatment strategies for acute fractures and nonunions of the proximal fifth metatarsal. J Am Acad Orthop Surg 2000; 8 (05) 332-338
    CrossrefPubMedGoogle Scholar
  • 84 Mandell JC, Khurana B, Smith SE. Stress fractures of the foot and ankle, part 2: site-specific etiology, imaging, and treatment, and differential diagnosis. Skeletal Radiol 2017; 46 (09) 1165-1186
    CrossrefPubMedGoogle Scholar
  • 85 Pountos I, Georgouli T, Calori GM, Giannoudis PV. Do nonsteroidal anti-inflammatory drugs affect bone healing? A critical analysis. ScientificWorldJournal 2012; 2012: 606404
    CrossrefPubMedGoogle Scholar