PEDIATRIC STRESS FRACTURES: A PICTORIAL ESSAY

Nirav H. Shelat, DO, Georges Y. El-Khoury, MD

ABSTRACT parts of the musculoskeletal system in children, are

More children are participating in organized
and recreational athletics at a younger age. It
has been well documented that increased athletic
specialization and year-round activities have re-
sulted in higher incidences of overuse injuries,
including stress fractures and stress reactions.
Initially, stress fractures can be radiographically
occult. Continued stress on the injured bone
or cartilage can lead to progressive radiographic
changes. Because of the prevalence of these in-
juries, both orthopedic surgeons and radiologists
should be aware of the radiographic and magnetic
resonance imaging (MRI) features of common
stress fractures in children. This article reviews
frequently encountered stress fractures involving
various bones in the pediatric population.
common sites for stress fractures. Abnormal stresses
at these sites may result in disruption of endochondral
ossification, ultimately resulting in physeal widening5.
Repetitive microtrauma also leads to bony cortical
defects and stress fractures, which can be in the form
of fatigue fractures (excessive forces on normal bone)
or insufficiency fractures (normal forces on abnormal
bone)2. This article reviews the classic radiographic
and MR findings of common stress fractures in children.
Spine: Spondylolysis
Spondylolysis is a stress fracture which occurs through
the pars interarticularis, and occasionally through the
pedicle. It is the result of repeated bouts of extension
and rotation about the spine6. It has been observed
with higher frequency not only in young athletes, but

INTRODUCTION
A recent increase in the number of children participat-
ing in competitive sports has resulted in an increase in
stress injuries1. These stress injuries can be difficult to
diagnose. In young children, the clinical examination is
often difficult given the inability of children to provide
detailed histories or fully participate in the physical exam.
Detection of the hallmark features of common stress inju-
ries on both radiographs and MRI can aid in the diagnosis.
Stress fractures are the result of repetitive forces on
the musculoskeletal system that has not had sufficient
time to recover2. In children, factors such as weaker
osteochondral junctions, thinner cortices, hormonal
changes, and decreased mineralization predispose to
stress fractures3,4. This is further compounded by par-
ticipation in sports with demanding schedules which may
not allow adequate time for the child to recover. The
physis and the apophysis, which are among the weaker

Nirav H. Shelat, DO
Georges Y. El-Khoury, MD
University of Iowa Hospitals and Clinics
200 Hawkins Drive
01043 JPP
Iowa City, IA 52242 Figure 1. 13-year-old basketball player complaining of low back
pain. (A) Axial T1 image demonstrates transversely oriented low
319-356-3654
signal (arrow) through the L5 pedicle and pars. (B) Axial T2 image
Nirav-shelat@uiowa.edu demonstrates corresponding edema (arrow), confirmed on sagittal
george-el-khoury@uiowa.edu T1 (C) and STIR (D) sequences (arrows). Findings are consistent
The authors have no conflicts of interest to disclose. with unilateral stress fracture through the left pars interarticularis.

138   The Iowa Orthopedic Journal


Figure 2. 16-year-old baseball pitcher with recent onset of low back pain. (A) Axial T1, (B) T2 and (C) sagittal STIR images demonstrates
bone marrow edema (arrows) in the left L3 pedicle, consistent with non-displaced stress fracture.
Figure 3. Collegiate American football player with shoulder pain and
known lesser tuberosity avulsion. (A) Axillar y shoulder radiograph
performed to follow up lesser tuberosity avulsion demonstrates an
unfused apophysis (arrow) at the acromion. (B) Follow up MRI
demonstrates edema at the apophysis (arrow), consistent with ac-
romial apophysiolysis.
Pediatric Stress Fractures: A Pictorial Essay
in certain populations that require repetitive flexion and
extension of their spine, such as the Eskimos7, 8. Lower
back pain in the young patient should prompt a search
for spondylolysis7. Conventional computed tomography
(CT), MRI, and single photon emission computed tomog-
raphy (SPECT) are all acceptable diagnostic modalities.
CT is superior to MRI in the detection of spondylolysis,
but involves the use of ionizing radiation. SPECT can
help confirm the diagnosis in cases which are indetermi-
nate on MRI9, 10. Typical MRI findings include low signal
on T1 and increased signal on T2 or STIR sequences at
the pars interarticularis and/or pedicle (Figures 1 & 2).
Shoulder
Acromial Apophysiolysis/Os Acromiale
One to four ossification centers are seen at the acro-
mion by 15-18 years of age. From anterior to posterior,
these ossification centers are the pre-acromion, the meso-
acromion, the meta-acromion, and the basi-acromion.
Failure of fusion of the acromion in the background of
chronic repetitive traction forces from the deltoid has
been termed acromial apophysiolysis11. Without healing,
this may progress to an os acromiale, which can in turn
lead to impingement symptoms in the shoulder. Patients
typically present with chronic shoulder pain of insidious
onset. In younger patients, differentiating between an
os acromiale and normal apophyseal development can be
challenging, as the age range of acromial fusion can vary
from 18 – 2512. However, irregular cortical margins and
abnormal marrow signal with adjacent bony edema favors
the diagnosis of acromial apophysiolysis13 (Figure 3).
Little Leaguer’s Shoulder
“Little leaguer’s shoulder” is a term used to describe
injury to the proximal humeral physis typically caused
by repetitive overhead throwing. It is often observed in
Volume 36   139
N. H. Shelat, G. Y. El-Khoury
A male baseball pitchers between the ages of 11 and 16 in
Figure 4. 13-year-old baseball pitcher. AP radiograph of the (A)
right shoulder shows diffuse widening of the right proximal humeral
physis (arrow). (B) For comparison, the left shoulder demonstrates
normal width of the physis.
140   The Iowa Orthopedic Journal
Figure 5. 14-year-old baseball pitcher with medial elbow pain for 1
month duration. (A) AP radiograph demonstrates asymmetric widen-
ing of the right medial epicondyle physis (arrow). (B) The left elbow,
submitted for comparison, is unremarkable. (C,D) MRI performed
the following day demonstrates edema within the medial condyle
epiphysis (arrow) and the adjacent metaphysis of the humerus. The
ulnar collateral ligament (not fully shown) was intact.
whom the excessive rotational forces of overhead throw-
ing lead to physeal injury14. Patients tend to present with
focal pain over the anterolateral shoulder that is worse
with overhead throwing. Radiographs demonstrate phy-
seal widening and irregularity15 (Figure 4). MR findings
include similar findings of widening of the physis, along
with marrow edema on fluid sensitive sequences16.
Elbow: Little Leaguer’s Elbow
“Little Leaguer’s elbow” is a term used to describe
injury to the medial epicondylar apophysis17. Patients are
usually young adolescent pitchers or catchers presenting
with medial elbow pain either with direct palpation or
valgus stress to the elbow. Children can present with
mild flexion contracture at the elbow secondary to pain17.
While generally the physical examination is sufficient
 Pediatric Stress Fractures: A Pictorial Essay

B C
A

Figure 6. 11-year-old gymnast just days away from a championship meet, with ongoing wrist pain. (A) AP radiograph of the wrist is essentially
unremarkable. Specifically, there is no evidence of physeal widening, irregularity, or fraying. (B, C) T1 and T2FS coronal MRI images demonstrate
marrow edema through the distal metaphyses of the radius and ulna (white arrows), and to a lesser extent, the radial and ulnar styloids (red arrows).

for making the diagnosis, radiographs demonstrate disease can lead to premature fusion and positive ulnar
widening or fragmentation of the apophysis (Figure variance, TFCC injury, and scapholunate or lunotriqu-
5). The contralateral asymptomatic elbow can be used etral ligament disruption19.
for reference in determining physeal widening. MRI
Pelvis
demonstrates marrow edema and aids in determining
the integrity of the common flexor tendon and ulnar Sacral Stress Fractures
collateral ligament18. Sacral stress fractures are known to have a higher in-
cidence in female athletes, particularly in runners21. The
Wrist: Gymnast’s Wrist
female athlete triad describes the relationship between
Gymnasts frequently start intense training at a young
caloric imbalance, hormonal dysregulation, and impaired
age, when repetitive stress on the upper extremities can
bone health22. The injury, therefore, has components of
lead to physeal injury. Mechanical forces of dorsiflexion
both a fatigue and insufficiency fracture. Radiographs
and compression triggers physeal injury at the distal
are often normal, while MRI demonstrates linear low
radius19. Similar forces can lead to the same injury in
signal intensity on T1 images with corresponding edema
weight lifters. Analogous to Little Leaguer’s shoulder,
(Figure 7). In endurance athletes, similar findings of a
radiographs can demonstrate widening and fraying or ir-
stress fracture can be seen in the inferior pubic rami23
regularity of the physis, while MRI demonstrates edema
(Figure 8).
through the metaphysis (Figure 6). Severe or chronic

Figure 7. 18-year-old female cross countr y runner with gradually worsening low back pain. (A) Coronal T1, (B) coronal STIR, and (C) oblique
coronal T2 fat saturated images demonstrate a stress fracture of the left sacral ala extending to the sacral foramen.

Volume 36   141

N. H. Shelat, G. Y. El-Khoury

Figure 8. 15-year-old female cross countr y runner with pubic pain, referred for MRI to “rule out sports hernia.” (A) Axial T1 and (B) T2FS
images demonstrate a healing fracture (arrows) through the left inferior pubic ramus. This was radiographically occult.

Pelvic Apophyseal Injury Femur: Stress Fracture

Traction apophysitis in the pelvis is a commonly
recognized overuse injury in children. When chronic,
children can present with dull pelvic or hip pain. This
injury is more frequently found in athletes involved in
twisting activity resulting in traction on the apophyses,
such as dancers, runners, football and lacrosse players.
The most common sites of injury include the anterior
superior iliac spine (origin of the sartorius and tensor
fasciae lata), the anterior inferior iliac spine (origin of the
rectus femoris), and the ischial tuberosity (origin of the
hamstrings)24. Radiographs can demonstrate a spectrum
of findings from cortical irregularity to frank avulsion of
bone. MRI most typically demonstrates marrow edema
and variable signal intensity in the corresponding ten-
dons, depending on the extent of their injury (Figure 9).
Femoral stress fractures are relatively rare in com-
parison to stress fractures of the tibia, fibula, and foot25.
Stress fractures of the femur result from repetitive load-
ing, and are most common in endurance runners, jump-
ers, and dancers. Repetitive loading results in subperi-
osteal bone resorption and microfractures which are not
given sufficient time to heal. Femoral stress fractures
can present with pain at the groin, hip, or knee, and are
typically aggravated by activity. While the most common
site of fracture is the femoral neck, fractures can occur
anywhere along the femoral diaphysis (24). While lack-
ing in sensitivity early in the disease, radiographs will
classically show linear sclerosis, periosteal elevation, and
cortical thickening, consistent with a protracted healing
response. MRI reveals the problem earlier, showing
linear low signal intensity on T1 sequences and corre-

Figure 9. 13-year-old baseball player (shortstop) with gradually worsening groin pain. (A) Axial T1 and (B) axial T2FS images demonstrate
bone marrow edema at the left ischial tuberosity (arrows). The hamstring tendons appeared normal. (C) Retrospective review of the radio-
graph shows subtle cortical irregularity along the lateral aspect of the left ischium (arrow).

142   The Iowa Orthopedic Journal

 Pediatric Stress Fractures: A Pictorial Essay

Figure 10. 9-year-old boy with histor y of renal transplant on chronic

immunosuppressive therapy presenting with thigh pain. (A, B) Fron-
tal and lateral radiographs demonstrate a linear band of sclerosis
(arrow in A) through the distal femoral metaphysis and periosteal
reaction (arrow in B), consistent with healing stress fracture. Inci-
dental note is made of fracture progression through a non-ossifying
fibroma along the medial cortex.

Figure 12. 3-year-old girl with a limp. Lateral radiograph dem-

onstrates an area of uninterrupted periosteal reaction along the
Figure 11. 16-year-old female runner with prior histor y of pelvic posteromedial aspect of the left tibia at the middle third of the tibia,
stress fracture, now complaining of tibial pain. Sagittal STIR image consistent with stress fracture.
demonstrates edema at the insertion of the patellar ligament (arrow),
consistent with active Osgood Schlatter disease. There is mild pre-
tibial edema in the soft tissues anterior to the tuberosity. There is
minimally increased signal within the ligament itself.

Volume 36   143

N. H. Shelat, G. Y. El-Khoury

Table I. Fredericson MRI Classification

System for Tibial Stress Injur y
Grade MR Findings
0 Normal
1 Periosteal edema only
2 Periosteal edema and bone marrow edema (on T2 only)
3 Periosteal edema and bone marrow edema (on T1 and
T2)
4a Multiple foci of intracortical signal abnormality and bone
marrow edema on both T1 and T2
4b Linear areas of signal abnormality on both T1 and T2

Figure 13. Two different patients. The patient in (A) is a 12-year

old-girl who had been immobilized following a Lisfranc injur y. The
second patient in (B) is a 12-year-old girl who had been immobilized
following medial cuneiform osteotomy. (A) Lateral radiograph dem-
onstrates a vertically oriented sclerotic line in the calcaneal tuberosity
(arrow). (B) AP radiograph demonstrates periosteal reaction (arrow)
surrounding the second metatarsal, consistent with stress fracture.

sponding edema on fluid sensitive images (Figure 10).

Subperiosteal fluid, when present, is a useful finding to
confirm the diagnosis3.
Tibia/Fibula
Osgood-Schlatter Disease
Osgood-Schlatter is one of the most common causes
of anterior knee pain in young athletes, caused by repeti-
tive microtrauma and subsequent traction apophysitis of
the tibial tuberosity. It is commonly seen in 12-15 year
old boys or 8-12 year old girls who participate in jump-
ing activities24. Patients present with anterior knee pain
and swelling. Physical examination is usually diagnostic,
with radiographs demonstrating soft tissue edema over-
lying the anterior tibial tuberosity, and some degree of
fragmentation and irregularity of the tibial tubercle. MRI
demonstrates edema in the tibial tuberosity and distal
patellar tendon. Hoffa’s fat pad may also show increased
signal on fluid sensitive sequences (Figure 11).
Figure 14. 14-year-old boy involved in multiple sports presents
with worsening ankle pain. (A) Sagittal T1 and (B) T2FS images of
the ankle demonstrate linear signal abnormality in the distal tibia
consistent with stress fracture (white arrow). Multiple additional
areas of signal abnormality (red arrows) are also consistent with
stress reaction.
Diaphyseal Stress Fracture
A common site for stress fractures in adolescents is
the tibia, followed by the fibula25. They are commonly
found in children participating in football, soccer, ten-
nis, and running. Radiographs demonstrate cortical
irregularity and periosteal reaction, typically along the
posteromedial proximal third of the tibial shaft (Figure
12). MRI can be useful in equivocal cases. The Fred-
ericson classification system classifies MR findings for
tibial stress injury, with grades 1-3 deemed as “stress
response” and grade 4 as “stress fracture”26 (Table I).

144   The Iowa Orthopedic Journal


Figure 15. 8-year-old girl with foot pain and a limp. (A) Lateral radiograph demonstrates subtle sclerosis in the cuboid (arrow). (B) Follow
up MRI demonstrates a linear low T1 signal intensity focus (arrow) through the lateral aspect of the cuboid with (C) corresponding edema on
T2 (arrow), consistent with stress fracture.
Ankle and Foot
In children, the most common sites of stress fractures
in the foot are the metatarsals and calcaneus, followed by
the cuboid, talus, and navicular27. It has been postulated
that following lower extremity immobilization for conven-
tional traumatic fractures, the child is more susceptible
to subsequent stress fracture distally in the ipsilateral ex-
tremity27. At our institution, a ten year informal review of
lower extremity fractures in children who were previously
immobilized for other fractures yielded several cases of
stress fractures (Figure 13). Radiographic findings of
sclerosis and marrow edema are equivalent to stress
fractures at other sites (Figure 14, 15).
CONCLUSIONS
With the increasing number of children participating
in sports, it is important for orthopedists and radiolo-
gists to be aware of the radiographic and MRI findings
associated with common overuse injuries. Familiarity
with these findings leads to prompt diagnosis and helps
prevent future disability.
REFERENCES
1. Caine D, DiFiori J, Maffulli N. Physeal injuries in
children’s and youth sports: reasons for concern? Br
J Sports Med. 2006 Sep;40(9):749-60.
2. Anderson MW, Greenspan A. Stress fractures.
Radiology. 1996 Apr;199(1):1-12.
3. Jaimes C, Jimenez M, Shabshin N, Laor T,
Jaramillo D. Taking the stress out of evaluating
stress injuries in children. Radiographics. 2012 Mar-
Apr;32(2):537-55.
Pediatric Stress Fractures: A Pictorial Essay
4. Jones BH, Harris JM, Vinh TN, Rubin C. Ex-
ercise-induced stress fractures and stress reactions
of bone: epidemiology, etiology, and classification.
Exerc Sport Sci Rev. 1989;17:379-422.
5. Laor T, Wall EJ, Vu LP. Physeal widening in the
knee due to stress injury in child athletes. AJR Am J
Roentgenol. 2006 May;186(5):1260-4.
6. Tower SS, Pratt WB. Spondylolysis and associated
spondylolisthesis in Eskimo and Athabascan popula-
tions. Clin Orthop Relat Res. 1990 Jan;(250):171-5.
7. Trainor TJ, Wiesel SW. Epidemiology of back pain
in the athlete. Clin Sports Med. 2002 Jan;21(1):93-103.
8. Simper LB. Spondylolysis in Eskimo skeletons. Acta
Orthop Scand. 1986 Feb;57(1):78-80.
9. Campbell RS, Grainger AJ, Hide IG, Papaste-
fanou S, Greenough CG. Juvenile spondylolysis: a
comparative analysis of CT, SPECT and MRI. Skeletal
Radiol. 2005 Feb;34(2):63-73.
10. Dunn AJ, Campbell RS, Mayor PE, Rees D. Ra-
diological findings and healing patterns of incomplete
stress fractures of the pars interarticularis. Skeletal
Radiol. 2008 May;37(5):443-50.
11. Roedl JB, Morrison WB, Ciccotti MG, Zoga AC.
Acromial apophysiolysis: superior shoulder pain and
acromial nonfusion in the young throwing athlete.
Radiology. 2015 Jan;274(1):201-9.201–209.
12. K othar y P, Rosenberg ZS. Skeletal develop-
mental patterns in the acromial process and distal
clavicle as observed by MRI. Skeletal Radiol. 2015
Feb;44(2):207-15.
Volume 36   145
N. H. Shelat, G. Y. El-Khoury
13. Winfeld M, Rosenberg ZS, Wang A, Bencardino
J. Differentiating os acromiale from normally de-
veloping acromial ossification centers using mag-
netic resonance imaging. Skeletal Radiol. 2015
May;44(5):667-72.
14. Carson WG Jr, Gasser SI. Little Leaguer’s shoul-
der. A report of 23 cases. Am J Sports Med. 1998
Jul-Aug;26(4):575-80.
15. Obembe OO, Gaskin CM, Taffoni MJ, Anderson
MW. Little Leaguer’s shoulder (proximal humeral
epiphysiolysis): MRI findings in four boys. Pediatr
Radiol. 2007 Sep;37(9):885-9.
16. Song JC, Lazarus ML, Song AP. MRI findings
in Little Leaguer’s shoulder. Skeletal Radiol. 2006
Feb;35(2):107-9.
17. Bennett, D Lee; El-Khour y, Georges Y. Pearls
and pitfalls in musculoskeletal imaging: variants and
other difficult diagnoses. Cambridge : Cambridge
University Press, 2013. Chapter 28, Little Leaguer’s
Elbow: What is it? p. 58-59.
18. Wei AS, Khana S, Limpisvasti O, Crues J, Pod-
esta L, Yocum LA. Clinical and magnetic resonance
imaging findings associated with Little League elbow.
J Pediatr Orthop. 2010 Oct-Nov;30(7):715-9.
19. Dwek JR, Cardoso F, Chung CB. MR imaging of
overuse injuries in the skeletally immature gymnast:
spectrum of soft-tissue and osseous lesions in the hand
and wrist. Pediatr Radiol. 2009 Dec;39(12):1310-6.
146   The Iowa Orthopedic Journal
21. Chen YT, Tenforde AS, Fredericson M. Update
on stress fractures in female athletes: epidemiology,
treatment, and prevention. Curr Rev Musculoskelet
Med. 2013 Jun;6(2):173-81.
22. Nattiv A, Loucks AB, Manore MM, Sanborn
CF, Sundgot-Borgen J, Warren MP; American
College of Sports Medicine. American College of
Sports Medicine position stand. The female athlete
triad. Med Sci Sports Exerc. 2007 Oct;39(10):1867-82.
23. Williams TR, Puckett ML, Denison G, Shin AY,
Gorman JD. Acetabular stress fractures in military
endurance athletes and recruits: incidence and MRI
and scintigraphic findings. Skeletal Radiol. 2002
May;31(5):277-81.
24. Bedoya MA, Jaramillo D, Chauvin NA. Overuse
injuries in children. Top Magn Reson Imaging. 2015
Apr;24(2):67-81.
25. Bennell KL, Brukner PD. Epidemiology and site
specificity of stress fractures. Clin Sports Med. 1997
Apr;16(2):179-96
26. Fredericson M, Bergman AG, Hof fman KL,
Dillingham MS. Tibial stress reaction in runners.
Correlation of clinical symptoms and scintigraphy
with a new magnetic resonance imaging grading
system. Am J Sports Med. 1995 Jul-Aug;23(4):472-81.
27. Oestreich AE, Bhojwani N. Stress fractures of
ankle and wrist in childhood: nature and frequency.
Pediatr Radiol. 2010 Aug;40(8):1387-9.