SEMS-journal

Managing Stress Fractures in Elite Female Gymnasts: Beyond the Obvious Diagnosis

paulburri64

Text with master prompt (see methodology article) + additional prompt to include staging and Fredericson 1995 reference.
AI Model: Sonnet 4 (Claude, Anthropic) on September 28th, 2025.
Expert: Prof Johannes Scherr

Clinical case

23-year-old female athlete (artistic gymnastics, national A-squad) with persistent symptoms for the past 8 months in the anterior tibial region, which occur after, but not during training (especially on vault and floor exercises). She has repeatedly taken breaks from training for approximately 3 weeks. After that, she resumed training progressively without jumps, but each time this led to a recurrence of pain. Treatment with vitamin D and calcium is ongoing. Currently, she is again reporting pain under load in the area of the right tibia. These symptoms are also present in daily life but improve with rest over a few days.
Due to the protracted course, a CT and MRI were performed (2 CT scan images and 1 MRI image, corresponding planes see below).

Further questions:
– What is the diagnosis?
– What other typical locations for such lesions are there?
– What are the differential diagnoses (based on the MRI images)?
– What additional information do you need in order to manage the case?
– How will you manage the case?

Introduction

As sports medicine clinicians, few conditions challenge us more than persistent bone stress injuries in elite female athletes. The intersection of biomechanical loading, hormonal influences, and performance pressures creates a complex clinical scenario that demands nuanced understanding and management. Over the past decade, our approach to bone stress injuries has evolved significantly, moving from simple rest protocols to comprehensive, multidisciplinary management strategies informed by the latest International Olympic Committee (IOC) and British Journal of Sports Medicine (BJSM) consensus statements [1,2].
Stress fractures account for 10-15% of all sports injuries, with particularly high prevalence in gymnastics, where repetitive high-impact loading combined with aesthetic sport pressures create perfect storm conditions [3]. In female gymnasts, the incidence reaches 20-25%, often complicated by the female athlete triad components that can significantly impact bone health and recovery trajectories [4].

Case Context and Clinical Challenges

The presented case exemplifies the diagnostic and management complexities I frequently encounter in my practice. This elite gymnast’s 8-month symptom duration, with characteristic post-exercise pain and recurrent episodes despite attempted conservative management, illustrates several critical pitfalls. The imaging clearly demonstrates a stress fracture of the right tibial shaft with surrounding bone marrow edema, but the case highlights deeper systemic issues common in aesthetic sports.
What concerns me most is the cyclical pattern of temporary improvement followed by symptom recurrence—a hallmark of inadequate healing combined with persistent underlying risk factors. The current vitamin D and calcium supplementation suggests prior recognition of nutritional deficiencies, but this represents only the tip of the iceberg in comprehensive bone health management.

Clinical Background and Differential Diagnosis

Tibial stress fractures in gymnasts typically occur at the posteromedial border of the mid-to-distal shaft, as demonstrated in these images. The MRI findings show characteristic features: linear T1 hypointensity with surrounding bone marrow edema and cortical involvement [5]. Other common locations in gymnasts include the second and third metatarsals, fibula, and lumbar pars interarticularis [6].

MRI Grading and Clinical Significance

The systematic MRI grading system developed by Fredericson et al. has revolutionized our understanding of bone stress injuries and provides crucial prognostic information [7]. This four-grade classification correlates bone marrow signal intensity changes with clinical severity and return-to-play timelines:

The images in this case demonstrate Grade 3-4 characteristics, with extensive bone marrow edema and possible cortical involvement, explaining the protracted 8-month symptom duration and recurrent episodes.
This grading system has proven invaluable in my practice for patient counseling and establishing realistic expectations. The correlation between MRI grade and recovery time helps athletes understand why seemingly “minor” injuries require extended rehabilitation periods [8].
The differential diagnosis from these images includes osteoid osteoma, chronic osteomyelitis, and bone tumors, though the clinical presentation and imaging characteristics strongly support stress fracture. The key distinguishing feature is the linear nature of the lesion with surrounding reactive changes, rather than the nidus pattern of osteoid osteoma or the more destructive appearance of infection or malignancy.

Comprehensive Management Strategy

My approach to this case involves immediate activity modification with a structured, multidisciplinary team including a sports medicine physician, physiotherapist specializing in gymnastics, sports psychologist, registered dietitian, and potentially an endocrinologist for hormonal assessment.

Phase 1: Acute Management and Assessment
(Weeks 1-4)
Initial management requires complete cessation of impact activities with maintenance of cardiovascular fitness through pool running and upper body training. I conduct comprehensive screening for relative energy deficiency in sport (REDs), including detailed nutritional assessment, menstrual history, bone density evaluation via DEXA scan, and hormonal profiling [9].

Phase 2: Rehabilitation and Risk Factor ­Modification
(Weeks 4-12)
Progressive weight-bearing activities begin with pain-free walking, advancing to jogging once clinical tenderness resolves. Simultaneously, I address underlying risk factors through nutritional optimization, biomechanical analysis, and training load modification. The physiotherapist focuses on addressing muscle imbalances and movement patterns that may contribute to tibial loading [10].

Phase 3: Sport-Specific Progression
(Weeks 12-20)
Return to gymnastics-specific activities follows a structured progression: basic skills without impact, low-level tumbling, progressive vault and floor work. Each phase requires demonstrated pain-free completion before advancement [11].

Return-to-Play Framework

Following the BJSM consensus on bone stress injuries, return-to-play decisions must consider both clinical and imaging factors [12]. I utilize a modified criteria system incorporating pain-free daily activities, normal clinical examination, and either imaging evidence of healing or successful completion of sport-specific loading without symptoms.
For elite gymnasts, I implement additional criteria including psychological readiness assessment and demonstration of modified landing techniques to reduce tibial loading. The progression timeline typically extends 16-24 weeks for complete return to full training, significantly longer than many athletes expect.
Table 1 demonstrates the extended timeline necessary for safe return-to-play, emphasizing the multidisciplinary approach required throughout the process.

Prognosis and Athlete Counseling

Recovery from tibial stress fractures in elite gymnasts typically requires 4-6 months for complete return to pre-injury performance levels. However, prognosis depends heavily on addressing underlying risk factors, particularly nutritional status and training modifications [13]. Predictors of prolonged recovery include delayed initial diagnosis, evidence of REDs, and history of previous stress fractures.
Counseling involves frank discussions about career longevity and the importance of addressing systemic factors rather than pursuing quick fixes. I emphasize that successful return requires lifestyle modifications that may initially seem restrictive but ultimately enhance both performance and long-term health. For national-level athletes, I coordinate closely with coaching staff to ensure training modifications align with competitive goals while prioritizing athlete health.
The psychological impact cannot be understated—extended time away from sport during peak competitive years creates significant stress. Regular psychological support helps athletes maintain perspective and develop coping strategies for the rehabilitation process.

Take-Home Messages

Image credits: Google Gemini, Model: Nana Banana 2,5 flash.
https://aistudio.google.com/

Prompt: “Create a detailed medical illustration showing the bone stress injury continuum from normal bone to complete fracture. Design it as a horizontal timeline with 5 distinct stages:
– NORMAL BONE (green zone): Healthy bone with balanced remodeling, no symptoms, normal imaging
– STRESS REACTION (yellow zone): Increased bone turnover, mild fatigue, possible early MRI changes
– STRESS RESPONSE (orange zone): Microdamage accumulation, pain during activity, bone marrow edema on MRI
– STRESS FRACTURE (red zone): Cortical break, pain at rest, visible fracture line on imaging.
– COMPLETE FRACTURE (dark red zone): Full fracture with displacement risk, severe pain, clear X-ray changes
For each stage, include: A cross-sectional bone diagram showing progressive damage, Clinical symptoms bullet points, Imaging findings, Recovery timeline (from no intervention to 20+ weeks), Load indicators showing increasing mechanical stress.
Use medical illustration style with clear labels, professional color coding, and anatomically accurate bone representations. Make it suitable for sports medicine education and clinical reference.
Style: Clean, professional medical textbook illustration with clear typography and scientific accuracy”.

Prompt 2: “Can you simplify the image with differentiation of stage 4a and 4b, and showing for each stage what it implies on the tibial bone. Please eliminate the text at the bottom part where too many mistakes are present. Use a long bone and show the cross section of the tibia in its actual shape. Use the same colour continuum but integrate stages 4a and 4b one after the other. Here are the stages of classification: Fredericson MRI classification system—Grade of stress injury, MRI findings:
0, No abnormality
1, Periosteal edema with no associated marrow signal changes
2, Periosteal edema and bone marrow edema visible on T2-weighted images only
3, Periosteal edema and bone marrow edema visible on T1-weighted and T2-weighted images
4a, Multiple focal areas of intracortical signal changes and bone marrow edema visible on T1-weighted and T2-weighted images
4b, Linear areas of intracortical signal changes and bone marrow edema visible on T1-weighted and T2-weighted images”.

References

  1. Mountjoy M, et al. The IOC consensus statement: beyond the Female Athlete Triad—Relative Energy Deficiency in Sport (RED-S). Br J Sports Med. 2014;48:491-7.
  2. Tenforde AS, et al. Running injury and bone stress injury prevention. Clin Sports Med. 2016;35:423-40.
  3. Warden SJ, et al. Bone stress injuries in runners: a systematic review. Sports Med. 2021;51:2041-58.
  4. Joy EA, et al. Bone stress injuries in female athletes. Phys Med Rehabil Clin N Am. 2020;31:399-415.
  5. Matheson GO, et al. Stress fractures in athletes: a study of 320 cases. Am J Sports Med. 1987;15:46-58.
  6. DiFiori JP, et al. Stress fractures in gymnasts: case series and review. Clin J Sport Med. 2006;16:367-73.
  7. Fredericson M, et al. Stress fractures in athletes. Top Magn Reson Imaging. 2006;17:309-25.
  8. Fredericson M, et al. Tibial stress reaction in runners: correlation of clinical symptoms and scintigraphy with a new magnetic resonance imaging grading system. Am J Sports Med. 1995;23:472-81.
  9. Pegrum J, et al. Diagnosis and management of bone stress injuries of the lower limb in athletes. BMJ. 2014;349:g5309.
  10. Elliott-Sale KJ, et al. Endocrine effects of relative energy deficiency in sport. Int J Sport Nutr Exerc Metab. 2018;28:335-49.
  11. Duckham RL, et al. Risk factors for stress fracture in female endurance athletes: a cross-sectional study. BMJ Open. 2012;2:e001920.
  12. Bennell KL, et al. The incidence and distribution of stress fractures in competitive track and field athletes. Am J Sports Med. 1996;24:211-7.
  13. Soligard T, et al. How much is too much? (Part 1) International Olympic Committee consensus statement on load in sport and risk of injury. Br J Sports Med. 2016;50:1030-41.
  14. Nattiv A, et al. The female athlete triad. Med Sci Sports Exerc. 2007;39:1867-82.

Not all references were assigned by AI.

The expert’s review

Prof Johannes Scherr

The manuscript is surprisingly strong in some parts: clinical framing is clear, the diagnosis is argued convincingly from the images, and the practical tone will resonate with clinicians. The narrative is easy to follow.

However, several major issues substantially reduce the scientific quality and must be addressed:
1. Outdated literature / missing key recent work.
The reference list leans heavily on older sources and omits multiple high-impact, contemporary papers central to current practice. Please integrate, at minimum:
 Warden SJ, Hoenig T, Sventeckis AM, Not all bone overuse injuries are stress fractures, Br J Sports Med 2023;57:76-77.
(https://doi.org/10.1136/bjsports-2022-106112)
 Esther R. M. George et al., Sports Medicine 2024; 54:2247-2265 on return-to-running after tibial bone stress injuries.
(https://doi.org/10.1007/s40279-024-02051-y)
 Hoenig T, et al., International Delphi consensus on bone stress injuries, Br J Sports Med 2025;59:78-90.
(https://doi.org/10.1136/bjsports-2024-108616)
2. Terminology: Triad vs. RED-S.
The manuscript uses Female Athlete Triad language where current standards require RED-S. Update terminology and discussion to align with the IOC consensus (Mountjoy M et al., Br J Sports Med 2018;52:687-697.
https://doi.org/10.1136/bjsports-2018-099193). Or even more update: Mountjoy M et al., Br J Sports Med 2023; 57:1073-1098, https://bjsm.bmj.com/content/57/17/1073.
3. Imaging overstatement/missing differential diagnosis.
The statement “imaging clearly demonstrates a stress fracture of the right tibial shaft” is not fully justified. Even experienced musculoskeletal radiologists can struggle to distinguish stress fracture from osteoid osteoma in similar configurations (especially if a nidus is suspected). The differential diagnosis should be explicitly more weighed, ideally with correlation to CT or targeted MRI sequences, and the uncertainty reflected in the text.
4. Incorrect anatomical localization (case-specific).
The text claims lesions “typically occur at the posteromedial border … as demonstrated in these images.” In the presented case, the reaction is anterior (margo anterior), not posteromedial. Because anterior tibial cortex findings carry different risk implications, the manuscript must correct the localization and ensure internal consistency (text, figure legends).
5. MRI classification and “stress fracture” vs. “stress reaction.”
The distinction between stress reactions (no fracture line) and stress fractures is blurred. The manuscript should incorporate MRI-based classification and acknowledge that a substantial subset are stress reactions, not frank fractures—see Warden SJ et al. 2023 (above), as well as prognostic/validation work on MRI grading.
6. Potentially misleading timeframes attached to Fredericson grades.
The listed recovery times for Grades 1-4 use inconsistent reference points (“resolve within 3 weeks of activity modification”, “requiring 3-6 weeks for resolution”, “demand 12-16 weeks of structured rehabilitation”, and “requiring 16-20 weeks for safe return to sport”). Readers may infer a level of precision the data do not support. Use a uniform clinical endpoint (e.g., time to symptom-adapted return to running/exercising) and provide a consistent mapping of MRI grade to prognosis, anchored in validation/prognostic studies (e.g., Hoenig 2022 where applicable).
7. Reference integrity and text–citation coherence.
– The sentence “Following the BJSM consensus on bone stress injuries…” cites BJSM, but the numbered reference is an Am J Sports Med paper—this is inconsistent.
– Reference 2 appears incorrect; likely intended probably is: Tenforde AD et al, Sports Med Phys Med Rehabil Clin N Am. 2016 Feb;27(1):139-49. doi: 10.1016/
j.pmr.2015.08.008.
– Also reference 3 seems to be a mixture: Warden SJ, et al. Bone stress injuries in runners: a systematic review. Sports Med. 2021;51:2041-58
– This could be continued almost indefinitely, since reference 4 is also incorrect (and should probably be the following: Bishop ME et al. Annals of Joint 2021;6:37. doi: 10.21037/aoj.2020.04.04.

A systematic audit of all references (journal, year, pages, DOI) is required to eliminate such mismatches.
In conclusion, while the manuscript initially appears solid and may aid practising physicians with limited sports-medicine experience, closer scrutiny reveals numerous errors; ­accordingly, its use without thorough prior critical review cannot be recommended.

Author profile

Prof Johannes Scherr
Johannes.Scherr@balgrist.ch

 

Affiliation: University Center for Prevention & Sports Medicine, Balgrist University Hospital, University of Zurich
Specializations: Internal Medicine, Sports Medicine, Nutritional Medicine (DAEM)
Year of my medical school graduation: 2005
Sports organizations/federations I work with: Schweizerischer Turnverband STV-FSG, Porsche Motorsport, GC Fussball und Basketball, American Football, Golf.
Fields/topics I am fond of: evidence-based medicine; Exercise is Medicine; translational medicine—leveraging knowledge from elite sports for optimal patient care, and vice versa.
Outside of Sports & Exercise Medicine, I also love: spending time with my loved ones and friends, and enjoying good food and drinks.
How I use AI: honestly, still too little when I look at my surroundings. Given the downsides – some of which I’ve experienced firsthand in my case – this skepticism is likely well justified.

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