Changes in Volumetric Bone Mineral Density Over 12 Months After a Tibial Bone Stress Injury Diagnosis: Implications for Return to Sports and Military Duty

Am J Sports Med. 2021 Jan;49(1):226-235. doi: 10.1177/0363546520971782. Epub 2020 Dec 1.


Background: Bone stress injuries (BSIs) occur in up to 20% of runners and military personnel. Typically, after a period of unloading and gradual return to weightbearing activities, athletes return to unrestricted sports participation or military duty approximately 4 to 14 weeks after a BSI diagnosis, depending on the injury location and severity. However, the time course of the recovery of the bone's mechanical competence is not well-characterized, and reinjury rates are high.

Purpose: To assess the bone microarchitecture and volumetric bone mineral density (vBMD) over 12 months after a tibial BSI diagnosis.

Study design: Case-control study; Level of evidence, 3.

Methods: We enrolled 30 female athletes from the local community (aged 18-35 years) with a tibial BSI (grade ≥2 of 4 on magnetic resonance imaging) for this prospective observational study. Participants completed a baseline visit within 3 weeks of the diagnosis. At baseline and 6, 12, 24, and 52 weeks after the BSI diagnosis, we collected high-resolution peripheral quantitative computed tomography scans of the ultradistal tibia (4% of tibial length) of the injured and uninjured legs as well as pain and physical activity assessment findings.

Results: From baseline to 12 weeks after the diagnosis, total, trabecular, and cortical vBMD declined by 0.58% to 0.94% (P < .05 for all) in the injured leg. Total and trabecular vBMD also declined by 0.61% and 0.67%, respectively, in the uninjured leg (P < .05 for both). At 24 weeks, mean values for all bone parameters were nearly equivalent to baseline values, and by 52 weeks, several mean values had surpassed baseline values. Of the 30 participants, 10 incurred a subsequent BSI during the course of the study, and 1 of these 10 incurred 2 subsequent BSIs. Participants who suffered an additional BSI were younger and had a later age of menarche, a greater incidence of previous fractures, and lower serum parathyroid hormone levels (P < .05 for all).

Conclusion: Bone density declined in both the injured and the uninjured legs and, on average, did not return to baseline for 3 to 6 months after a tibial BSI diagnosis. The observed time to the recovery of baseline vBMD, coupled with the high rate of recurrent BSIs, suggests that improved return-to-sports and military duty guidelines may be in order.

Keywords: epidemiology; female athlete; running; stress fractures.

MeSH terms

  • Adolescent
  • Adult
  • Bone Density
  • Case-Control Studies
  • Female
  • Fractures, Stress / diagnosis
  • Fractures, Stress / diagnostic imaging*
  • Humans
  • Male
  • Military Personnel*
  • Prospective Studies
  • Return to Sport*
  • Tibia / diagnostic imaging*
  • Young Adult