Stress fractures and spondylolysis plague serious skaters

2002 02 06 16 20 34 706

Figure-skating fans can point to the sublime, seemingly effortless beauty of athletes gliding and spinning on thin metal blades. But imaging confirms the physical toll of skaters' efforts, and the results aren't always as pretty.

Beginning skaters are the ones most likely to end up in hospital emergency rooms with fractures, said Dr. Rina Bloch, assistant professor in the department of physical medicine and rehabilitation at Tufts University School of Medicine in Boston. But competitive figure skaters and professional ice dancers are at risk for a number of physical ailments, particularly chronic conditions.

"Bursitis is quite common in places where non-skaters don’t have it," Bloch said, pointing to the stiff ankle boots used in skating. "And hammer-toes are very common -- one study found that 70% of skaters had hammer-toes."

As for injuries, the ones most commonly seen among figure skaters are often due to overuse, according to Bloch, herself a former figure skater who has written on medical issues in the sport. Skaters should avoid repeatedly practicing only a single jump they are trying to master, Bloch said. Some research has noted a marked propensity toward injury in the "take-off" leg, on which a skater initiates a jump (Physical Medicine and Rehabilitation Clinics of North America, February 1999, Vol.10:1. pp. 177-188).

The lower extremities naturally bear the largest burden, although pair skaters and dancers do sustain more upper extremity injuries than single skaters. Knee pain is common and may indicate Osgood-Schlatter’s, an inflammatory necrosis of the tibial tuberosity. Hamstring injuries are also frequently seen. Female skaters may often develop amenorrhea, putting them at greater risk for osteoporosis later in life, Bloch said.

Medical imaging helps diagnose the most common -- and some of the most serious -- problems faced by skaters. One medical survey of 42 world-class figure skaters found that nearly a quarter had suffered some kind of stress fracture, including fibular, tibial, tarsal navicular, and various metatarsal fractures. All of those surveyed were training 6 days a week from 3 to 8 hours a day (American Journal of Sports Medicine, May-June 1990, Vol.18:3, pp. 277-279).

Therefore, traditional radionuclide bone scans with SPECT would likely show a substantial number of stress fractures among serious skaters. The American College of Radiology’s expert panel on musculoskeletal imaging currently recommends MRI as the most appropriate diagnostic tool in non-vertebral stress/insufficiency fractures because of its superior specificity.

Imaging is also critical for ruling out serious conditions that may be the cause of common pain experienced by skaters -- especially in young and skeletally immature participants, Bloch said. In those with back pain, spondylolysis and spondylolisthesis should be considered as a possibility. Symptomatic pars lesions appear to be a clinical problem particularly in adolescent athletes, according to a literature review by Puget Sound Sports and Spine Physicians in Seattle (British Journal of Sports Medicine, December 2000, Vol.34:6, pp. 415-422).

Radiologists at the Italian Olympic Committee’s Sports Science Institute in Rome reviewed the lumbar spine x-rays of 4,243 symptomatic male and female athletes and found that 14% had spondylolysis. Of the 590 diagnosed athletes, 280 or 47% had concomitant spondylolisthesis. Given the high prevalence of spondylolysis in athletes with low-back pain compared with the general population, the authors suggested that MRI exams of symptomatic athletes might be routinely warranted (Radiography, February 2001, Vol.7:1, pp.37-42).

In skaters with hip pain, MRI again appears to be the most useful modality for diagnosing potential slipped capital femoral epiphysis (SCFE). Radiologists at the Albert Einstein College of Medicine in New York City found that MRI delineates physeal changes of SCFE at an early point -- even "pre-slip" -- when radiographs and CT may appear normal.

In examinations of more than a dozen symptomatic patients, the researchers found evidence of physeal widening on T1-weighted MR images for every case of SCFE, including one presumed pre-slip. T2-weighted images showed synovitis and marrow edema but obscured the physeal abnormalities in these patients. Physeal and metaphyseal changes were variably identified on both radiographs and CT in all cases of SCFE, but not in the pre-slip (Skeletal Radiology, March 1998, Vol.27:3, pp. 139-144).

Overly stiff boots may also prevent skaters from developing adequate ankle strength, a problem that may seem counterintuitive to the occasional skater whose ankles have repeatedly flopped to the side. But it does demonstrate the very different situation faced by serious skaters compared to the casual masses, according to Bloch. "Rental skates are passed down through 30 years of garage sales," she said. "They don’t give much support."

By Tracie L. Thompson contributing writer
February 20, 2002

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