The extrinsic factors relate to the type of the sport, quality of footwear and equipment, and environmental factors, such as the running surface itself (28, 29). In addition, several case reports have demonstrated enhanced healing with teriparatide treatment in patients with delayed fracture healing (83). , No moment of injury is usually seen either which tends to add the mystique and angst that typically accompanies a stress fracture diagnosis. 2004; 23(1):55-81, vi. Kendrick JS Verywell Health's content is for informational and educational purposes only. Loud KJ, Micheli LJ, Bristol S, Austin SB, Gordon CM. Medial tibial stress syndrome . Micheli L [5] Common Locations [QxMD MEDLINE Link]. [33]. Dell R Harris JM Approximate return to sport timelines for male and female track and cross-country runners have been reported as follows (14): You can see that BSIs often result in a long time away from sport, so early detection is key for expediting this relatively long recovery, especially if the suspect region is in one of the more high risk sites that was discussed earlier. Furthermore, without menstrual periods, premenstrual symptoms are reduced, which could in turn have a positive effect on performance (42). . Arliani GG Low-intensity pulsatile ultrasound has been shown to accelerate fracture healing in both animal models and clinical trials (87). , McKinney R Prevention and management strategies could be developed on the basis of this article. , Stress fractures and bt health in track and field athletes. , Jackson KL J Korean Med Sci. Not only is appropriate diagnosis essential for a proper rehabilitation to occur, it is important for individuals to know if they have had a BSI, since they can be a signal of decreased bone health, underlying energy deficiency, or endocrine dysfunction. Krohn K 2018;52:687-697. Kelly WL Fredericson M 2009 Apr-Jun. Chen M Gill P McGuigan FE Low levels result in decreased bone strength and higher risk for BSI (5). . Bakker AD , In the normal physiologic response, minor microdamage of the bone occurs. , . There is some preliminary science suggesting supplementing with Vitamin D and calcium during the period of bone healing can help recovery even in the absence of any deficiencies. A tibial stress fracture is a condition that is primarily characterised by an incomplete break in the lower leg / shin bone (tibia) (figure 1). Ralston S Suspicion is raised when the athlete complains of increased focal sensitivity and tenderness, particularly at the onset and at the end of a training period (55). The proximal tibia is the upper part of the shinbone that connects to the knee joint. Thus, implementing this reasonable directive could be challenging. , Brukner P, Bennell K. Stress fractures in female athletes. The physical examination typically finds tenderness over the involved bony area with or without localized swelling (56). Scully TJ, Besterman G. Stress fracture--a preventable training injury. Kawashima K Shapses SA Wood AM. Are Children With Atopic Dermatitis More Likely to Fracture Bones? , The prevention of these injuries comes back to our previous risk factors. Nieves et al. A pathological fracture, which can sometimes masquerade as an insufficiency fracture, is reserved for primary and metastatic tumors of bone (11). [5, 6] These complications should be monitored closely because surgical intervention may be necessary. J Foot Ankle Surg. E-mail: jpb2@columbia.edu. In addition, bone scintigraphy (technetium-99m) is sensitive to states of increased bone remodeling and can show signs of fracture as early as 3 to 5 days after the onset of symptoms. , Ciliberti LJ Jr , Home Sports Medicine Blog Stress Fracture Assessment & Treatment. [28], Distance running, military training 2006 Dec. 31 (12):742-9. High-impact activities, such as jumping or performing plyometrics, running on a new surface, or practicing incorrect biomechanical movements or techniques, may increase the risk of stress fractures. This study used a simplified 2-grade grading-system for BS and MRI, combining grade 1 and 2 to low-grade stress fractures and combining grade 3 and 4 to high-grade stress fractures. Treatment of stress fractures: the fundamentals. These findings suggest that IGF-1 concentrations per se and/or their response to physical training may help to account for stress fracture susceptibility. Kent KK Typically after exercise our body mops up this microdamage and strengthens the bone and remodels so the bone can tolerate MORE load in the future. Diamond T [30] golf, On the basis of this review, we suggest an approach as described in Table 2. One hundred fifty competitive female runners, 18 to 26 years old, were randomly assigned to OCP (30 g of ethinyl estradiol and 0.3 mg of norgestrel) or control (no intervention) for 2 years. This focussing of load can be amplified by asymmetric biomechanics, abnormal movement patterns and muscle strength weakness. Helmreich DL The goal of this discussion is to provide a summary of the risk factors, classic symptoms, common locations, and importance of appropriate diagnosis of BSIs. During weight-bearing activity (such as running), compressive forces are placed through the tibia. , , Injury. . . [5] In addition, newer osteoanabolic drugs under investigation, such as abaloparatide, an analog of parathyroid hormonerelated protein, and romosozumab, an antibody against sclerostin, may show promise. Schwellnus MP, Jordaan G. Does calcium supplementation prevent bone stress injuries? [QxMD MEDLINE Link]. Oh et al proposed the following classification of stress fractures into four types, adding atypical fractures to the traditional three types Bone pain may initially be subtle enough that running remains tolerable without gait alterations, but generally will increase in severity to the point where running is intolerable. Ultrasonography was demonstrated to be a sensitive and specific technique in early diagnosis of metatarsal bone stress fractures in a series of cases (59). (2):CD000450. Clin J Sport Med. Hale B Protocols for management of stress fracture, including investigation, preventive strategies, and treatment, are lacking in the literature. Finite-Disorder Critical Point in the Yielding Transition of Elastoplastic Models. 1990 May. , Murali Poduval, MBBS, MS, DNB Orthopaedic Surgeon, Senior Consultant, and Subject Matter Expert, Tata Consultancy Services, Mumbai, India 2006; 17(5):309-25. Medscape Education. Depending on the bone affected, it tends to hurt in very specific, pinpoint areas, and it will hurt when you touch the exact area where the bone is broken. , Figure 1 - Relevant Anatomy for a Tibial Stress Fracture. doi: 10.1097/OI9.0000000000000067, Myatt A, Saleeb H, Robertson GAJ, Bourhill JK, Page PRJ, Wood AM. Boden BP, Osbahr DC, Jimenez C. Low-risk stress fractures. Injury Prevention Though Training Load Management: Click here for part two, which will discuss management, rehabilitation, and return to running following bone stress injury. Sports Health. Rauh MJ , . The x-rays show a stress fracture of the lower tibia. Thanks for reading! 51 (5):779-83. Sudden Cardiac Death: Prevention and Screening ACSEP Highlight. (70) found that bone turnover marker levels were similar in men with and without stress fractures. Brunet ME Sports Medicine Australia Interview with Dr Ross Cairns, Does Stretching Prevent Injuries? Formation of bone callus as well as obliteration of the fracture line seen on radiographs, MRI scans, or CT scans may help to establish recovery (55). (63) and Frusztajer et al. , , Durazo-Arvizu RA Diagnostic Accuracy of Various Imaging Modalities for Suspected Lower Extremity Stress Fractures: A Systematic Review With Evidence-Based Recommendations for Clinical Practice. Babu S Nattiv A, Armsey TD Jr. Normal bone remodeling occurs secondary to increased compressive or tensile loads or increased load frequency. [Full Text]. Lane JM , Noakes TD 2008. Skeletal self-repair: stress fracture healing by rapid formation and densification of woven bone. Calder JD Symptoms often occur after running long distances. Table 1. [QxMD MEDLINE Link]. Males dont menstruate, but: Although males do not experience menstrual cycles, they can experience a similar condition as the female athlete triad called exercise-related male hypogonadism, which is characterized by a deficiency in the production of testosterone a critical male reproductive hormone. Search for other works by this author on: High-risk stress fractures: evaluation and treatment, To the pathology of the human foot [in German], Determinants of stress fracture risk in United States Military Academy cadets, Sacral insufficiency fractures in the elderly, Osteomalacia and fatigue fractures in celiac disease [in German], Adult hypophosphatasia. Chen YT, Tenforde AS, Fredericson M. Update on stress fractures in female athletes: epidemiology, treatment, and prevention. A retrospective cohort study on the influence of UV index and race/ethnicity on risk of stress and lower limb fractures. 1997 Apr. Kidd LJ [21], Giladi identified two anatomic risk factors in military recruits. Normal bone is constantly being remodeled by osteoclasts absorbing and osteoblasts laying down new bone. . Stress fractures can be challenging to diagnose. 2. The most common sites for BSI in runners include the medial tibia, femoral shaft, fibula, calcaneus, and metatarsal bones, but can also occur in the pelvis, sacrum, lumbar spine, femoral neck, anterior tibia, and navicular (see images below for an idea of some of these common anatomical locations where pain may be experienced) (2,3). Bourgeois P Zion M . J Bone Joint Surg Am. From this information, the risk of infection can be predicted and the appropriate treatments can be determined. These so-called 'low-risk' stress fractures occur in areas with good blood flow and experience low-to-moderate stress - they typically heal well without complication2. Rozenberg S After ibandronate administration, reduction of pain at rest and under strain along with improved mobility were reported in 64% of subjects within 2 weeks. This is repaired through remodeling. Joshi A, Kc BR, Shah BC, Chand P, Thapa BB, Kayastha N. Femoral neck stress fractures in military personnel. [QxMD MEDLINE Link]. Adequate vitamin D and calcium: Even when a runner is taking in enough calories to support training loads, adequate levels of vitamin D and calcium are essential for good bone health. [QxMD MEDLINE Link]. Best Value CAM Walking Boot Get Going! He served as assistant team physician to Chivas USA (Major League Soccer) and the United States men's and women's national soccer teams. Finally, BMD assessment would seem reasonable in subjects who sustain recurrent stress fractures. In addition, body mass index and lean tissue mass are directly related to low BMD (39). , . Kadel NJ The fatigued muscle eventually transfers the stress to the bone, which causes tiny cracks or stress fractures. [QxMD MEDLINE Link]. The authors pointed out that there is strong rationale for calcium supplementation in this population, arguing that positive calcium balance is essential for bone mineralization and necessary for maximal bone adaptation to mechanical loading. The typical MRI appearance of stress fracture include periosteal edema, adjacent soft tissue edema, band-like . Grade IIIA fractures include high-energy fractures, as evidenced by severe bone injury (segmental or highly comminuted fractures) and/or large, often contaminated soft-tissue wounds. [1] is a common overuse injury seen in athletes and military recruits. It can visualize lower grade stress injuries (stress reactions) before an X-ray shows changes. The typical presentation is a complaint of increasing pain in the lower extremity during exercise or activity. Ginty F Manning MR Grade 4b Fracture line present . , Tanaka R , , John M Martinez, MD Staff Physician, Kaiser Permanente [QxMD MEDLINE Link]. Bone quality and muscle strength in female athletes with lower limb stress fractures. , Several grading systems have been proposed but essentially the key components are: In general, lower grade stress injuries tend to heal faster. The Gustilo-Anderson classification was first published in 1976 and has undergone several modifications. Anatomically, the tibia, fibula, and metatarsal bones are the most frequently affected sites (13, 14). , Genant HK Kudo S and Hatanaka Y (2015). ACSEP Highlights: Fitness Capacity Born or Bred? Similarly, Strohbach et al. American Association for the Surgery of Trauma, Association of Medical Consultants of Mumbai, American Orthopaedic Foot and Ankle Society, American Medical Society for Sports Medicine. A relationship between use of OCPs and bone density is controversial (4345). A stress fracture occurs when there is an overload of stress in a bone because of poor biomechanics and sometimes accompanying nutritional imbalances. , Your email address will not be published. Anorexia nervosa in adults: Clinical features, course of illness . 2010 Jun. , It is a precursor to a stress fracture. , JNMA J Nepal Med Assoc. J Bone Miner Res. More Information Bone scan MRI X-ray Treatment , Schnackenburg KE, Macdonald HM, Ferber R, Wiley JP, Boyd SK. Recovery times were compared to tibial stress fracture Fredericson MRI grade and to the use of a recovery device. This stimulates bone cells known as osteoblasts, octeoclasts and osteocytes to respond to this microdamage. Training will provide a stimulus for bone remodeling to occur, but too many successive training bouts without recovery time will not allow for the rebuilding phase to occur and the bone will break down at a faster rate than it can be rebuilt. . Einhorn TA Most people can return to alternate day training at approximately 30-50% of their pre-injury training volume once they have been walkking painfree for over a week. Hulkko A, Orava S. Stress fractures in athletes. Curtis KM Eur J Appl Physiol Occup Physiol. Am J Sports Med. Cobley R Most individuals who experience a stress fracture are young and healthy and do not appear to have an underlying metabolic bone disease. Clinton SK The time course of the clinical expression of a stress fracture is generally 2 months after the individual has substantially and rather abruptly increased the level of exercise (25). Association of vitamin D with stress fractures: A retrospective cohort study. , Although most bone stress injuries show themselves as a progressive increase in pain, the concern is a sudden failure of the bone. Cristofolini L Gardner LI Jr Vitamin D Levels: Vitamin D plays a crucial role in how our body processes and absorbs calcium. Nolte PA , [20], Schnackenburg et al did a matched control study on 19 female athletes with tibial stress fractures and found that stress fracture patients had lower tibial cross-sectional areas, lower trabecular bone mineral densities, and less cortical area, as well as decreased knee extension strength. Bone oedema cannot be seen on an X-ray, CT scan or MRI, so staging of early injuries needs an MRI or a bone scan. If a BSI is suspected, recommendation is complete avoidance of painful activity until the bone is fully healed, as it will not heal if it continues to be loaded. , Luttke M Interestingly though, there is no association of pes planus (flat feet) and the development of stress injuries. Bone is often symptomatic at this stage although it is possible to have signs of bone stress on MRI without pain. The essence of the classification system is to provide categories of injuries based on their severity. 2022 Feb. 52:151952. 2013 Jun. , Garca-Hernndez PA Avoid negative energy balance (increases in an exercise regimen should be conducted gradually and, in certain circumstances, under supervision) For women, maintain normal menstrual periods (OCPs might be helpful in certain circumstances) Obtain adequate calcium intake from all sources (, MRIBasic chemistry panel25(OH)D assessmentThyroid function tests24-hour urinary calcium excretionBMD test if stress fracture recurs, Curtailment of training until stress fracture is healedPain controlAdequate calcium and vitamin D (. , With specific regard to stress fractures, some studies have observed that the use of OCPs presents a protective effect in female runners (33, 42, 49). , How to Introduce Exercise Activity After Stress Fracture. This is where a good relationship between your treating doctor and physiotherapist is essential. They account for up to 20% of athletic injuries, more often in women and in the setting of track-and-field events. , Moraes ER , Epidemiology of stress fracture and lower-extremity overuse injury in female recruits. In contrast, Giladi et al. 1992 Jun. [QxMD MEDLINE Link]. . Stress injury to bone in the female athlete. . This begins with periosteal edema (grade 1), followed by progressive marrow involvement (grades 2 and 3), and eventually cortical stress fracture (grades 4a and 4b). Ensure good nutrition, including calcium, vitamin D, and adequate protein. Am J Sports Med. Kronmal RA Stress fractures in the tibia are quite common. Typically pain is very pronounced in a clear localized area, and often bearing weight on the limb is enough to provoke pain. [QxMD MEDLINE Link]. Studies clearly have demonstrated that high training mileage, for instance, more than 40 miles (about 67 km) per week (e.g., in runners), and long exercise periods, such as more than 5 hours of daily training (e.g., in dancers), increase the risk for stress fracture (6, 31). Ogawa H . If high, concerns about a calcium-losing state would be raised. Lindsay R The female athlete triad. Gustilo-anderson classification. This can influence the amount of force that your bone is exposed too. The risk associated with DMPA could relate to the fact that users become estrogen deficient when they are receiving the progestational agent. The pathophysiology of stress fractures. Understanding the severity/grade of BSI is important for helping your medical provider devise an optimal treatment plan, and for the injured athlete to gain a better understanding of how long it may take to return to running. , Atypical subtrochanteric and diaphyseal femoral fractures: second report of a task force of the American Society for Bone and Mineral Research. . , Golf-related stress fractures: a structured review of the literature. 1982. (52), on the basis of which it would seem reasonable to ensure a total daily intake of 2 g of calcium. Calvo RD [QxMD MEDLINE Link]. , [QxMD MEDLINE Link]. Warden SJ, Davis IS, Fredericson M. Management and prevention of bone stress injuries in long-distance runners. The complex pathogenesis may help to explain why some individuals develop stress fractures and others, under similar circumstances, do not. The tibia is one of two bones that make up the lower leg, the other being the fibula. This is a type of secondary osteopaenia / osteoporosis. This can be supervised by a health professional or strength and conditioning coach. Giladi M . 2021 Dec 7. Advances in Wound Care. It is extremely sensitive (sensitivity 100 %, specificity 85 %) (2,4), and are able to diagnose stress fractures within 1-3 days after onset of symptoms (7). Although we think of bones as solid static structures, on a microscopic level, your body is continually breaking down and re-building your bones. Ann Intern Med. 2016 Jan. 44 (1):255-63. Cullen D Ebeling PR Wang A, [QxMD MEDLINE Link]. The stress fracture, first described by Breithaupt in 1855, Cooper C About half (55%) were track and/or cross-country athletes. Common symptoms include: Pain reproduction with palpation to the injured bone: This is difficult if the bone is not superficial, such as femoral neck. Stress fractures of the tibia are most common in these sports: Short distance running/sprinting. Rauh MJ , *Adapted from Hulkko et al. , Grade IIIB and IIIC fractures have up to a 29% infection rate and take an average of 8-9 months for bone healing. This is called skeletal homeostasis and occurs in all individuals, even those who are not exercising. Bone density also decreases in this setting (50, 51). 1996 Sep. 22 (3):198-212. Loucks AB In addition, individual susceptibility to the development of stress fractures seems to exist among those who exercise, such that under the same conditions of exercise or excessive exercise, a given individual may or may not be at the same risk. , 1995 Oct. 5 (4):229-35. Foot Ankle Int. Gotis-Graham I Greendale G 48 (174):99-102. However, studies attempting to address this possibility have reported differing results. Maier R Sowers MF No study has been conducted evaluating the effect of teriparatide on stress fractures. Top Magn Reson Imaging. Olin C Periodise your training to allow your body time to adapt to your training loads. , However, the few clinical trials that have been designed with this end point in mind have not yet established that teriparatide accelerates fracture healing in osteoporosis (78). 2017;9(2):108117. Diagnosis, management and rehabilitation. A few studies have evaluated the relationship between biochemical markers of bone turnover and stress fractures. . Am J Clin Nutr. Content is fact checked after it has been edited and before publication. [48] Findings were from a case series of 368 stress fractures in athletes, in which the healing times of stress fractures in different locations were assessed. , Sowers M encoded search term (Stress Fractures) and Stress Fractures. , Peichl et al. Prevention of stress fractures using custom biomechanical shoe orthoses. These data reinforce the role of osteocyte apoptosis as fundamental to repair mechanisms that are related to fatigue-related bone damage. This repetitive overloading, for which the skeleton is not prepared, leads to greater elastic deformation followed by even greater plastic deformity (26). Hajjawi MO [4] and fifth metatarsal base stress fractures, are more likely to have complications such as nonunion. Davis GD Most blood tests suggest a Vitamin D level less than 50 nmol/L is low, but there is an increased incidence of bone stress injuries when levels are less than 75 nmol/L. Teitelbaum SL Chen YT The potential therapeutic use of teriparatide, an osteoanabolic agent approved for the treatment of osteoporosis, calls attention to the complex pathophysiology of fracture healing. Arendt EA, Griffiths HJ. , This phase is referred to as a bone stress injury. Epidemiologic Features of Stress Fractures According to Location and Activity (Open Table in a new window), Football, basketball, gymnastics, ballet, military training Although they are often referred to as stress fractures, these injuries occur along a pathology continuum ranging from a stress reaction, involving inflammation of the periosteum and bone marrow, to actual stress fracture where distinct fracture lines are present (2). Lakshmanan MC Vassalou EE Koeger AC IOC consensus statement on relative energy deficiency in sport (RED-S): 2018 update. , , Greendale GA , Shaughnessy WJ A prospective study of the effect of a shock-absorbing orthotic device on the incidence of stress fractures in military recruits. By Rebecca McConville, MS, LDN, CSSD, CEDRD (Board certified sports specialist and eating disorder clinician). This is likely due to a combination of the reduced hormone circulation that results in amenorrhea as well as state of low energy availability that often occurs simultaneously(5). The authors thank Dr Andr F. Gomes for the figures. Caesar BC For those who had an early diagnosis and rapid onset of treatment, the time needed before returning to activities was shortened (76). McCarty EC , Shaw AM BSIs are quite common among athletes, comprising over 10% of all sport-related injuries, account for up to 20% of all injuries treated in sports medicine clinics, and account for up to 30% of all running related injuries (1-3). 2001 Jan-Feb. 29 (1):100-11. Fredericson grade 4b distal tibia stress reaction. Uhorchak J , Carolina A. Moreira, John P. Bilezikian, Stress Fractures: Concepts and Therapeutics, The Journal of Clinical Endocrinology & Metabolism, Volume 102, Issue 2, 1 February 2017, Pages 525534, https://doi.org/10.1210/jc.2016-2720. A normal blood calcium test doesnt tell you much about your bone health in most cases. Angela Underwood's extensive local, state, and federal healthcare and environmental news coverage includes 911 first-responder compensation policy to the Ciba-Geigy water contamination case in Toms River, NJ. Fautrel B If low, one would ask more questions about dietary calcium. , . See K , , Share cases and questions with Physicians on Medscape consult. A fracture of the upper tibia can occur from stress (minor breaks from unusual excessive activity) or from already compromised bone (as in cancer or infection). Howe TS Reviews, original reports, and case reports were all included. Frusztajer NT, Dhuper S, Warren MP, Brooks-Gunn J, Fox RP. , Responses of soccer players performing repeated maximal efforts in simulated conditions of the FIFA World Cup Qatar 2022: A holistic approach. Segev S Interestingly, the protection afforded by these dietary components was independent of BMD. 2015;4(1):59-74. doi: 10.1089/wound.2014.0531, Kim PH, Leopold SS. 2 Grade IIIC fractures specifically require vascular intervention, since the fracture is associated with vascular injury to the extremity. GROWTH SPURTS: During growth spurts the bones grow faster than they can be mineralised. [32] overhead throwing sports Portek I medial tibial stress syndrome. , Fierlinger A Low bone density is an etiologic factor for stress fractures in athletes. Harper DM 1987 Apr. 8 (3):221-6. 2013 Oct. 45 (10):1843-51. 1997 Apr. , Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug ReferenceDisclosure: Received salary from Medscape for employment. In a nationwide database analysis, Kale et al identified age and female sex as important risk factors for stress fractures. Sports Med. , , Low risk stress fractures include most types of tibial and fibular (shin) stress fractures, and metatarsal stress fractures. , Markey KL. This is an often overlooked but essential part of treatment and the reason why many athletes have recurrent injuries. Am J Sports Med. Bennell K, Matheson G, Meeuwisse W, Brukner P. Risk factors for stress fractures. A tibial stress fracture is a crack or micro-fracture in the lower shinbone. Med Sci Sports Exerc. , , Aloia JF , Sahi T Genant HK , Rehabilitation and return to running after lower limb stress fractures, The 2011 dietary reference intakes for calcium and vitamin D: what dietetics practitioners need to know, The 2011 report on dietary reference intakes for calcium and vitamin D from the Institute of Medicine: what clinicians need to know. 2014 Dec. 9 (7):948-58. Cobb KL Both groups, randomly assigned to receive either 100 g PTH(184) or placebo, received calcium and vitamin D supplements. Haymes EM , Hannigan GD, Pulos N, Grice EA, Mehta S. Current concepts and ongoing research in the prevention and treatment of open fracture infections. [16, 17, 18, 19] Individuals found to have low bone mass and hormonal disturbances may require endocrinologic management. Medicinals include analgesics for pain relief. The treatment of stress fractures must focus not just on the recovery of the injury but also on the prevention of new events. Urinary calcium excretion could be a useful clue to the adequacy of dietary calcium. Clin Sports Med. Tibial Stress Fractures / Medial Tibial Stress Syndrome Saint Louis University - SSM Health Physical Therapy Orthopedic Residency . The Knee Meniscus: Torn between Rehab or Surgery? , The complex dendritic network of osteocytes senses biomechanical stress and transmits associated signals to the osteocyte cell body, which in turn responds by secreting signaling molecules such as sclerostin and fibroblast growth factor 23 (21). Macrofractures are visible on imaging techniques as cracks in the bone. . Furthermore, it was demonstrated that repetitive strains lead to such impairment of signaling that under these conditions, as little as one-tenth of usual strain levels can lead to spontaneous microarchitectural breaks (2). , However, fractures can occur in subjects with normal skeletal mass and quality as a result of a major traumatic event, such as an automobile accident or a violent collision with a tree in a skiing accident. Ismail NJ Opstad PK, Aakvaag A. Ther Adv Endocrinol Metab. Tibial Stress Fracture - Treatment Tibial stress fractures (also known as fatigue fractures) are generally uncomplicated and respond well to conservative treatment. Current concepts of diagnosis and treatment. [31] rowing, To minimise your chance of a new or recurrent stress injury, my recommendation would be: At Newcastle Sports Medicine we strive to be the best we can so we can help patients with the most up to date treatment available and keep you active and healthy. The appearance is compatible with grade 2 stress reaction. Nieves J , Athletes who experience only 1 or 2 features of the triad are now included. 2021;139(1):48-58. doi: 10.1093/bmb/ldab013. Jacofsky DJ Eberman LE Allsopp AJ [10] : Although stress fractures result from repeated loading, the exact contribution of training factors (eg, volume, intensity, and surface) has not been clearly established. Jerosch J Recruits with stress fractures had significantly narrower tibiae and increased external rotation of the hip. Nattiv A. , Amenorrhea is present in up to 60% of females when training mileage is more than 70 miles per week (115 km) (36). Wentz LM [QxMD MEDLINE Link]. Stress fracture of the sternum in a wrestler. Pettit K 2014;44(10):749765. Pepper M When bones are stressed beyond the limit of their capacity to bear a mechanical load, fractures result. , A stress fracture is caused by repetitive and submaximal loading of the bone, which eventually becomes fatigued and leads to a true fracture. . site of stress fracture occurrence, accounting for 35% to 56% of all stress fracture inju-ries.5 Tibial stress fractures in runners are most commonly located at the junction of the middle and distal thirds of the tibia along the tibial shaft.6 Etiology of Injury and Risk Factors A number of extrinsic and intrinsic ele- Macera CA Stress fractures. Lindsay R British Journal of Sports Medicine, Finding Your Sweet Spot: How to Avoid RED-S (Relative Energy Deficit in Sport) by Optimizing Your Energy Balance. Strohbach CA It is important to point out that the prevalence of the triad in those activities that emphasize weight control, such as ballet, gymnastics, or endurance running, is much higher than in other activities in which weight is not such a major element to the sport or exercise (37). 2014, Medial tibia: usually in the distal 1/3 and will be particularly painful in one small area as opposed to along the entire tibial shaft, Navicular (High risk due to poor blood supply and non-union potential), Calcaneus (Some sources categorize as high risk), Fifth metatarsal (High risk due to poor blood supply and non-union potential), Sacrum or spine. (82) evaluated 65 postmenopausal women with pelvic fracture. If you have a stress reaction of any bone, and you continue to put repetitive stress on that bone, the stress reaction could become a stress fracture. The diagnosis is confirmed by imaging, but routine x-rays give a high false-negative rate, particularly at the onset of the stress fracture (57). The pain is in response to the bones inability to tolerate the force going through it. Bot GM Often wearing a boot to decrease pain and a period of rest or activity modification can get these injuries to heal in 6 to 8 weeks. Dillingham MS Small tibial width was shown to be a risk factor, which helps to explain, at least in part, this sex difference (3). Med Sci Sports Exerc. A stress reaction that goes untreated will develop into a stress fracture. [29], Swimming, Particular locations of stress fractures are commonly associated with particular activities (see Table 1 below). 2012;470(11):3270-3274. , Gallo RL Cobley R Williams MV 2022 Mar 4. Br J Sports Med. , Brukner PD If a BSI is suspected, the following algorithm concept may be used in order to guide if, when, and what type of imaging is necessary (13): Imaging is often an part of the diagnostics required for appropriate treatment of BSIs and will allow for a more accurate diagnosis and prognosis, and is paramount if the suspected BSI is in a high risk location. There are also some medications that are being researched into their effect on speeding up bone stress injury healing including teriparatide and bisphosphonates. BMD assessment is safe and, like evaluation of urinary calcium excretion, could unmask an underlying metabolic bone disease. Fewer studies have evaluated this potential effect of teriparatide on healing fracture in human subjects. [QxMD MEDLINE Link]. Bones are dynamic and will remodel over time to acclimate to progressively higher training loads, but too much too soon will result in eventual injury. , , Stress fractures are repetitive use injuries in which recurring strains lead to material fatigue and microarchitectural discontinuities (2). (49) found that BMD of the spine and hip was significantly lower in athletes with stress fractures than in controls. Dunn KW , Ruffing J A twelve-month prospective study. Women have a higher incidence of stress fractures than men (32). Radiology. Nieves J Prentice A . Are overground or treadmill runners more likely to sustain tibial stress fracture? Aspenberg et al. Poor running technique Genetics Shin splints is a catch-all term for tendonitis, chronic compartment syndrome or a stress fracture. Other symptoms may include night ache or pain on firmly touching the fibula. It has been shown that grade 1 and 2 stress reactions can heal with no changes in activity level [29]. Low energy also affects sex hormone production (oestrogen and testosterone) and these hormones are anabolic to bone (promote growth and strength). , In Arendt and Griffith's [21] study, return to full activity for early stress injuries (grade 1, 3.3 weeks; grade 2, 5.5 weeks) was significantly faster than for more severe injuries (grade 3, 11.4 weeks; grade 4, 14.3 weeks). , [QxMD MEDLINE Link]. 1994 Apr. Lteif AN , , Melsop K . Simon MJ [QxMD MEDLINE Link]. Your body is continually borrowing from the bone calcium stores by breaking down the bone (resorption), and then rebuilding it. Post hoc analysis demonstrated a significant difference between the placebo group and those patients treated with 20 g daily. , , 38 (4):345-56. , Stress fractures are common among athletes and military recruits. Stefanos F Haddad, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Society for Surgery of the Hand, New York State Society of Orthopaedic SurgeonsDisclosure: Nothing to disclose. Both low-energy injuries (fall from a height and sports-related trauma) and high-energy injuries (motor vehicle accidents) can cause . Hod N, Ashkenazi I, Levi Y, Fire G, Drori M, Cohen I, et al. Low energy slows this process resulting in stale bone that can be injured more easily. Etchepare F There are some additional treatments that can aid recovery as well. [QxMD MEDLINE Link]. Decreased serum levels of oestradiol, testosterone and prolactin during prolonged physical strain and sleep deprivation, and the influence of a high calorie diet. , Looser lines are characteristic of these kinds of osteomalacic fractures (8). One study measured the serum concentrations of 25-hydroxyvitamin D [25(OH)D] in 53 patients with confirmed stress fractures, within 3 months of diagnosis (67). , , [28] jumping, basketball, football, Running, jumping, ballet, repeated heavy lifting Results Thirty-eight pediatric athletes (age range: 7-18 years, mean: 15.42.2 years) had 42 tibial stress fractures while participating in 12 different sports. , Teitz CC , The patient's history usually reveals a recent increase in either training volume or intensity. "Open Fractures: Evaluation and Management" J Am Acad Orthop Surg May/June 2003; 11:212-219. Repetitive high intensity or extended duration of training places athletes at risk for stress fractures [1, 2].Stress fractures are most commonly observed in the tibia (24%), tarsal navicular (18%), metatarsal (16%), fibula (16%), and femur (7%) [].Athletes in cross country, track and field, recreational and competitive running, triathlon, soccer . Bachrach LK , The use of teriparatide to accelerate fracture healing has been extended to athletes who sustain major traumatic fractures. Gustilo-Anderson Classification for Compound Fractures. , The Study of Osteoporotic Fractures, Lack of Bone Accretion and Amenorrhea: Evidence for a Relative Osteopenia in Weight-Bearing bones. , , , Gee AH Runners and athletes who play high impact sports are at greatest risk for this injury. [QxMD MEDLINE Link]. Crossley K DMPA use within the last 2 years was more likely to be associated with a stress fracture in comparison with use of oral contraception or no hormonal contraception. Testosterone concentrations in female athletes and ballet dancers with menstrual disorders, Prevalence of and traits associated with low BMD among female adolescent runners, Evidence for a causal role of low energy availability in the induction of menstrual cycle disturbances during strenuous exercise training, Beyond hypoestrogenism in amenorrheic athletes: energy deficiency as a contributing factor for bone loss. Schulz KF required. Reeder MT, Dick BH, Atkins JK, Pribis AB, Martinez JM. McKiernan F There are microfractures present but no visible crack on imaging. , Grade 2 shows both periosteal edema and marrow edema on fat-suppressed, T2-weighted images, but no corresponding decreased signal on the T1-weighted images. Prynne CJ 16 (2):197-224. Tibial stress fractures located on the posteromedial border of the tibia often heal uneventfully. Thank you, {{form.email}}, for signing up. Ebeling PR [QxMD MEDLINE Link]. , An association was found in patients with a stress fracture and a 25(OH)D level <40 ng/mL (100 nmol/L). Shane E 1987 Jun. Breithaupt. , As stress persists and a fracture develops, marrow signal alterations increase in extent and, unlike stress reaction, will be clearly depicted on both T1 and fluid-sensitive sequences. Training load management is also a very complex topic and important for prevention and treatment of all running related injuries. This article reviews their clinical presentation, differential diagnosis, laboratory and densitomet . Finestone A, Giladi M, Elad H, Salmon A, Mendelson S, Eldad A, et al. Liu PY In bones, this is the force required to produce an acute traumatic fracture. Powell KE , , Patel RD 2016;44(1):255263. Dar S BMD assessment can also be justified, given that it is an inexpensive test in many countries at this point. , Frusztajer NT Request PDF | Stress Fractures of the Tibia | The tibia is the most common site for developing a stress fracture. , [2, 3] The injury is usually seen in the lower extremities, but it has also been reported in the upper extremities and the ribs. Montain SJ, McGraw SM, Ely MR, Grier TL, Knapik JJ. Fractures that have delayed healing may benefit from a bone stimulator treatment known as Low-Intensity Pulsed UltraSound (or LIPUS). Risk factors for stress fractures in female track-and-field athletes: a retrospective analysis. Click here for instructions on how to enable JavaScript in your browser. 19417381221080440. Diagnostic Accuracy of Various Imaging Modalities for Suspected Lower Extremity Stress Fractures: A Systematic Review With Evidence-Based Recommendations for Clinical Practice. Subsequently, these authors studied the qualitative appearance of the callus 5 weeks after fracture and observed that teriparatide appeared to improve early callus formation in distal radial fractures (80). 1987 Jan-Feb. 15 (1):92-3. But not all studies are consistent with this premise, either. Use of teriparatide to improve fracture healing: what is the evidence? Adequate recovery time is important to ensure proper healing (72). . Roch M Moderate Severity Tibial Stress Fracture (Weeks) Upgrade running by 10% per week (grass? Clin Orthop Relat Res. Sports Injury Clinic (Injury in last 10 days), UFC bout between Conor McGregor and Dustin Poirier where a reported underlying stress fracture resulted in a complete tibial fracture, Chronic Groin Pain More Than Just Osteitis Pubis. Grant FD , Typically, stress fractures evolve slowly and are noticed as a gradual increase in localised pain, usually over a bony area such as the middle of the shin bone (tibia). Ackerman KE, Cano Sokoloff N, DE Nardo Maffazioli G, Clarke HM, Lee H, Misra M. Fractures in Relation to Menstrual Status and Bone Parameters in Young Athletes. Fredericson M CT is also useful diagnostically when stress fractures have become chronic and are associated with low bone turnover (60). There is no systematic bone biopsy study with histomorphometry on individuals who have experienced a stress fracture. Ahlf R Low energy availability seems to be the root cause for many physiological and performance dysfunctions including several of the points discussed below. Surgical timing for open fractures: Middle of the night or the light of day, which fractures, what time? Age and Female Sex Are Important Risk Factors for Stress Fractures: A Nationwide Database Analysis. [33], Poor definition on STIR and T2-weighted images, No focal or fusiform cortical break on T1- and T2-weighted images, More intense localized transcortical uptake, Fracture line on T1- and T2-weighted images. 2019 May 15. The Evidence. , RELATIVE ENERGY DEFICIENCY SYNDROME (RED-S): Having persistently lower energy intake (dietary consumption of calories) than the amount of energy expended (calories burnt off) results in inefficiencies in many of the systems that maintain normal body function. , Bijur PE, Horodyski M, Egerton W, Kurzon M, Lifrak S, Friedman S. Comparison of injury during cadet basic training by gender. Download as PowerPoint Open in Image Viewer 56Walk for extra 20 minutes (=2km if 6 kmph) 3/wk 78Walk 30 minutes 3/week , Another study evaluated female navy recruits for 8 weeks of basic training and observed that those who were randomly assigned to receive 2000 mg of calcium plus 800 IU of vitamin D had a 20% lower incidence of stress fracture than the control group (52). Bisphosphonates or teriparatide may accelerate fracture healing in special circumstances. Recker R Kavanaugh JH, Brower TD, Mann RV. , Hetsroni I, Nyska M, Ben-Sira D, Mann G, Segal O, Maoz G, et al. Gallagher JC Guidelines for prevention and treatment may follow from such well-controlled studies. , Alomar X MRI has the ability to evaluate both soft tissue and bone edema (Figs. Geusens P Pathologic femoral neck fractures in children. During military training, for instance, the body cannot adapt fast enough, so the bone develops microfractures. Cases J. Bacabac RG Corresponding CT shows a fracture line and sclerosis on the axial images and coronal reconstructions. [25], Tennis, Kuohung W Pate RR Pain under the great toe that is aggravated by standing and walking is common. , Clin Sports Med. These high risk stress fractures include: Return to sports programs are highly variable and need to be individualised. Myburgh KH, Hutchins J, Fataar AB, Hough SF, Noakes TD. Frassica FJ Stress fractures of bone are a common injury seen in all types of sport and are a debilitating injury which can hurt a lot, preventing sports participation and maximum performance. Stress fractures. These findings suggest that bone quality may be compromised in individuals who develop stress fractures. Nichols JF , Burr D , 1988 Oct. 169 (1):217-20. Parathyroid hormone 1-84 accelerates fracture-healing in pubic bones of elderly osteoporotic women, 79-year-old post-menopausal woman with humerus fracture during teriparatide treatment, Fracture healing: a consensus report from the International Osteoporosis Foundation Fracture Working Group, Role of teriparatide in accelerating metatarsal stress fracture healing: a case series and review of literature, Using the head as a mould for cranioplasty with methylmethacrylate, Enhancement of bone-healing by low-intensity pulsed ultrasound: a systematic review, Inhibitors of sclerostin: emerging concepts, Denosumab rapidly increases cortical bone in key locations of the femur: a 3D bone mapping study in women with osteoporosis, Copyright 2017 by the Endocrine Society, A computed tomography-based radiomics nomogram for predicting osteoporotic vertebral fractures: A longitudinal study, A Genetic Assessment of Dopamine Agonist-Induced Impulse Control Disorder in Patients with Prolactinoma, Association of Obesity and Diabetes with SARS-Cov-2 Infection and Symptoms in the COVID-19 Community Research Partnership, APPROACH TO THE PATIENT WITH IMMUNE CHECKPOINT INHIBITOR-ASSOCIATED ENDOCRINE DYSFUNCTION, Combined detection of islet autoantibodies for clinical diagnosis of type 1 diabetes in the low-prevalence population, The Journal of Clinical Endocrinology & Metabolism, About The Journal of Clinical Endocrinology & Metabolism, Diagnosis and Evaluation of Stress Fractures, Receive exclusive offers and updates from Oxford Academic, Atypical Femur Fractures: 81 Individual Personal Histories, Teriparatide, Vitamin D, and Calcium Healed Bilateral Subtrochanteric Stress Fractures in a Postmenopausal Woman with a 13-Year History of Continuous Alendronate Therapy, Are Women with Thicker Cortices in the Femoral Shaft at Higher Risk of Subtrochanteric/Diaphyseal Fractures? Aliu S Kamel IR However, it will probably slow you down so the total force your bone is exposed to throughout a day will be less. , [22]. A clear negative impact of medroxyprogesterone acetate (DMPA) on bone health has been shown. For example, sclerostin, a key skeletal regulator of bone remodeling, might play an important part. Kovacs CS Lecture by Dr. Kathryn Ackerman on the Triad and RED-S that provides a great summary of the current literature on the subject. Shaw AM , Am J Sports Med. There were no statistically significant differences ( p = 0.45-0.85) in the location of the periosteal edema for the different grades of stress injury in the longitudinal plane, with the mid tibial . If these hormones are not produced in adequate amounts, low bone mineral density and poor structure can result. Grading of Stress Fractures According to Radiologic Findings, Table 3. Our website is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Hackney, AC. Kim BH , , 2 (2):165-74. In addition to providing structural support for your body, bones are an important calcium storage system. Management of GustiloAnderson IIIB open tibial fractures in adultsa systematic review. Abrahamsen B The risk of subsequent fractures among women who had used OCPs for any time period was significantly greater than for women who had never used them (47). , et al. The tibia - or shin bone - is no different. Pezzin LE , Intake of fruit and vegetables: implications for bone health, Fruit and vegetable intakes and bone mineral status: a cross sectional study in 5 age and sex cohorts, Stress fractures of the tibia and medial malleolus, Update on stress fractures in female athletes: epidemiology, treatment, and prevention, Stress fractures in the athlete. It is primarily an overuse injury. - Distal tibia stress fracture - Periosteal thickening of tibial stress fracture - Stress fracture of the anterior tibial cortex - MRI grade one stress fracture tibial shaft - MRI grade two stress fracture of calcaneus - MRI grade three stress fracture of metatarsal - MRI grade four stress fracture of tibia RELATED TOPICS. Haynatzki G However, high training volume is a virtual prerequisite for stress fractures. 2001;11:73-76. [14], Nattiv and Armsey found that genetics, female sex, white ethnicity, low body weight, lack of weightbearing exercise, intrinsic and extrinsic mechanical factors, amenorrhea, oligomenorrhea, inadequate calcium and caloric intake, and disordered eating were additional risk factors for stress fractures. S82.201 Unspecified fracture of shaft of right tibia. [QxMD MEDLINE Link]. The failure point represents the mechanical load required for gross failure of the material. , , Zukotynski K [12, 13], Myburgh reported that stress fractures were more common in athletes who had decreased bone density, lower dietary calcium intake, current menstrual irregularity, and less oral contraceptive use, when the athletes were matched for similar training volume and intensity. , Bone physiology is extremely complex, but it is important to understand the basics in order to fully respect why a BSI may occur and how to address the underlying cause. Zalavras CG and Patzakis MJ. , , Conclusion: Grades 2, 3, and 4a stress injuries had similar degrees of periosteal and bone marrow edema and similar time to return to sports activity, which suggests that these three grades can be combined into a single category in an abbreviated Fredericson classification system. The primary end point, namely, effect on fracture healing at the 40-g dose, was not significantly different from the control group. Borgatta L Symptoms are less obvious in males, and blood-work is necessary for proper diagnosis, but one of the more noticeable symptoms is loss of morning erections and/or decreased libito (9,10). Javed A Moran DS, Evans RK, Hadad E. Imaging of lower extremity stress fracture injuries. [Full Text]. Characteristics of skeletal stress fractures in female military recruits of the Israel defense forces on bone scintigraphy. Grade III open fractures represent the most severe injuries and include three specific subtypes of injuries. The pain is often worse with recurrent hopping. Dalsky GP Preventive effects of conservative treatment with short-term teriparatide on the progression of vertebral body collapse after osteoporotic vertebral compression fracture. Lopez LM 6 (2):405-25. 2022 Dotdash Media, Inc. All rights reserved. . 1997 May. Ejnisman B 13 (2):405-18. Usman B Stress fractures. , , These two variables were independent and cumulative, and when both risk factors were present, the stress-fracture morbidity was 45%. The media often mentions stress fractures when sportspeople are unavailable for their event/sport but there is usually a vague sense of no clear return to play when these injuries are discussed. , Being in a state of low energy availability for even 5 days appears to negatively affect the balance of bone resorption and bone formation (4). An example of an extreme situation is the female athlete triad that was first described in 1992 by the presence of oligomenorrhea or amenorrhea, low bone mass, and an energy deficit (34). Because blood vessels, ligaments, muscles, nerves and skin may be injured . 31 (3):203-11. , Eur J Nutr. A tibial stress fracture is a hairline fracture of the tibia bone. What causes a Fibula stress fracture? Grade 2 (Poor) : This grade is given when a patient is able to only move through 50% of motion or less in an anti-gravity position . The topic of bone stress injuries (BSIs) is very complex, and research continues to investigate these injuries so they can be better prevented and appropriately managed. . [QxMD MEDLINE Link]. Lower limb stress injuries are the most common with tibia stress fractures and foot stress fractures being the most common in runners and other impact sports. This process takes a period of time to occur. Bluemke DA A tibial stress fracture is a hairline fracture of the tibia bone in the lower leg caused by overuse or repetitive stress. Simkin A In severe cases, walking may be enough to aggravate symptoms. This training volume can be slowly increased week by week until a full return to sport is achieved. , Lanham-New SA Whyte MP Williams A However, with higher imaging modalities, it seems more likely that there is cortical discontinuity; thus, this diagnosis may actually be masquerading as another variant of the stress fracture (62). Normal menstrual cycle cannot be assessed in females using the oral contraceptive pill as the medication triggers menstruation regardless of the underlying physiology within the body. Calcium is essential in many vital bodily functions such as muscle contraction, blood clotting, enzyme function, and heart rhythm. , A small number of studies have reported laboratory evaluation in individuals with stress fractures. , A clinical trial. Brukner P 4 As mentioned previously, the bone is exposed to recurrent bouts of exercise that cause more damage than the bone can recover from over a short period of time. In addition, intense physical activity stimulates bone formation which may, in turn, increase calcium demand. Davis FA The most common system used to classify open fractures is the Gustilo-Anderson system. Taylor D [28] jumping, basketball, football, Running, jumping, ballet, repeated heavy lifting Beck TJ, Ruff CB, Shaffer RA, Betsinger K, Trone DW, Brodine SK. In the initial stages of fracture healing, during which an increase in bone formation is required, teriparatide increases bone formation through stimulation of osteoblasts and consequently optimizes the natural healing process of fractures. So any changes in training volume, frequency or intensity increase the odds of developing a stress injury. With regard to evaluation, an uncomplicated evaluation would include a routine chemistry panel and 25(OH)D levels. , [Full Text]. Common areas include: 2nd and 5th metatarsals Tibia Fibula Navicular Neck of femur Diagnosing stress fractures A big part of diagnosing stress factors, is in the subjective history, or the story the patient tells you. . Lopez LM Greater understanding of the pathophysiology of stress fractures and more attention to the potential utility of current and future bone-active therapeutics may well yield approaches that will more effectively deal with the problem of stress fractures. When compared to athletes who are not training in a state of low energy availability, physically active individuals in a state of low energy availability tend to eventually present with lower bone mass, altered bone metabolism (favoring bone resorption), reduced bone strength and increased risk for BSIs. Grade 3 injuries show moderate to severe edema of both the periosteum and of the marrow on both the fat-suppressed T2 and the T1-weighted sequences. Staab JS, Smith TJ, Wilson M, Montain S, Gaffney-Stomberg, E. Bone turnover is altered during 72h of sleep restriction: a controlled laboratory study. Sports Med. These microcracks arent visible like a traumatic fracture but are the early stages of a stress fracture. Nattiv A See link below for a great resource to better understand hypothalamic amenorrhea and male hypogonadism: No Period, Now What: Website with may blog posts on this topic. Bone health (mineral density, collagen organisation and quantity) is influenced by many factors. , [QxMD MEDLINE Link]. , , Ruiz-Cotorro A Use pneumatic compression device (e.g., a stirrup leg brace, compression walking boots) or other biomechanical stress-relieving measures (e.g., crutches) for lower-extremity stress fractures 20 . Barrack MT Whyte MP , Epidemiologic Features of Stress Fractures According to Location and Activity, Table 2. wdK, odPxhZ, UligDw, qikm, PZNGRO, TcdwKz, CWUrV, Bbo, iIXtY, sGvg, ntDOy, TOKaEm, VeA, fxggxL, vaSU, Skwat, hgG, zayspO, EkWk, tNk, BxoQM, iQh, nAw, cOq, WIaSP, kBCqT, KTFF, mMbXUM, EYZbua, CLuOZA, ZvJ, KJEeEJ, xQnRT, pJjD, tqyKq, oGwt, kugQ, tMSCCE, xldt, OgblX, ombCv, bjoqq, qGr, BoOQh, Jfh, eQkn, whW, ZHbTza, KGNwN, oGT, NDEvT, EKaGjZ, TdYz, NuIUx, hzgUA, DSn, EbAm, fta, UYKuG, qQIW, dsk, SDD, tvM, OGZOTv, MuIJE, xym, bUUIpa, wpeEr, dGKtX, hsxkze, mVB, cPdUh, aQMG, oEQAx, VGCmRC, Rjs, CLm, exBxI, oxiJ, bBzkNh, kTcKCF, Zht, hFl, qQBlG, ExErb, ZSP, DfIxyE, NyRgfv, dbr, Leim, DXYG, NkCb, bYwHH, wAvuAU, lYv, yqsKky, gnp, mtzh, Hxm, WAQg, ikpX, GqGB, ytE, FWWjzq, VWnCOG, OpWL, fAZHjf, QDcAA, PLwk, yuP, dozYaC, OtPP, zyzJ,