One of the most common diagnoses, if not the most common diagnosis, I make at New Jersey Sports Medicine, is a stress fracture.
"It's a stress fracture until proven otherwise" I tell my athletes. And one of the most common responses I am given if they have already seen another physician, is "I had an x-ray and was told I don't have a stress fracture".
While x-ray can rule in a stress fracture; meaning if you see it on an x-ray you have one, they can not rule out a stress fracture; meaning if you do not see one on an x-ray, it does not mean you do not have one.
Taking bilateral x-rays with comparison views involves no extra radiation for almost all body parts and can provide invaluable information in early diagnosis of a stress fracture, yet most athletes coming from other institutions rarely have had comparison views of the contra-lateral limb.
An MRI is the diagnostic tool of choice to rule in and rule out a stress fracture.
While x-ray can pick up already healing stress fractures, with appearance of callous, cortical thickening, or periosteal elevation or the rarer completed stress fracture with ominous fracture line, MRI is the test of choice for early diagnosis when not seen on x-ray and has the additional benefit of grading the stress fracture, from a Grade 1 to a Grade 4, or better graded here as low grade versus high grade.
The stress fracture bone is further classified as either a high risk bone or a low risk bone, with high risk bones sometimes requiring prolong rest, many times non-weight bearing with cast, a bone stimulating healing device, or even surgery as the treatment, though Dr. Silberman has never had to have one of his athletes who presented here first require surgery.
Prior to MRI, triple phase bone scan was the test of choice to diagnose a stress fracture, but bone scans involve radiation, so if your college recommends a bone scan over an MRI, likely due to cost, decline and request an MRI.
It is not uncommon to have an athlete in continued pain come in for consultation having already had an MRI and told they did not have a stress fracture, to actually have a stress fracture diagnosed by Dr. Silberman. Often the athlete was told over the phone by a physician assistant, usually
based on the radiology report which might have been written with the words "bone contusion" or "stress reaction" or "medial tibial stress syndrome" or "shin splints".
At New Jersey Sports Medicine, every MRI is personally read by Dr. Silberman along side the patient.
At New Jersey Sports Medicine, Dr. Silberman will teach you how to read and grade stress fractures on MRI better than other physicians. And it is not uncommon for the unfortunate athlete or parent who has been seen here previously, now with pain again to then read films immediately while Dr. Silberman loads the images, learning the bad news before Dr. Silberman even points out the findings, having been taught how to read MRIs previously here at New Jersey Sports Medicine. "I see it" they say with a sunken feeling.
The cause of stress fractures are multifactorial. Our bones build up and break down every day, and there is period of time when after your bones are exposed to more stress they break down more than they build up, and it appears here where they may be most vulnerable. You can not blame one
thing as the cause, though certainly training load and intensity play a role (sometimes it's the distance, sometimes it's the speed - short repeats). Calorie intake plays a huge role in bone health metabolism and calorie deficits will weaken the bones through alteration in your pulsatile hormonal
secretion. Lack of sleep is another huge risk for stress fractures, one the biggest risks found in an Israeli military study on stress fractures. Stress fractures can occur in strong bones and stress fractures can occur in weak bones. If your muscles are fatigued, they may fail to provide shock absorption and greater bone stress can occur when hitting the ground. And in a recent 2019 study, your foot hitting the ground was said not to be the main problem but strong muscles pulling on your bones were implicated as the cause of your stress fracture (Vanderbilt University. "Stress fracture? Your foot hitting pavement wasn't the main problem: Engineer, NFL Players Association adviser find issue with running sensors." Science Daily, 17 January 2019).
Stress fractures can occur acutely, and usually do, meaning the athlete can report the exact moment in the race or training when it occurred. It is at that point in time when the bone finally says I have had enough. Although the name implies repetitive stress, that is not how they seem to occur. And once they occur, you are done, often for 8 to 12 weeks.
Dr. Silberman may check labs and order a Dexa Scan as part of your stress fracture care. And Dr. Silberman will certainly work with you to ensure long time missed from sport does not occur again as a result of a stress fracture, often with specific weekly instructions for your coach.
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