Bilateral Looser zones or pseudofractures in the anteromedial tibia as a component of medial tibial stress syndrome in a
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SPORTS TRAUMATOLOGY
Bilateral Looser zones or pseudofractures in the anteromedial tibia as a component of medial tibial stress syndrome in athletes Julian Stürznickel1 · Nico Maximilian Jandl1,2 · Maximilian M. Delsmann1 · Emil von Vopelius1 · Florian Barvencik1 · Michael Amling1 · Peter Ueblacker1,3 · Tim Rolvien1,2 · Ralf Oheim1 Received: 5 June 2020 / Accepted: 14 September 2020 © The Author(s) 2020
Abstract Purpose Medial tibial stress syndrome (MTSS) represents a common diagnosis in individuals exposed to repetitive highstress loads affecting the lower limb, e.g., high-performance athletes. However, the diagnostic approach and therapeutic regimens are not well established. Methods Nine patients, diagnosed as MTSS, were analyzed by a comprehensive skeletal analysis including laboratory bone turnover parameters, dual-energy X-Ray absorptiometry (DXA), and high-resolution peripheral quantitative computed tomography (HR-pQCT). Results In 4/9 patients, bilateral pseudofractures were detected in the mid-shaft tibia. These patients had significantly lower levels of 25-hydroxycholecalciferol compared to patients with MTSS but similar levels of bone turnover parameters. Interestingly, the skeletal assessment revealed significantly higher bone mineral density (BMD) Z-scores at the hip (1.3 ± 0.6 vs. − 0.7 ± 0.5, p = 0.013) in patients with pseudofractures and a trend towards higher bone microarchitecture parameters measured by HR-pQCT at the distal tibia. Vitamin D supplementation restored the calcium-homeostasis in all patients. Combined with weight-bearing as tolerated, pseudofractures healed in all patients and return to competition was achieved. Conclusion In conclusion, deficient vitamin D levels may lead to pseudofractures due to localized deterioration of mineralization, representing a pivotal component of MTSS in athletes with increased repetitive mechanical loading of the lower limbs. Moreover, the manifestation of pseudofractures is not a consequence of an altered BMD nor microarchitecture but appears in patients with exercise-induced BMD increase in combination with reduced 25-OH-D levels. The screening of MTSS patients for pseudofractures is crucial for the initiation of an appropriate treatment such as vitamin D supplementation to prevent a prolonged course of healing or recurrence. Level of evidence III. Keyword Pseudofracture · Vitamin D · Looser zone · Athlete · Medial tibial stress syndrome (MTSS)
Electronic supplementary material The online version of this article (https://doi.org/10.1007/s00167-020-06290-0) contains supplementary material, which is available to authorized users. * Michael Amling [email protected] 1
Department of Osteology and Biomechanics, University Medical Center Hamburg-Eppendorf, Lottestraße 59, 22529 Hamburg, Germany
2
Department of Orthopedics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
3
Orthopedics and Sports Medicine, Munich, Germany
Abbreviations MTSS Medial tibial stress syndrome DXA Dual-energy X-Ray absorptiometry HR-pQCT Hig
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