KidsMD Health Topics

Stress Fractures

  • Overview

    "We advise kids not to specialize in just one sport. Multi-sport athletes tend not to get as many stress fractures and other kinds of overuse injuries. And for practicing, we advise kids and coaches to alternate exercises and vary drills. In the long term, your muscle memory is better if you change up your practice exercises."

    Orthopedic Team, Boston Children's Hospital, Orthopedic Center

    If your teen or child has been diagnosed with a stress fracture, we at Children’s Hospital Boston know that she’s experiencing discomfort, as well as some disappointment that her sports training has been disrupted. We’ll approach your child’s treatment with sensitivity and support—to get her back into sports safely.

    About stress fractures

    With more and more kids playing organized sports and specializing early, there’s been a rise in the number of overuse injuries among children and teens. As a common overuse injury, stress fractures occur largely among runners and other athletes whose sports involve high-impact contact of the foot with the ground or floor—say, basketball and tennis players, track and field athletes, gymnasts, runners and dancers. At Children’s, our patients with stress fractures are usually teenagers or post-adolescents, since this is the age group that’s most likely to run and train competitively.

    • Stress fractures and other overuse injuries are sports-related microtraumas (small injuries) that result from repetitively using the same parts of the body.
    • A stress fracture results when fatigued muscles can’t absorb the shock (stress) of impact and transfer the stress load to a bone.
    • Most stress fractures occur in the weight-bearing bones of the foot or lower leg; over half occur in the lower leg—but can also occur to the hip (femoral neck).
    • Signs and symptoms of stress fractures—pain and inflammation—can resemble those of shin splints—so a proper diagnosis is important.
    • The risk of stress fractures increases if a runner:
      • has flat feet (fallen arches), which unevenly distribute the stress from impact
      • trains too hard before being properly conditioned

    Stress fractures can often be prevented with:

    • proper conditioning and training (especially cross-training)
    • sport-appropriate equipment and protective gear
    • adequate rest between exercise sessions
    • a calcium- and vitamin D-rich diet (especially for teenage girls)
      • While boys and girls are equally vulnerable to stress fractures, adolescent female athletes experience these more often than boys (see more on this in In-Depth)

    Children’s Hospital Boston’s approach to stress fractures and overuse injuries

    You can have peace of mind knowing that the team in Children’s Orthopedic Center has treated thousands of children, adolescents, adults and professional athletes with injuries ranging from the minor to the highly complex. We can provide your child with expert diagnosis, treatment and care—as well as the benefits of some of the most advanced clinical and scientific research in the world.

    Sports Medicine at Children’s has provided care to thousands of young athletes and is the health care choice of professional athletes and world-renowned dancers. We are the official orthopedic caregivers for the internationally famous Boston Marathon and the renowned Boston Ballet.

    Children’s orthopedic team  provides comprehensive assessment, treatment and follow-up care to children, adolescents and young adults who have sports-related orthopedic injuries. Our skilled orthopedists and sports medicine experts work with physical therapy staff to develop long-term treatment and activity plans. Our team has also developed innovative evaluation programs and effective injury prevention programs and strategies.

    Our orthopedic staff includes 24 orthopedic surgeons, 10 primary care sports medicine specialists, two podiatrists, a nutritionist, a sports psychologist, eight physician assistants, 14 nurses and four certified athletic trainers. In addition to our busy practice in Boston, Children's physicians see hundreds of patients every week at our locations in Lexington, Weymouth, Peabody and Waltham. Our surgeons perform an average of 5,000 procedures each year.

    Children’s Orthopedic Center: Ranked With The Highest

    As one of the first comprehensive, multidisciplinary programs, Children’s Orthopedic Centeris the nation’s largest and most experienced pediatric orthopedic surgery center, performing more than 5,000 surgical procedures each year. Our program—consistently ranked among the top three by U.S.News & World Report—is the preeminent care center for children and young adults with congenital, neuromuscular, developmental and post-traumatic musculoskeletal problems.

     

    Stress fractures: Reviewed by Yi-Meng Yen, MD, PhD
    © Children’s Hospital Boston; posted in 2012

     

    Boston Children's Hospital
    300 Longwood Avenue
    Fegan 2
    Boston MA 02115
     617-355-6021


  • In-Depth

    If your child or teen has developed a stress fracture, it will comfort you to know that Children’s Hospital Boston’s Orthopedic Center has a tremendous amount of experience treating this injury, developing therapies for healing and conducting research that leads to better care.


    What are stress fractures, and why do they occur?

    Stress fractures are an overuse injury caused by repetitive stress—usually to the shin bone (tibia) or foot bones but also to the hip (femoral neck)—over a period of time without enough rest to give the bone enough time to heal.

    Muscles adapt to stress—that’s how they become stronger. But they also need to rest and rebuild between the episodes of stress. When a muscle gets repeatedly overtaxed with the stress of impact (running, quick cutting, pivoting), it can transfer that stress to the bones of the foot or lower leg.


    What factors can contribute to young people getting stress fractures?

    Stress fractures can occur if a runner or athlete:

    • is experienced but is overtraining (often occurs late in the sports season)
    • resumes hard training too soon after a lay-off
    • increases the duration or intensity of training too quickly
    • trains on hills
    • is a novice who begins training too hard before she’s conditioned
    • runs on surfaces that are too hard or uneven
    • runs in improper or outworn footwear
    • has flat feet (fallen arches), which unevenly distribute the stress from impact
    • has poor running mechanics
    • has tight muscles
    • is an anorexic girl, whose bones are already deprived of nutrients, brittle and vulnerable to injury; this profile occurs often in runners and gymnasts


    What are the symptoms of stress fractures?

    Pain and/or inflammation in the foot or lower leg can be symptoms of stress fractures. The pain tends to intensify in stages:

    • At first, the injury may hurt mildly when the child plays her sport.
    • As more trauma occurs, the child will experience constant pain when she’s playing.
    • At the end stage, the child has constant pain in her foot or lower leg, even when she’s not playing. At that point, the affected area will have sustained a significant amount of damage.


    How are stress fractures diagnosed?

    Your child’s doctor will do a physical examination, and may use diagnostic tests—including x-rays, an MRI (magnetic resonance imaging) or CT scan and, rarely, a bone scan—to get detailed images of the injury to determine if there’s a stress fracture.


    How are stress fractures treated?

    The primary therapy for most stress fractures is simply to rest the injured foot or leg—restricting weight-bearing actions and all activities that involve stressing the injured area for a period of weeks or months. Your child’s doctor may also recommend a cast or walking boot in order to:

    • relax the stress on the leg
    • protect the leg from further damage
    • force the athlete to rest


    For a more severe stress fracture, treatment options may include:

    • temporary use of crutches or a wheelchair
    • physical therapy to stretch and strengthen the injured muscles and tendons
    • surgery (less common, but is sometimes needed)  


    Why are girl athletes more vulnerable to a stress injury?

    Occasionally, an adolescent girl runner or gymnast (or other athlete) might have an eating disorder, which will result in a cascade of problems. An anorexic or bulimic girl can lose her period (amenorrhea) and suffer bone density loss (osteopenia or osteoporosis). Her bones can become brittle and thus vulnerable to injury and fracture. It’s important for teenage girl athletes to maintain healthy, vitamin D- and calcium-rich diets.


    Why is there an increase in overuse injuries in kids these days?

    Youth and teen participation in organized sports has grown to about 35 to 40 million kids across the United States. Not surprisingly, the incidence of sports injuries has also grown—and statistics suggest that 30 to 60 percent of student athletes will have an overuse injury at some point in time. In one Sports Medicine practice at Children’s, for example, at least half of the young patients have an overuse injury.


    Aren’t organized sports supposed to be good for kids?

    Organized sports are very important and help kids—not just in the sports themselves, but in academics and social situations—and they’re good for children’s overall development and growth. The downside is that “overuse syndrome,” where the kids repeat the same drill over and over, causes overuse injuries.


    How can parents and coaches help kids avoid stress fractures and other overuse injuries?

    Parents and coaches have a great deal of influence—for better or for worse. Parents and coaches should emphasize moderation in training and should restrain the zeal with which they push youth and teens.


    Coaches should:

    • become certified
    • learn and use proper training techniques
    • avoid assigning too many repetitive drills—the overwhelming cause of overuse injuries
    • teach proper running mechanics and other sport-specific motion techniques

    Physical education departments should make sure that the surfaces of tracks and fields are in good shape, and that proper equipment, footwear and protective gear are used for each sport.


    Our Sports Medicine specialists advise:

    • warming up and stretching before practice
    • resting at least one day a week
    • cross-training/alternating sports: It is usually unwise for a child or teen to specialize in just one sport. Multi-sport athletes tend to get fewer overuse injuries than those who specialize in just one sport.
    • alternating exercises during practice: By alternating exercises, the athlete is less likely to experience an injury—and over the long term, her muscle memory will actually improve.


    Are there other guidelines and resources for injury prevention and safer training?

    The American Academy of Orthopaedic Surgeons (AAOS) has issued comprehensive guidelines for helping to prevent sports injuries. Below is an excerpt from the AAOS recommendations:

    • Use proper equipment.
      • Replace athletic shoes as they wear out.
      • Wear loose-fitting clothes that are light enough to release body heat.
      • In cold weather, dress in removable layers.
    • Warm up.
      • Warm up to prepare to exercise, even before stretching.
      • Run in place for a few minutes.
      • Breathe slowly and deeply, or gently rehearse the motions of the exercise to follow.
    • Stretch.
      • Stretch slowly to the point of muscle tension.
      • Hold each stretch for 10 to 20 seconds, then slowly release.
      • Inhale before each stretch, exhale on release.
      • Do each stretch only once.
      • Never bounce on a fully stretched muscle.
    • Drink water.
      • Drink enough water to prevent dehydration, heat exhaustion and heat stroke.
      • Drink 16 ounces (one pint) of water 15 minutes before exercising, another 16 ounces after cool-down.
      • Drink water every 20 minutes or so while exercising.
    • Cool down.
      • Cool down for twice as long as warm-up.
      • Slow down motion and lessen intensity for at least 10 minutes before stopping completely.
    • Rest.
      • Schedule regular days off from exercise, and rest when tired.
      • Fatigue, soreness and pain are good reasons to not exercise.


    Who at Children’s will be caring for my child if she develops a stress fracture? Members of our orthopedic team will provide expert care and support for your child. Our staff includes 10 primary care sports medicine specialists, 24 orthopedic surgeons, two podiatrists, a nutritionist, a sports psychologist, eight physician assistants, 14 nurses and four certified athletic trainers.

    What is the Orthopedic Center at Children’s doing to encourage injury prevention and safer training?

    To support our goal of dramatically reducing overuse injuries in youth sports, members of our team often travel to local and regional schools, youth groups and sports clubs to teach leg strengthening and other techniques. We also conduct frequent safe training programs and clinics for coaches. Call 617-355-3501 for details.


    FAQ

    Q: What are stress fractures?
    A:
    Stress fractures are sports-related microtraumas (small injuries) that result from repetitively using the same parts of the body, usually the foot or lower leg and often from running or gymnastics. A stress fracture results when fatigued muscles can’t absorb the shock (stress) of impact and transfer the stress load to a bone.

    Q: How do stress fractures happen?
    A:
    Muscles adapt to stress—that’s how they become stronger. But they also need to rest and rebuild between the episodes of stress. When a muscle gets repeatedly overtaxed with the stress of impact (running, quick cutting, pivoting), it can transfer that stress to a bone in the foot or lower leg, which can crack. Repetitive or overly-rigorous training (usually running) can result in the pain and inflammation of a stress fracture.

    Q: What are the signs and symptoms of a stress fracture?
    A:
    Pain and/or inflammation in the foot or lower leg can be signs and symptoms of stress fractures or shin splints, so a proper diagnosis is important. The pain tends to intensify in stages—from occasional and mild to constant and severe.

    Q: What should we do before we see the doctor for a diagnosis?

    A: If you suspect that your child has a stress fracture, home care before your child gets to the doctor should include:

    • rest:Make sure she doesn’t exert in any way that involves the injured area; she can use crutches or a cane, if it helps.
    • ice:Wrap a towel around ice cubes, or use a bag of frozen vegetables, to ice the area at two-hour intervals, for 20 minutes each time.
    • compression:Wrap a bandage or soft brace (from the drugstore) around her injury.
    • elevation:Your child should remain seated or reclining, with her leg elevated, as much as possible before seeing the doctor.

    Q: How are stress fractures usually diagnosed?
    A:
    Your child’s doctor will do a physical examination, and may use diagnostic tests—including x-rays, an MRI (magnetic resonance imaging) or CT scan and, rarely, a bone scan—to get detailed images of the injury to determine if there’s a stress fracture.

    Q: How does Children’s treat a stress fracture?
    A:
    The most important therapy for a stress fracture is simply to rest the injured area—restricting weight-bearing actions and all activities that involve using the injured bone—for a period of weeks or months. Your child’s doctor may also recommend a cast or boot to protect the shin or foot from further injury. A severe case can require surgery.

    Q: Will my child be OK?

    A: Most kids with stress fracture can return to sports and regular activities after several weeks or months of rest and healing time. Your child’s doctor will give you guidance about how long your child’s foot or leg should be rested in order for it to heal.

    During the healing period, it’s important to support your young athlete’s resolve to rest her injured bone, since she may feel disappointed and frustrated at not being able to play her sport.

    Q: How long will it take for my child to recover from a stress fracture?
    A:
    Children usually heal faster and better than adults. Your child should heal from a stress fracture in a period of weeks or months, depending on the severity of the injury.

    Q: If my child has been injured playing sports, should she go back to sports?

    A:If your child’s doctor has cleared her to go back to sports, the many benefits and life lessons she’ll gain from playing greatly outweigh the risks of injury. These benefits include:

    •  physical fitness
    • teamwork, competitive prowess, accomplishment
    • improved body composition—less risk of obesity
    • reduced risk of heart disease and diabetes
    • stronger immune system
    • academic fitness—kids who play sports often academically outperform kids who don’t
    • emotional and psychological fitness—improved self-esteem, self-concept, self-confidence, empowerment and perception of competence

    Q: What is Children’s experience in orthopedics?

    A:
    At Children’s Orthopedic Center we’re known for our clinical innovations, research and leadership. Ranked among the top three in orthopedics for 2012-13 by U.S.News & World Report, we provide the most advanced diagnostics and treatments, several of which were pioneered and developed by Children’s researchers and clinicians—including platelet-rich plasma (PRP) treatment for tendon repair and physeal-sparing ACL procedures for children whose growth plates are still open.


    Causes

    As more and more kids play organized sports, there’s been a rise in the number of stress fractures and other overuse injuries (microtraumas to bones, tendons, ligaments or muscles) among adolescents and children, largely from repetitively using the same parts of the body. Stress fractures are often seen in runners and gymnasts—possibly because of overtraining, running with improper footwear or training too hard while still a beginner.


    Signs and symptoms

    Pain and/or inflammation in the foot or shin bone can be symptoms of a stress fracture. The pain tends to intensify in stages:

    • At first, the injury may hurt mildly when the child plays her sport.
    • As more trauma occurs, the child will experience constant pain when she’s playing.
    • At the end stage, the child will have constant pain in her lower leg, even when she’s not playing. At that point, the affected area will have sustained a significant amount of damage.


    When to seek medical advice

    Consult your child’s doctor if her lower leg is painful or inflamed. Tell the doctor if your child:

    • has been training very hard (usually running or aerobics)
    • has changed her exercise routine
    • has been running on hard surfaces
    • has been running with improper footwear
    • has an eating disorder or has been diagnosed with osteopenia or osteoporosis


    Questions to ask your doctor

    You and your family are key players in your child’s medical care. It’s important that you share your observations and ideas with your child’s health care provider and that you understand your provider’s recommendations.

    You probably already have some ideas and questions on your mind, but it can be easy to forget the questions you wanted to ask when you’re talking to your child’s doctor. It’s often helpful to jot them down ahead of time to make sure that all your concerns have been addressed. You may also suggest to your child that she writes down questions to ask her health care provider, too. Some of the questions you may want to ask include:

    • What has happened to my child’s foot or leg, and why?
    • Is a stress fracture a serious injury? Will it do any permanent damage?
    • What tests will you perform to diagnose my child?
    • What actions might you take after you reach a diagnosis?
    • Will my child be OK if she has a stress fracture?
    • Will there be restrictions on my child’s activities? If so, for how long?
    • What should we do at home?
    • How can we help her understand that she needs to rest the injury?


    Who’s at risk

    • runners, gymnasts
    • runners who
      • run on surfaces that are too hard or uneven
      • have recently changed their training routine or started running hard up steep hills
      • are using outworn footwear
      • have had prior stress fractures
      • are not conditioned, yet are suddenly training rigorously
      • have flat feet or rigid arches
    • athletes whose sports involve quick cutting and side-to-side motions, such as basketball


    Complications

    Complications after proper treatment for a stress fracture are uncommon, but can occur. These can include:

    • failure to respond to treatment or to heal properly
    • vulnerability of the area to re-injury
    • a re-injury resulting in chronic problems


    For teens

    Many teens who have stress fractures are not only high-performing, determined athletes, but also high-performing, determined students. If you approach your rest and healing period with that same spirit of determination, you should be back to sports and your active lifestyle within a few weeks or months, depending on how severe your injury was in the first place.

    The most important thing you can do to get back into your sport is to give your foot or leg a total rest. But even though you know the importance of rest and recovery, you still could find this to be a tough time. If you feel frustrated, depressed or angry during this important time, speak to your doctor, parent or counselor—they’re all on your team, and they all want to help.


    For parents

    If your teen is like many young athletes who have an overuse injury, she’s not only a high-performing, determined athlete—she’s also a high-performing, determined student. Encourage her to approach her rest and recovery period with the same spirit of determination that she applies to other areas of her life. With patience and perseverance, she’ll probably be back to sports and her active lifestyle within a few weeks or months.

    Even though you and your teen know the importance of resting her foot or leg, you both might experience her healing period as a difficult time. Parents who identify with their children’s success can feel frustrated or depressed along with their children, so speak to your doctor or counselor if you need help.


    Prevention

    Our Sports Medicine specialists advise young athletes to:

    • warm up and stretch before practice
    • rest at least one day a week
    • cross-train/alternate sports: It’s usually unwise for a child or teen to specialize in just one sport. Multi-sport athletes tend not to sustain as many overuse injuries as those who just specialize in one sport.
    • alternate exercises during practice: By alternating exercises, an athlete is less likely to experience an injury—and over the long term, her muscle memory actually improves.


    Stress fractures glossary

    • cast or walking boot: custom-made protections worn around the lower leg while shin splints heal
    • diagnosis, diagnostics: identifying disease or injury through examination, testing and observation
    • microtrauma: a small injury to the body, such as microtears to muscle fibers, stress to the tendon, bruising of the bone; can occur to bone, muscle, tendon or ligament. If not allowed rest in order to heal, accumulated microtraumas can lead to overuse injuries, such as stress fractures.
    • non-surgical (non-operative) treatments: alternatives to surgery; most treatments for overuse injury are non-surgical
    • orthopedics: the medical specialty concerned with diagnosing, treating, rehabilitating and preventing disorders and injuries to the spine, skeletal system and associated muscles, joints and ligaments
    • orthopedist/orthopedic surgeon: a physician concerned with diagnosing, treating, rehabilitating and preventing disorders and injuries to the spine, skeletal system and associated muscles, joints and ligaments
    • osteopenia: less bone mineral density than normal, a precursor to osteoporosis
    • osteoporosis: loss of bone density
    • overuse injuries: sports-related microtraumas that result from repetitively using the same parts of the body, usually by overtraining; can occur to muscle, tendon, ligament or bone
    • physical therapy: a rehabilitative health specialty that uses therapeutic exercises and equipment to help patients improve or regain muscle strength, mobility and other physical capabilities
       
    • stress fractures: tiny overuse fractures, usually to a bone in the foot or the shin bone (tibia),causing pain and inflammation
    • tibia: shin bone
       
    Sports Trauma and Overuse Prevention(STOP)

    Sports Trauma and Overuse Prevention(STOP, stopsportsinjuries.org) is an organization sponsored by the AAOS and the American Orthopaedic Society for Sports Medicine (AOSSM) that’s dedicated to reducing overuse injuries in kids’ sports.

    Co-founded in 2010 by Mininder Kocher, MD, MPH, associate director of Children’s Division of Sports Medicine and an associate professor of Orthopaedic Surgery at Harvard Medical School, STOP provides resources for athletes, coaches and parents. It offers a community outreach toolkit, as well as engaging, instructive videos on topics relating to various sports.

    Pro athletes on STOP’s Council of Champions are carrying the organization’s prevention message out to the sports-minded public. St. Louis Rams QB and 2008 Heisman trophy winner Sam Bradford has done prevention interviews on ESPN on behalf of STOP. Other pros on STOP’s Council of Champions include Hank Aaron (baseball), Bo Jackson (baseball and football), Howie Long (football), Bonnie Blair (skating), Jack Nicklaus (golf) and John Smoltz (baseball).
  • Tests

    At Children’s Hospital Boston, we know that the first step to treating your child is forming an accurate, timely diagnosis. To diagnose a stress fracture, your child’s Sports Medicine specialist will take a medical history and perform a physical exam on your child.

    Your child’s doctor will also get x-rays to look for a fracture. But because children can have stress fractures and damage to their growth plates that can’t be seen on x-rays, the clinician may also use an MRI (magnetic resonance imaging) or CT scan and, rarely, a bone scan to get detailed images of the injury to determine if there’s a stress fracture.

    If you live far from Boston, we can help

    As an international pediatric orthopedics center, Children’s treats young patients from all over the world. Our International Center assists families residing outside the United States: We facilitate the medical review of patient records; coordinate appointment scheduling; and help families with customs and immigration, transportation, hotel and housing accommodations.

    Our Orthopedic Clinical Effectiveness Research Center (CERC)

    The Orthopedic Clinical Effectiveness Research Center (CERC) was established by Children’s Orthopedic Center to improve the quality of life for children with musculoskeletal disorders. This collaborative clinical research program is unique in the nation and is playing an instrumental role in establishing, for the first time, evidence-based standards of care for pediatric orthopedic patients throughout the world.

  • Boston Children's Hospital's Orthopedic Center provides patients with comprehensive care—including evaluation, diagnosis, consultation, non-surgical therapies, surgery and follow-up care.


    Initial first aid

    Initial first aid for a stress fracture usually involves “R.I.C.E.” (rest, ice, compression and elevation), as well as medications to help control pain and swelling:

    • rest:Make sure your child doesn't exert in any way that involves the injured area; she can use crutches or a cane, if it helps.
    • ice:Wrap a towel around ice cubes, or use a bag of frozen vegetables, to ice the area at two-hour intervals, for 20 minutes each time.
    • compression:Wrap a bandage or soft brace (from the drugstore) around her injury.
    • elevation:The child should remain seated or reclining, with her leg elevated, as much as possible before seeing the doctor.


    The primary therapy for most stress fractures is simply to rest the injured foot or leg—restricting weight-bearing actions and all activities that involve using the injured area for a period of weeks or months. Your child's doctor may also recommend a cast or walking boot in order to:

    • relax the stress on the leg
    • protect the leg from further damage
    • force the athlete to rest


    Treatments

    Treatment options may also include:

    • temporary use of crutches or a wheelchair
    • physical therapy to stretch and strengthen the injured area
    • (less often) surgery     


    Caring for your child as she heals

    Your child's doctor will give you guidance regarding:

    • how long your child's foot or leg should be rested in order for it to heal
    • tools for getting the injured foot or leg back in shape, such as massage, stretching exercises and strength training


    Most kids with stress fractures can return to sports and regular activities after several weeks or months of rest and healing time. But during the healing period, it's important for everybody in the family to support the young athlete's resolve to rest the healing area, since she may feel disappointed and even a bit depressed at not being able to play her sport.


    Coping and support

    At Boston Children's Hospital, we understand that a hospital visit can be difficult, and sometimes overwhelming. So, we offer many amenities to make your child's—and your own—hospital experience as pleasant as possible. Our Center for Families staff will give you all the information you need regarding:

    • getting to Children's
    • accommodations
    • navigating the hospital experience
    • resources that are available for your family


    In particular, we understand that you may have a lot of questions when your child is diagnosed with a stress fracture. Will this affect my child long term? When can she return to sports and weight-bearing activities? Children's can connect you with extensive resources to help you and your family through this stressful time, including:

    • patient education: From the first doctor's appointment to treatment and recovery, our staff will be on hand to walk you through your child's treatment and help answer questions you may have—How long will her recovery take? Will she need home exercises and physical therapy? We'll help you coordinate and continue the care and support your child received while at Children's.
    • parent-to-parent: Want to talk with someone whose child has been treated for stress fractures? We can often put you in touch with other families who've been through the same process that you and your child are facing, and who will share with you their experience at Children's.
    • faith-based support: If you're in need of spiritual support, we'll connect you with the Children's chaplaincy. Our program includes nearly a dozen clergy— representing Protestant, Jewish, Muslim, Roman Catholic and other faith traditions—who will listen to you, pray with you and help you observe your own faith practices during your Children's experience.
    • social work: Our clinical social workers have helped many families in your situation. Your Children's social worker can offer counseling and assistance with issues such as coping with your child's diagnosis, stresses relating to dealing with a child's injury, changing family dynamics and financial issues.

     

    A long history of firsts

    With a long history of excellence and innovation and a team of clinicians and researchers at the forefront of orthopedic research and care, Children's is home to many treatment breakthroughs:

    • advanced techniques and microsurgery care for complex fractures and soft tissue injuries to the hand and upper extremity
    • one of the first pediatric sports medicine clinics in the nation
    • a hip program that has performed more than 1,400 periacetabular osteotomies
    • advances in our spinal program, such as video-assisted thorascopic surgery

    Children's is also:

    • the oldest and largest comprehensive center for the care of spina bifida
    • one of the first scoliosis clinics in the nation
    • one of the first centers in the nation to use adjuvant chemotherapy and perform limb salvage surgery for patients with osteosarcoma
  • Research & Innovation

    For more than a century, orthopedic surgeons and investigators at Children’s Hospital Boston have played a vital role in the field of musculoskeletal research—pioneering treatment approaches and major advances in the care and treatment of trauma to the joint, scoliosis, polio, TB, hip dysplasias and traumas to the hand and upper extremities.

    Our advanced research helps answer the most pressing questions in pediatric orthopedics today—providing the children we treat with the most innovative care available.

    Children’s research shows that too much high-impact training can lead to stress fractures in pre-teen and teen girls
    Today’s kids are urged to participate in sports at younger and younger ages and at greater levels of intensity. While weight-bearing activity is generally thought to increase bone density, a Children's study found that for preadolescent and adolescent girls, too much high-impact activity can lead to stress fractures.

    If stress fractures are detected too late in children and adolescent athletes, they pose a risk of true fracture, deformity or growth disturbance requiring surgical treatment, say the researchers, led by Alison Field, ScD, of Children's Division of Adolescent Medicine, and Mininder S. Kocher, MD, MPH, associate director of Sports Medicine at Children's.

    Their study, published online on April 4, 2011, by the Archives of Pediatric and Adolescent Medicine, followed 6,831 girls aged 9 to 15 participating in the large national Growing Up Today study, co-founded by Field. During the seven years after enrollment, 4 percent of the girls developed a stress fracture. The most significant predictors were high-impact activities—particularly running, basketball, cheerleading and gymnastics.

    "This is the first study to look prospectively at causes of stress fracture among a general sample of adolescent girls," says Field, who is also affiliated with Brigham and Women's Hospital. "Most research has been on specialized groups, such as army recruits or college athletes, making it difficult to figure out if the results apply to average adolescents. Our study was large enough to look at the risk associated not only with hours per week of activity, but also hours per week in a variety of activities."

    When researchers adjusted for other risk factors (age, later onset of menstruation and family history of osteoporosis and low bone density), the association between high-impact sports and fractures only strengthened. Girls engaging in eight or more hours of high-impact activity per week were twice as likely to have a stress fracture as those engaged in such activity for four hours or fewer.

    "We are seeing stress fractures more frequently in our pediatric and adolescent athletes," says Kocher, senior author on the report. "This likely reflects increased intensity and volume of youth sports. Kids are often playing on multiple teams, including town and travel teams, and participating in high-intensity showcases and tournaments. It's not uncommon to see young athletes participating in more than 20 hours of sports per week."

    Each hour of high-impact activity per week increased fracture risk by about 8 percent. Basketball, cheerleading/gymnastics and running were independent predictors.

    "The youth athlete is specializing in a single sport at a younger age," says Kocher. "This does not allow for cross-training or relative rest, as the athlete is constantly doing the same pattern of movement and impact. Small injuries are being made in the bone with greater cumulative frequency than the body can handle."

    The key to the treatment of stress fractures is early recognition, Kocher adds. If recognized early, most stress fractures will heal fully with activity restriction. "Kids should not play through pain," he says. "'No pain-No gain' is not an appropriate adage for the young athlete."

    The study was supported by the Department of Orthopedic Surgery at Boston Children's Hospital and the National Institutes of Health.

    Sports Medicine Research Laboratory

    Children’s Sports Medicine Research Laboratory, led by principal investigator Martha M. Murray, MD, focuses on sports medicine injuries, including those of the ACL (anterior cruciate ligament), knee meniscus and articular cartilage.

    In conjunction with our collaborators, we are studying these problems on multiple levels: gene, protein, cell, tissue and organism.


    Researchers at Children’s Sports Medicine Research Laboratory

    The lab’s research includes projects in:

    • molecular orthopedics
    • platelet optimization and characterization
    • Tissue Engineering
    • joint imaging
    • biomechanics of injury repair
    • histology and immunohistochemistry
    • device design and development
    • injury prevention
    • outcomes research

    The Orthopedic Center  conducts research into:

    • the mechanisms of sports injuries
    • the techniques of rehabilitation and treatment
    • the physiology of exercise and conditioning

    Ongoing research includes the study of:

    • knee injuries
    • running injuries
    • injuries to pre-adolescent children
    • the psychological impact of sports and sports injuries
    • the treatment and prevention of injuries to dancers

    Division of Sports Medicine director Lyle J. Micheli, MD, is one of the world's leading authorities on sports care. Micheli has treated world-renowned dancers and professional athletes, and is the author of hundreds of published clinical studies and scholarly review articles and books.

    Innovations for tendon and ligament treatment

    Platelet-rich plasma. For tendon repair, as with tennis elbow, the Orthopedic Center is now incorporating the latest in tendon regeneration—the application of platelet-rich plasma (PRP). This treatment has been popular in Europe—and now in the United States—for stimulating tissue regeneration in difficult-to-heal areas such as tendons (including Achilles, elbow and patella) that don’t respond to physical therapy or to limits on activity.

    There are normally many healing growth factors in our platelets. The process involves isolating these growth factors in the patient’s blood platelets, and then injecting them into the affected areas under ultrasound guidance. This special procedure is performed by Children’s Pierre d'Hemecourt, MD.

    Physeal sparing. A series of innovative, age-specific reconstruction techniques for treating the ACL injuries of growing children has been developed by Children’s orthopedic surgeon and director of the Division of Sports Medicine Lyle Micheli, MD. These are classified as physeal sparing procedures—that is, they spare the child’s growth plates (physes) from disruption that would occur in traditional ACL reconstructive surgery.

    These physeal sparing treatment techniques are customized to the growing child’s age: pre-pubescent, adolescent or older adolescent. Originally developed as a temporary procedure until a child reached skeletal maturity, follow-up studies have found that five years after their surgeries, 95 percent of children who’d had physeal sparing procedures were doing so well that they didn’t need ACL reconstructive surgery, after all.

    Stress fractures in girls and sports   

    Alison Field, ScD, of Children's Division of Adolescent Medicine and Mininder S. Kocher, MD, MPH, associate director of Children's Sports Medicine  led a study showing that frequent participation in high-impact sports is linked to stress factors in girls, particularly from basketball, running, gymnastics and cheerleading. Learn more about this study in the Children’s newsroom.

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