Close
New

Medscape is available in 5 Language Editions – Choose your Edition here.

 

Physical Medicine and Rehabilitation for Stress Fractures Clinical Presentation

  • Author: Stephen Kishner, MD, MHA; Chief Editor: Consuelo T Lorenzo, MD  more...
 
Updated: Nov 13, 2015
 

History

The most salient historical feature in the diagnosis of stress fracture is the insidious onset of activity-related pain.

Early on, the pain typically is mild and occurs toward the end of the inciting activity.

Subsequently, the pain may worsen and occur earlier, limiting participation in sports activities. While rest may provide transient relief of symptoms in the early stages, as the stress injury progresses, the athlete's pain may persist even after cessation of activity. Night pain is a frequent complaint. Pain resulting from long-bone fractures is thought to be localized, while pain associated with stress injury of trabecular bone is characteristically described as more diffuse.

Stress fractures, like most overuse injuries, typically are multifactorial in etiology; thus, if the diagnosis has been made or is suspected, the clinician is in the position to try to determine what risk factors precipitated or contributed to the injury. Details of the athlete's training history should be noted, both in terms of volume and intensity. Intensive sustained muscular activity may result in bone strain and overload. This type of mechanism of injury is common in rowers, who are prone to stress fractures of the ribs.

Muscle fatigue, perhaps because of poor conditioning or as the result of overtraining, can attenuate the shock-absorbing capacity of the muscular system, resulting in greater transmission of GRFs to the associated parts of the skeleton.

Structural malalignments (eg, leg-length discrepancies) or biomechanical inefficiencies (eg, excessive subtalar pronation) can result in increased stress and strain on the tibiae.

Concurrent injury may result in subclinical biomechanical adaptations along the kinetic chain, placing atypical loads on bone and precipitating a stress injury.

Poor bone health, whether because of hormonal, dietary, or pathological causes (eg, osteoporosis, hyperparathyroidism, skeletal involvement from malignancy), can weaken bone and make it more susceptible to injury.

These conditions and other intrinsic and extrinsic risk factors for the development of stress fractures are summarized in Causes below.

Next

Physical

Upon physical examination, individuals with stress fractures typically report pain upon palpation or percussion of the affected area.

Inspection of the site may reveal localized swelling and, possibly, erythema.

Loading the affected bone using specific maneuvers (such as the "hop test" or the "fulcrum test") may reproduce the athlete's pain. Note that no single physical examination test is sufficiently sensitive and specific to permit the unequivocal diagnosis of a stress fracture. Rather, taking the individual's history and examination into consideration, the clinician must have sufficient clinical suspicion to include the diagnosis among the different possible causes of the presenting complaints.

Some practitioners believe that application of a vibrating tuning fork over the affected bone can provoke the athlete's pain, but Brukner et al dispute the validity of this test.[13]

As part of a thorough physical examination, the practitioner should assess the athlete's flexibility, lower limb alignment (including leg lengths), foot structure (eg, pes cavus vs pes planus), and motor function (eg, evaluating for strength imbalances).

Previous
Next

Causes

Disrupted bone homoeostasis and inadequate repair in the face of repetitive overload cause stress fractures. A variety of risk factors are thought to predispose individuals to the development of stress fractures.

Intrinsic risk factors are as follows:

  • Low BMD (potentially modifiable)
  • Lower limb malalignment (potentially modifiable)
  • Foot structure (unmodifiable)
  • Height - Tall stature (unmodifiable)
  • Muscle fatigue/poor overall conditioning (modifiable)
  • Weakness/strength imbalance (modifiable)
  • Pathologic bone states (potentially unmodifiable)
  • Menstrual/hormonal irregularities (potentially modifiable)
  • Genetic predisposition (unmodifiable)

Extrinsic risk factors are as follows:

  • Excessive volume or intensity of training (modifiable)
  • Sporting discipline (modifiable) - For example, runners are prone to tibial shaft stress fractures, whereas tennis players appear to be most vulnerable to navicular injuries, and volleyball players may be at a relatively increased risk of pars interarticularis injuries.
  • Change in training regimen - "New coach" phenomenon (potentially modifiable)
  • Change in training surface - Density or topography (modifiable)
  • Worn-out training shoes (modifiable)
  • Cigarette smoking (modifiable)
  • Inadequate nutrition - Energy (calories), calcium, vitamin D (modifiable)
  • Medication usage - For example, long-term steroid use (potentially modifiable)

A literature review by Yoder et al indicated that high-prevalence risk factors for fatigue-related sacral stress fractures include dietary deficiency and a recent increase in training intensity, while high-prevalence risk factors for sacral insufficiency fractures include osteoporosis, rheumatoid arthritis, long-term corticosteroid treatment, pelvic radiation therapy, and a postmenopausal state.[14]

Previous
 
 
Contributor Information and Disclosures
Author

Stephen Kishner, MD, MHA Professor of Clinical Medicine, Physical Medicine and Rehabilitation Residency Program Director, Louisiana State University School of Medicine in New Orleans

Stephen Kishner, MD, MHA is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, American Association of Neuromuscular and Electrodiagnostic Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Michael T Andary, MD, MS Professor, Residency Program Director, Department of Physical Medicine and Rehabilitation, Michigan State University College of Osteopathic Medicine

Michael T Andary, MD, MS is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, American Association of Neuromuscular and Electrodiagnostic Medicine, American Medical Association, Association of Academic Physiatrists

Disclosure: Received honoraria from Allergan for speaking and teaching.

Chief Editor

Consuelo T Lorenzo, MD Medical Director, Senior Products, Central North Region, Humana, Inc

Consuelo T Lorenzo, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation

Disclosure: Nothing to disclose.

Additional Contributors

Everett C Hills, MD, MS Assistant Professor of Physical Medicine and Rehabilitation, Assistant Professor of Orthopaedics and Rehabilitation, Penn State Milton S Hershey Medical Center and Pennsylvania State University College of Medicine

Everett C Hills, MD, MS is a member of the following medical societies: American Academy of Disability Evaluating Physicians, Association of Academic Physiatrists, American Academy of Physical Medicine and Rehabilitation, American Association for Physician Leadership, American Congress of Rehabilitation Medicine, American Medical Association, American Society of Neurorehabilitation, Pennsylvania Medical Society

Disclosure: Nothing to disclose.

Acknowledgements

Jonathan C Reeser, MD, PhD Office of Research Integrity and Protections, Marshfield Clinic Research Foundation

Jonathan C Reeser, MD, PhD is a member of the following medical societies: Alpha Omega Alpha, American College of Sports Medicine, American Medical Association, Association of Academic Physiatrists, Phi Beta Kappa, and State Medical Society of Wisconsin

Disclosure: Nothing to disclose.

References
  1. Berger FH, de Jonge MC, Maas M. Stress fractures in the lower extremity. The importance of increasing awareness amongst radiologists. Eur J Radiol. 2007 Apr. 62(1):16-26. [Medline].

  2. Hauret KG, Jones BH, Bullock SH, et al. Musculoskeletal injuries description of an under-recognized injury problem among military personnel. Am J Prev Med. 2010 Jan. 38(1 Suppl):S61-70. [Medline].

  3. Evans JT, Guyver PM, Kassam AM, Hubble MJ. Displaced femoral neck stress fractures in Royal Marine recruits--management and results of operative treatment. J R Nav Med Serv. 2012. 98(2):3-5. [Medline].

  4. Corrarino JE. Stress fractures in runners. Nurse Pract. 2012 Jun 10. 37(6):18-28. [Medline].

  5. Briskin SM. Injuries and medical issues in softball. Curr Sports Med Rep. 2012 Sep. 11(5):265-71. [Medline].

  6. Kahanov L, Eberman LE, Games KE, Wasik M. Diagnosis, treatment, and rehabilitation of stress fractures in the lower extremity in runners. Open Access J Sports Med. 2015. 6:87-95. [Medline]. [Full Text].

  7. Miller TL, Kaeding CC. Upper-extremity Stress Fractures: Distribution and Causative Activities in 70 Patients. Orthopedics. 2012 Sep 1. 35(9):789-93. [Medline].

  8. Milner CE, Hamill J, Davis IS. Distinct hip and rearfoot kinematics in female runners with a history of tibial stress fracture. J Orthop Sports Phys Ther. 2010 Feb. 40(2):59-66. [Medline].

  9. Kiuru MJ, Niva M, Reponen A, Pihlajamaki HK. Bone stress injuries in asymptomatic elite recruits: a clinical and magnetic resonance imaging study. Am J Sports Med. 2005 Feb. 33(2):272-6. [Medline].

  10. Oestreich AE, Bhojwani N. Stress fractures of ankle and wrist in childhood: nature and frequency. Pediatr Radiol. 2010 Feb 24. [Medline].

  11. Changstrom BG, Brou L, Khodaee M, Braund C, Comstock RD. Epidemiology of stress fracture injuries among US high school athletes, 2005-2006 through 2012-2013. Am J Sports Med. 2015 Jan. 43 (1):26-33. [Medline].

  12. Tenforde AS, Sayres LC, McCurdy ML, Sainani KL, Fredericson M. Identifying sex-specific risk factors for stress fractures in adolescent runners. Med Sci Sports Exerc. 2013 Oct. 45 (10):1843-51. [Medline].

  13. Brukner P, Bennell K, Matheson G. Stress Fractures. 1st ed. Melbourne, Australia: Blackwell Science Asia; 1999.

  14. Yoder K, Bartsokas J, Averell K, McBride E, Long C, Cook C. Risk factors associated with sacral stress fractures: a systematic review. J Man Manip Ther. 2015 May. 23 (2):84-92. [Medline].

  15. Fayad LM, Kawamoto S, Kamel IR, Bluemke DA, Eng J, Frassica FJ. Distinction of long bone stress fractures from pathologic fractures on cross-sectional imaging: how successful are we?. AJR Am J Roentgenol. 2005 Oct. 185(4):915-24. [Medline].

  16. Smith JT, Halim K, Palms DA, Okike K, Bluman EM, Chiodo CP. Prevalence of vitamin D deficiency in patients with foot and ankle injuries. Foot Ankle Int. 2014 Jan. 35 (1):8-13. [Medline].

  17. Jaimes C, Jimenez M, Shabshin N, Laor T, Jaramillo D. Taking the stress out of evaluating stress injuries in children. Radiographics. 2012 Mar-Apr. 32(2):537-55. [Medline].

  18. Bui-Mansfield LT, Thomas WR. Magnetic resonance imaging of stress injury of the cuneiform bones in patients with plantar fasciitis. J Comput Assist Tomogr. 2009 Jul-Aug. 33(4):593-6. [Medline].

  19. Sanchez TR, Jadhav SP, Swischuk LE. MR imaging of pediatric trauma. Magn Reson Imaging Clin N Am. 2009 Aug. 17(3):439-50, v. [Medline].

  20. Schmid MR, Hodler J, Vienne P, Binkert CA, Zanetti M. Bone marrow abnormalities of foot and ankle: STIR versus T1-weighted contrast-enhanced fat-suppressed spin-echo MR imaging. Radiology. 2002 Aug. 224(2):463-9. [Medline].

  21. Wright AA, Hegedus EJ, Lenchik L, Kuhn KJ, Santiago L, Smoliga JM. Diagnostic Accuracy of Various Imaging Modalities for Suspected Lower Extremity Stress Fractures: A Systematic Review With Evidence-Based Recommendations for Clinical Practice. Am J Sports Med. 2015 Mar 24. [Medline].

  22. Rush JK, Astur N, Scott S, Kelly DM, Sawyer JR, Warner WC Jr. Use of magnetic resonance imaging in the evaluation of spondylolysis. J Pediatr Orthop. 2015 Apr-May. 35 (3):271-5. [Medline].

  23. Arendt E, Agel J, Heikes C, Griffiths H. Stress injuries to bone in college athletes: a retrospective review of experience at a single institution. Am J Sports Med. 2003 Nov-Dec. 31(6):959-68. [Medline].

  24. Hoffman DF, Adams E, Bianchi S. Ultrasonography of fractures in sports medicine. Br J Sports Med. 2015 Feb. 49 (3):152-60. [Medline].

  25. Nicola TL, El Shami A. Rehabilitation of running injuries. Clin Sports Med. 2012 Apr. 31(2):351-72. [Medline].

  26. Soler T, Calderon C. The prevalence of spondylolysis in the Spanish elite athlete. Am J Sports Med. 2000 Jan-Feb. 28(1):57-62. [Medline].

  27. Sairyo K, Katoh S, Takata Y, Terai T, Yasui N, Goel VK. MRI signal changes of the pedicle as an indicator for early diagnosis of spondylolysis in children and adolescents: a clinical and biomechanical study. Spine (Phila Pa 1976). 2006 Jan 15. 31(2):206-11. [Medline].

  28. Kuhn KM, Riccio AI, Saldua NS, et al. Acetabular retroversion in military recruits with femoral neck stress fractures. Clin Orthop Relat Res. 2009 Jul 9. [Medline]. [Full Text].

  29. Snyder RA, Deangelis JP, Koester MC, et al. Does shoe insole modification prevent stress fractures? A systematic review. HSS J. 2009 Jun 9. [Medline]. [Full Text].

  30. Anderson K, Sarwark JF, Conway JJ, et al. Quantitative assessment with SPECT imaging of stress injuries of the pars interarticularis and response to bracing. J Pediatr Orthop. 2000 Jan-Feb. 20(1):28-33. [Medline].

  31. Swenson EJ, DeHaven KE, Sebastianelli WJ, et al. The effect of a pneumatic leg brace on return to play in athletes with tibial stress fractures. Am J Sports Med. 1997 May-Jun. 25(3):322-8. [Medline].

  32. Whitelaw GP, Wetzler MJ, Levy AS, et al. A pneumatic leg brace for the treatment of tibial stress fractures. Clin Orthop. 1991 Sep. (270):301-5. [Medline].

  33. Kilcoyne KG, Dickens JF, Rue JP. Tibial stress fractures in an active duty population: long-term outcomes. J Surg Orthop Adv. 2013 Spring. 22(1):50-3. [Medline].

  34. Entwistle RC, Sammons SC, Bigley RF, et al. Material properties are related to stress fracture callus and porosity of cortical bone tissue at affected and unaffected sites. J Orthop Res. 2009 Apr 20. [Medline].

  35. Keeley A, Bloomfield P, Cairns P, et al. Iliotibial band release as an adjunct to surgical management of patellar stress fracture in the athlete: a case report and review of the literature. Sports Med Arthrosc Rehabil Ther Technol. 2009 Jul 30. 1(1):15. [Medline]. [Full Text].

  36. Torg JS, Moyer J, Gaughan JP, et al. Management of Tarsal Navicular Stress Fractures: Conservative Versus Surgical Treatment: A Meta-Analysis. Am J Sports Med. 2010 Mar 2. [Medline].

  37. Ruohola JP, Laaksi I, Ylikomi T, Haataja R, Mattila VM, Sahi T. Association between serum 25(OH)D concentrations and bone stress fractures in Finnish young men. J Bone Miner Res. 2006 Sep. 21(9):1483-8. [Medline].

  38. Lappe J, Cullen D, Haynatzki G, Recker R, Ahlf R, Thompson K. Calcium and vitamin d supplementation decreases incidence of stress fractures in female navy recruits. J Bone Miner Res. 2008 May. 23(5):741-9. [Medline].

  39. McCabe MP, Smyth MP, Richardson DR. Current concept review: vitamin D and stress fractures. Foot Ankle Int. 2012 Jun. 33(6):526-33. [Medline].

  40. McClung JP, Karl JP. Vitamin D and stress fracture: the contribution of vitamin D receptor gene polymorphisms. Nutr Rev. 2010 Jun. 68(6):365-9. [Medline].

  41. Buvanendran A, Reuben SS. COX-2 inhibitors in sports medicine: utility and controversy. Br J Sports Med. 2006 Nov. 40(11):895-6. [Medline].

  42. Fredericson M, Ngo J, Cobb K. Effects of ball sports on future risk of stress fracture in runners. Clin J Sport Med. 2005 May. 15(3):136-41. [Medline].

  43. Hofmann AA, Bloebaum RD, Koller KE, Lahav A. Does celecoxib have an adverse effect on bone remodeling and ingrowth in humans?. Clin Orthop Relat Res. 2006 Nov. 452:200-4. [Medline].

  44. Hoy G, Wood T, Phillips N, Connell D, Hughes DC. When physiology becomes pathology: the role of magnetic resonance imaging in evaluating bone marrow oedema in the humerus in elite tennis players with an upper limb pain syndrome. Br J Sports Med. 2006 Aug. 40(8):710-3; discussion 713. [Medline].

  45. Ivkovic A, Bojanic I, Pecina M. Stress fractures of the femoral shaft in athletes: a new treatment algorithm. Br J Sports Med. 2006 Jun. 40(6):518-20; discussion 520. [Medline].

  46. Komatsubara S, Sairyo K, Katoh S. High-grade slippage of the lumbar spine in a rat model of spondylolisthesis: effects of cyclooxygenase-2 inhibitor on its deformity. Spine. 2006 Jul 15. 31(16):E528-34.

  47. Lippi G, Franchini M, Guidi GC, Kean WF. Non-steroidal anti-inflammatory drugs in athletes. Br J Sports Med. 2006 Aug. 40(8):661-2; discussion 662-3. [Medline].

  48. Maquirriain J, Ghisi JP. The incidence and distribution of stress fractures in elite tennis players. Br J Sports Med. 2006 May. 40(5):454-9; discussion 459. [Medline].

  49. Miller SF, Congeni J, Swanson K. Long-term functional and anatomical follow-up of early detected spondylolysis in young athletes. Am J Sports Med. 2004 Jun. 32(4):928-33. [Medline].

  50. Milner CE, Ferber R, Pollard CD, Hamill J, Davis IS. Biomechanical factors associated with tibial stress fracture in female runners. Med Sci Sports Exerc. 2006 Feb. 38(2):323-8. [Medline].

  51. Murnaghan M, Li G, Marsh DR. Nonsteroidal anti-inflammatory drug-induced fracture nonunion: an inhibition of angiogenesis?. J Bone Joint Surg Am. 2006 Nov. 88 Suppl 3:140-7. [Medline].

  52. Rauh MJ, Macera CA, Trone DW, Shaffer RA, Brodine SK. Epidemiology of stress fracture and lower-extremity overuse injury in female recruits. Med Sci Sports Exerc. 2006 Sep. 38(9):1571-7. [Medline].

  53. Rome K, Handoll HH, Ashford R. Interventions for preventing and treating stress fractures and stress reactions of bone of the lower limbs in young adults. Cochrane Database Syst Rev. 2005. (2):CD000450. [Medline].

  54. Shaffer RA, Rauh MJ, Brodine SK, Trone DW, Macera CA. Predictors of stress fracture susceptibility in young female recruits. Am J Sports Med. 2006 Jan. 34(1):108-15. [Medline].

  55. Stewart GW, Brunet ME, Manning MR, Davis FA. Treatment of stress fractures in athletes with intravenous pamidronate. Clin J Sport Med. 2005 Mar. 15(2):92-4. [Medline].

  56. Torstveit MK, Sundgot-Borgen J. The female athlete triad: are elite athletes at increased risk?. Med Sci Sports Exerc. 2005 Feb. 37(2):184-93. [Medline].

  57. Valimaki VV, Alfthan H, Lehmuskallio E, Loyttyniemi E, Sahi T, Suominen H. Risk factors for clinical stress fractures in male military recruits: a prospective cohort study. Bone. 2005 Aug. 37(2):267-73. [Medline].

  58. Wheeler P, Batt ME. Do non-steroidal anti-inflammatory drugs adversely affect stress fracture healing? A short review. Br J Sports Med. 2005 Feb. 39(2):65-9. [Medline].

 
Previous
Next
 
This image is of a 17-year-old male wrestler with a 2-month history of left-sided low back pain, worse with extension. Total body scintigraphy findings were unremarkable. Courtesy of Michael Spieth, MD, and Nandita Bhattacharjee, MD, MHA; Marshfield Clinic Department of Radiology.
Same patient as in the above image. Single-photon emission computed tomography (SPECT) images demonstrate abnormal delayed uptake in the posterior elements of L5. Courtesy of Michael Spieth, MD, and Nandita Bhattacharjee, MD, MHA; Marshfield Clinic Department of Radiology.
Same patient as in the above 2 images. Subsequent MRI revealed an area of bright signal in the left pars interarticularis of L5 on T2-weighted images, confirming the diagnosis of acute unilateral spondylolysis. The patient was treated successfully with activity restriction and bracing with a lumbar corset for 3 months, at which point he was asymptomatic. Plain film imaging at follow-up (not shown) was unremarkable, with no evidence of spondylolysis on oblique views. Courtesy of Michael Spieth, MD, and Nandita Bhattacharjee, MD, MHA; Marshfield Clinic Department of Radiology.
A 17-year-old female dancer with a 2-week history of left shin pain. Plain film imaging was unremarkable. Three-phase bone scanning demonstrated an area of linear uptake in the posterior medial aspect of the left tibia on blood pool images, but delayed images were considered normal. This scintigraphic pattern is consistent with medial tibial stress syndrome (shin splints), but not with stress fracture. Courtesy of Michael Spieth, MD, and Nandita Bhattacharjee, MD, MHA; Marshfield Clinic Department of Radiology.
This is a 55-year-old female industrial worker with a 1-week history of right foot pain. Plain film imaging was unremarkable. Bone scanning revealed a stress fracture of the second metatarsal. Courtesy of Michael Spieth, MD, and Nandita Bhattacharjee, MD, MHA; Marshfield Clinic Department of Radiology.
This image is of an 18-year-old female soccer player with a 3-week history of left leg pain, which was worse at night and with activity. Upon examination, she reported tenderness in response to palpation over the midtibia. Bilateral pes planus was noted. Plain film radiography failed to demonstrate a fracture. Bone scanning revealed a focal area of delayed uptake on the posterior medial aspect of the proximal third of the left tibia, confirming the diagnosis of stress fracture. Courtesy of Michael Spieth, MD, and Nandita Bhattacharjee, MD, MHA; Marshfield Clinic Department of Radiology.
A 63-year-old man with metastatic thyroid carcinoma went for a walk and awoke the following morning with left hip girdle pain. Plain film imaging revealed a subtle area of linear cortical lucency at the proximal left femoral metadiaphysis, consistent with an insufficiency fracture through pathologic bone. The patient subsequently underwent internal fixation. Courtesy of Michael Spieth, MD, and Nandita Bhattacharjee, MD, MHA; Marshfield Clinic Department of Radiology.
Enlarged view of the fracture shown in the above image. Plain film imaging revealed a subtle area of linear cortical lucency at the proximal left femoral metadiaphysis, consistent with an insufficiency fracture through pathologic bone. The patient subsequently underwent internal fixation. Courtesy of Michael Spieth, MD, and Nandita Bhattacharjee, MD, MHA; Marshfield Clinic Department of Radiology.
This case involves a 16-year-old female basketball player with a 2-year history of left foot pain refractory to casting and reduced weight bearing. Bone scanning revealed a focal area of delayed uptake lateral to the left first metatarsal phalangeal joint, which corresponded to a bipartite sesamoid on plain films. Courtesy of Michael Spieth, MD, and Nandita Bhattacharjee, MD, MHA; Marshfield Clinic Department of Radiology.
Sesamoid stress fractures are prone to nonunion, and sesamoidectomy is indicated for patients who do not respond to conservative management. Some clinicians recommend bone grafting as an alternative to complete or partial sesamoidectomy. Courtesy of Michael Spieth, MD, and Nandita Bhattacharjee, MD, MHA; Marshfield Clinic Department of Radiology.
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2016 by WebMD LLC. This website also contains material copyrighted by 3rd parties.