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. 2025 Jan 2;59(2):78-90.
doi: 10.1136/bjsports-2024-108616.

International Delphi consensus on bone stress injuries in athletes

Tim Hoenig  1 , Karsten Hollander  2 , Kristin L Popp  3   4 , Michael Fredericson  5 , Emily A Kraus  5 , Stuart J Warden #  6 , Adam S Tenforde #  7 ; Bone Stress Injury Authorship Group
Collaborators, Affiliations

International Delphi consensus on bone stress injuries in athletes

Tim Hoenig et al. Br J Sports Med. .

Abstract

Bone stress injuries, commonly referred to as stress reactions and stress fractures, represent overuse injuries to bone. These injuries result in physical limitations in activity and can be career-ending for high-level athletes. While bone stress injuries have received increased attention in recent years, international consensus is lacking on definitions, risk factors and strategies for management and prevention. This study aimed to ascertain and improve the level of agreement on bone stress injuries by utilising a three-part modified Delphi approach on (1) pathophysiology, diagnosis, terminology and classification systems; (2) risk factors, screening and prevention; and (3) management and return to sport. A multidisciplinary steering committee initiated the consensus process. A panel of 41 members from six continents was formed to complete three rounds of voting, including experts (scientists and clinicians) and representatives (athletes and coaches). Thirty-three, 28 and 28 panel members completed Delphi rounds 1, 2 and 3, respectively. Consensus was reached on 41 out of 58 statements. Findings from this Delphi study outline a multifactorial approach to identify and manage bone stress injuries and to promote bone health in athletes. This includes recommendations for diagnostic workup and treatment to assist clinicians in caring for patients with bone stress injuries. Finally, this consensus process identifies knowledge gaps and provides a framework for future research to advance the clinical care and prevention of bone stress injuries.

Keywords: Athletes; Consensus; Fractures, Stress; Injuries.

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Conflict of interest statement

Competing interests: KH receives research grants from the German Federal Institute of Sports Science, International Ski Federation (FIS) and German Federal Ministry for Economic Affairs and Energy, and honoraria for lectures from the German Athletics Federation and German Olympic Sport Federation. KP receives research grants from the Department of Defense and consulting fees and support for attending conferences from the Female Athlete Program at Boston Children’s Hospital, and participates on the scientific advisory board for HealthPartners Institute in Minneapolis. SW receives support from the National Institutes of Health and serves as Associate Editor for Medicine & Science in Sports & Exercise. AT serves as Senior Editor for PM&R Journal and gives professional talks such as grand rounds and medical conference plenary lectures and receives honoraria from conference organisers. AT has participated in research funded by Arnold P. Gold Foundation (physician and patient care disparities), Football Player Health Study at Harvard (health in American-Style Football players), American Medical Society for Sports Medicine (bone density research), Uniform Health Service and Enovis (Achilles tendinopathy) and MTEC/Department of Defense (bone stress injuries with shockwave). He is a paid consultant for State Farm Insurance and Strava.

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