eMedicine Specialties > Physical Medicine and Rehabilitation > Lower Limb Musculoskeletal Conditions

Stress Fracture: Differential Diagnoses & Workup

Author: Jonathan C Reeser, MD, PhD, Office of Research Integrity and Protections, Marshfield Clinic Research Foundation
Contributor Information and Disclosures

Updated: Aug 10, 2009

Differential Diagnoses

Lumbar Spondylolysis and Spondylolisthesis

Other Problems to Be Considered

Strains
Sprains
Contusions
Delayed-onset muscle soreness
Tumors of bone, especially osteoid osteomas
Shin splints (ie, medial tibial stress syndrome, tibial traction periostitis)
Exertion-related compartment syndrome
Referred pain from the spine
Diskogenic low back pain
Facet-mediated low back pain
Morton neuroma
Plantar fasciitis
Subluxed cuboid

Workup

Laboratory Studies

  • If in the course of the diagnostic workup for the stress injury the individual is discovered to have metabolic bone disease or another comorbidity (eg, inadequate nutritional status), the clinician should obtain the appropriate laboratory and imaging studies to permit definitive management of the condition (or request specialty-level consultation).

Imaging Studies

  • Imaging studies can help the physician confirm the suspected clinical diagnosis.
    • Conventional radiographic findings are often unremarkable, particularly early in the continuum that leads from stress reaction to stress fracture.
    • In most instances, conventional radiographic signs of a periosteal reaction are not evident within the first several weeks of symptoms.
    • In some cases, conventional radiography remains negative, despite clear diagnostic evidence of fracture on bone scan or cross-sectional imaging.
    • Other conventional radiographic findings include an area of cortical lucency (ie, the so-called thin black line) that suggests a nonhealing stress fracture.
  • Computed tomographic (CT) scanning is a useful diagnostic imaging tool, as is magnetic resonance imaging (MRI).3 These cross-sectional modes of imaging may be helpful in defining the extent of the suspected fracture.
  • A 3-phase bone scan (scintigraphy) may be indicated if conventional radiographic findings are negative or nondiagnostic and the clinical suspicion of stress fracture remains high. The bone scan is diagnostic of stress fracture if focal isotope uptake occurs in the area of clinical interest on the third phase of the scan.
  • Scintigraphy is extremely sensitive.
    • If the scan shows no evidence of focal uptake, the diagnosis of stress fracture is quite unlikely. Note that as a result of the sensitivity of this imaging modality, focal radiotracer uptake may persist at healing stress fracture sites long after the patient has become asymptomatic. Furthermore, the bone scan may be positive even before the clinical onset of symptoms.
    • Drawbacks of scintigraphy include a relative lack of specificity and anatomic resolution. Nevertheless, the temporal pattern of uptake during the scan may be useful in distinguishing the etiology of the patient's symptoms. Radiotracer uptake on the third phase of the scan generally is specific to bony pathology.
    • For example, tibial periostitis and acute tibial stress fracture both usually demonstrate uptake on the first and second phases of the 3-phase bone scan; however, only the stress fracture results in focal uptake on the third phase.
    • Note that other processes besides stress fracture, including osteomyelitis and tumor, can have a similar appearance on 3-phase bone scans. Thus, for the clinician to consider the imaging study result in the context of the patient's history and physical examination findings is important.
  • Because of the limitations inherent to scintigraphy, MRI may be a reasonable first-line imaging procedure. MRI provides greater anatomic detail of the area in question, and fat-suppressed (short TI inversion recovery [STIR]) and water-weighted (T2) signal sequences permit detection of marrow edema and/or periosteal reaction occurring during the earliest stages of stress fracture formation with a level of sensitivity that rivals bone scanning.
  • In 2003, Arendt et al described a radiographic grading system that incorporates both conventional radiographic findings and those from MRI.4 The authors found that the grade of bone stress injury correlated with the average time to full recovery. For example, athletes with grade 1 stress injury who were treated with a standardized rehabilitation protocol returned to sporting activity in 3.3 weeks, on average, while those with grade 4 stress injury returned in 14.3 weeks.

More on Stress Fracture

Overview: Stress Fracture
Differential Diagnoses & Workup: Stress Fracture
Treatment & Medication: Stress Fracture
Follow-up: Stress Fracture
Multimedia: Stress Fracture
References
Further Reading
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Keywords

stress fracture, stress fractures, metatarsal fracture, stress fracture foot, stress fracture treatment, stress fracture symptoms, stress fracture tibia, tibial stress fracture, stress fracture femur, fatigue fracture, insufficiency fracture, stress fracture of the lower limbs, lower limb stress fracture, overuse injury, overuse injuries, bone mineral density, disrupted bone homeostasis, inadequate bone repair, bone strain, pars interarticularis stress fracture, spondylolysis, neck of the femur stress fracture, femur neck stress fracture, stress fracture of the tibia, second metatarsal stress fracture

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Contributor Information and Disclosures

Author

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, Physiatric Association of Spine, Sports and Occupational Rehabilitation, and State Medical Society of Wisconsin
Disclosure: Nothing to disclose.

Medical Editor

Everett C Hills, MD, MS, Medical Director, Penn State Hershey Rehabilitation Hospital, Assistant Professor of Orthopaedics and Rehabilitation, Assistant Professor of Neurology, Penn State Milton S. Hershey Medical Center and Penn State University College of Medicine
Everett C Hills, MD, MS is a member of the following medical societies: American Academy of Disability Evaluating Physicians, American Academy of Physical Medicine and Rehabilitation, American College of Physician Executives, American Congress of Rehabilitation Medicine, American Medical Association, American Society of Neurorehabilitation, Association of Academic Physiatrists, and Pennsylvania Medical Society
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Michael T Andary, MD, MS, Residency Program Director, Professor, 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, and Association of Academic Physiatrists
Disclosure: allergan Honoraria Speaking and teaching; Pfizer Honoraria Speaking and teaching

CME Editor

Kelly L Allen, MD, Regional Medical Director, IMX-Medical Management Services
Disclosure: Nothing to disclose.

Chief Editor

Consuelo T Lorenzo, MD, Consulting Staff, Department of Physical Medicine and Rehabilitation, Alegent Health Care, Immanuel Rehabilitation Center
Consuelo T Lorenzo, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation
Disclosure: Nothing to disclose.

 
 
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