Imaging of Fatigue Fractures in the Adult Athlete

Vito Chianca; Marco Curti; Martin Riegger; Filippo Del Grande

doi:10.1055/s-0045-1806793

Seminars in Musculoskeletal Radiology, Table of Contents

Semin Musculoskelet Radiol 2025; 29(03): 357-365
DOI: 10.1055/s-0045-1806793

Review Article

Imaging of Fatigue Fractures in the Adult Athlete

Vito Chianca

¹Clinica di Radiologia EOC IIMSI, Lugano, Switzerland

²Lilt Avellino Provincial Association, Avellino, AV, Italy

,

Marco Curti

¹Clinica di Radiologia EOC IIMSI, Lugano, Switzerland

,

Martin Riegger

³Faculty of Biomedical Sciences, Università della Svizzera Italiana (USI), Lugano, Switzerland

⁴Department of Orthopedics and Traumatology, Ospedale Civico e Italiano, (EOC), Lugano, Switzerland

,

Filippo Del Grande

¹Clinica di Radiologia EOC IIMSI, Lugano, Switzerland

³Faculty of Biomedical Sciences, Università della Svizzera Italiana (USI), Lugano, Switzerland

› Author Affiliations

Abstract

Fatigue fractures, also known as stress fractures, are frequent overuse injuries among athletes. They result from repetitive mechanical loads that exceed the bone's adaptive capacity, leading to microdamage and eventual fracture. Early and accurate diagnosis, primarily through magnetic resonance imaging, prevents complications and facilitates optimal recovery. This article provides a comprehensive review of the imaging of fatigue fractures.

Keywords

stress fracture imaging - magnetic resonance imaging - computed tomography - bone marrow edema - radiology of sports injuries

Full Text

References

References
1 Warden SJ, Hoenig T, Sventeckis AM, Ackerman KE, Tenforde AS. Not all bone overuse injuries are stress fractures: it is time for updated terminology. Br J Sports Med 2023; 57 (02) 76-77
2 Johnston TE, Jakavick AE, Mancuso CA. et al Risk factors for stress fractures in female runners: results of a survey. Int J Sports Phys Ther 2021; 1: 72-86
3 Fredericson M, Jennings F, Beaulieu C, Matheson GO. Stress fractures in athletes. Top Magn Reson Imaging 2006; 17: 309-325
4 Matcuk Jr GR, Mahanty SR, Skalski MR, Patel DB, White EA, Gottsegen CJ. Stress fractures: pathophysiology, clinical presentation, imaging features, and treatment options. Emerg Radiol 2016; 23: 365-375
5 Abbott A, Bird ML, Wild E, Brown SM, Stewart G, Mulcahey MK. Part I: epidemiology and risk factors for stress fractures in female athletes. Phys Sportsmed 2020; 48 (01) 17-24
6 Da Rocha Lemos Costa TM, Borba VZC, Correa RGP, Moreira CA. Stress fractures. Arch Endocrinol Metab 2022; 66 (05) 765-773
7 Schroeder JD, Trigg SD, Capo Dosal GE. Bone stress injuries: diagnosis and management. Am Fam Physician 2024; 110: 592-600
8 Kelly AW, Hecht S. The female athlete triad. Ann Jt 2022; 7: 6
9 Behrens SB, Deren ME, Matson A, Fadale PD, Monchik KO. Stress fractures of the pelvis and legs in athletes: a review. Sports Health 2013; 5: 165-174
10 Patel DS, Roth M, Kapil N. Stress fractures: diagnosis, treatment, and prevention. Am Fam Physician 2011; 83: 39-46
11 Bencardino JT, Stone TJ, Roberts CC. et al ACR appropriateness criteria stress (fatigue/insufficiency) fracture, including sacrum, excluding other vertebrae. J Am Coll Radiol 2017; 14: S293-S306
12 Anderson MW, Greenspan A. Stress fractures. Radiology 1996; 199: 1-12
13 Gaeta M, Minutoli F, Scribano E. et al CT and MR imaging findings in athletes with early tibial stress injuries: comparison with bone scintigraphy findings and emphasis on cortical abnormalities. Radiology 2005; 235: 553-561
14 Fredericson M, Bergman AG, Hoffman KL, Dillingham MS. Tibial stress reaction in runners: correlation of clinical symptoms and scintigraphy with a new magnetic resonance imaging grading system. The American Journal of Sports Medicine 1995; 23: 472-481
15 Datir AP. Stress-related bone injuries with emphasis on MRI. Clin Radiol 2007; 62: 828-836
16 Chai JW, Hong SH, Choi JY. et al Radiologic diagnosis of osteoid osteoma: from simple to challenging findings. Radiographics 2010; 30: 737-749
17 Papalada A, Malliaropoulos N, Tsitas K. et al Ultrasound as a primary evaluation tool of bone stress injuries in elite track and field athletes. Am J Sports Med 2012; 40: 915-919
18 Moran DS, Evans RK, Hadad E. Imaging of lower extremity stress fracture injuries. Sports Med 2008; 38: 345-356
19 Ponce A, Peris P, Frade-Sosa B, Arango C, Rojas C, Gómez-Puerta JA. Ultrasound: a useful tool for diagnosing tibial stress fractures. Rheumatology 2025; 28: keaf118
20 Chianca V, Di Pietto F, Zappia M, Albano D, Messina C, Sconfienza LM. Musculoskeletal ultrasound in the emergency department. Semin Musculoskelet Radiol 2020; 24 (02) 167-174
21 Connolly LP, Connolly SA. Rib stress fractures. Clin Nucl Med 2004; 29 (10) 614-616
22 Jones GL. Upper extremity stress fractures. Clin Sports Med 2006; 25 (01) 159-174
23 Koslosky EJ, Heath DM, Atkison CL, Dutta A, Brady CI. Upper extremity stress fractures. Sports Med Open 2024; 10 (01) 100
24 Deshmukh NS, Phansopkar P. Medial tibial stress syndrome: a review article. Cureus 2022; 14 (07) e26641
25 Draghi F, Gitto S, Bortolotto C, Draghi AG, Belometti GO. Imaging of plantar fascia disorders: findings on plain radiography, ultrasound and magnetic resonance imaging. Insights Imaging 2017; 8 (01) 69-78
26 Talusan PG, Diaz-Collado PJ, Reach Jr JS. Freiberg's infraction: diagnosis and treatment. Foot Ankle Spec 2014; 7: 52-56
27 Bencardino J, Rosenberg ZS, Beltran J, Liu X, Marty-Delfaut E. Morton's neuroma: is it always symptomatic?. AJR Am J Roentgenol 2000; 175: 649-653
28 Giuliani L, Ottonello C, Giuliani A. et al MRI in the evaluation of plantar plate disease: diagnostic value of the “stress test”. J Orthop Traumatol 2024; 25: 70
29 Duarte A, Román Antonio A, Bencardino JT. Diagnostic evaluation of stress injuries of the hip using MR imaging. Magn Reson Imaging Clin N Am 2025; 33: 135-142
30 Xu L, Hayashi D, Guermazi A. et al The diagnostic performance of radiography for detection of osteoarthritis-associated features compared with MRI in hip joints with chronic pain. Skeletal Radiol 2013; 42: 1421-1428
31 Fearon AM, Scarvell JM, Neeman T, Cook JL, Cormick W, Smith PN. Greater trochanteric pain syndrome: defining the clinical syndrome. Br J Sports Med 2013; 47: 649-653
32 Maisi N, Patoulias D, Tsagkaris C, Tsagatakis M, Goules D. Transient hip osteoporosis: etiopathogenetic, clinical, and imaging approach. Mediterr J Rheumatol 2022; 30; 33: 196-200
33 Vereecke E, Diekhoff T, Eshed I. et al ESR Essentials: Imaging of sacroiliitis-practice recommendations by ESSR. Eur Radiol 2024; 34: 5773-5782
34 Hopayian K, Danielyan A. Four symptoms define the piriformis syndrome: an updated systematic review of its clinical features. Eur J Orthop Surg Traumatol 2018; 28: 155-164
35 Mayer SW, Joyner PW, Almekinders LC, Parekh SG. Stress fractures of the foot and ankle in athletes. Sports Health 2014; 6 (06) 481-491
36 Vosoughi AR, Borazjani R, Ghasemi N, Fathi S, Mashhadiagha A, Hoveidaei AH. Different types and epidemiological patterns of calcaneal fractures based on reviewing CT images of 957 fractures. Foot Ankle Surg 2022; 28 (01) 88-92
37 Flores DV, Goes PK, Damer A, Huang BK. The heel complex: anatomy, imaging, pathologic conditions, and treatment. Radiographics 2024; 44 (04) e230163
38 Proulx AM, Zryd TW. Costochondritis: diagnosis and treatment. Am Fam Physician 2009; 80 (06) 617-620
39 Gross CE, Nunley JA. Navicular stress fractures. Foot Ankle Int 2015; 36: 1117-1122
40 Lucasti CJ, Namdari S. Acromial stress fractures: a systematic review. Arch Bone Jt Surg 2019; 7 (05) 397-401
41 Bezsmertnyi YO, Bondarenko DV, Shevchuk VI, Bezsmertna HV. Bilateral stress fractures of amputated tibial stumps in the setting of chronic compartment syndrome. Orthop Res Rev 2024; 16: 273-281
42 Teitz CC, Harrington RM. Patellar stress fracture. Am J Sports Med 1992; 20 (06) 761-765
43 Koslosky E, Elder G, Heath D, Brady C, Dutta A. Stress fractures of the hand and wrist in athletes. Injury 2024; 55 (02) 111218