eMedicine Specialties > Physical Medicine and Rehabilitation > Lower Limb Musculoskeletal Conditions
Stress Fracture: Treatment & Medication
Updated: Aug 10, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
- Multimedia
Treatment
Rehabilitation Program
Physical Therapy
See Deterrence. The foundation of treatment for symptomatic stress injury is activity modification. To create an environment conducive to healing the stress injury, interrupting the cycle of repetitive overload is essential. For athletes, this typically results in time lost from competition and intensive training. For most stress fractures, the period of relative rest may be expected to last from 4-12 weeks. Factors influencing the duration of the activity restriction include the anatomic site of the stress injury, the extent of the stress injury, and the anticipated demands on the athlete upon return to play. During the period of restricted activity, the clinician should evaluate the athlete for modifiable risk factors that might have contributed to the development of the stress fracture.Training errors (eg, too much, too soon) are a common contributing factor to bone stress injury. One generally espoused (although inadequately validated) principle is that the athlete's training regimen (ie, volume of sport-related activity) should not increase by any more than 10% from one week to the next.
Runners should replace their shoes every 500 km to ensure adequate midsole cushioning. Shoes should be selected with attention to the athlete's foot structure. Flexible flatter feet should be fitted with shoes that provide optimal support and motion control (possibly including orthoses), whereas rigid highly arched feet should be fitted with shoes that provide maximal cushioning.
Rehabilitation of the individual with a stress fracture should include a program of muscle strengthening and generalized conditioning. Strong, well-conditioned muscles help to dissipate GRFs that otherwise would be transmitted to bones and joints along the kinetic chain.
Fitness training during the rehabilitation period should include cross-training so that excessive loading of the affected bone is avoided. A brief period of restricted weight bearing may be indicated if the athlete initially experiences intolerable pain while walking. Occasionally, bracing and even casting may prove beneficial. Aquatic exercise programs are effective for maintaining the athlete's cardiorespiratory conditioning while effectively eliminating weight bearing.
If pain persists or becomes further limiting, analgesics may be helpful. Nonsteroidal anti-inflammatory drugs (NSAIDs) are prescribed frequently, but some clinicians believe these agents should be relatively contraindicated in this setting. NSAIDs inhibit the production of prostaglandins, which are demonstrated to be involved in normal bone remodeling and fracture healing. Although animal studies have shown reasonably conclusively that NSAIDs inhibit fracture healing, the evidence from human studies is somewhat contradictory in this regard. If used at all, NSAIDs should therefore be used cautiously with a full understanding of their potential adverse effects.
The intravenous administration of the bisphosphonate pamidronate has been reported to benefit athletes with stress fractures, and it may hold some promise as an adjunctive treatment for symptomatic bony stress injury.
In addition to pharmacotherapy, physical therapy modalities, such as ice or interferential current, may be used to help treat symptoms. No compelling evidence exists in the literature to suggest that adjunctive therapeutic modalities (eg, electrical stimulation, pulsed ultrasonography, laser therapy) have a significant role to play in the routine treatment of bony stress injury.
As the fracture heals and symptoms subside, advance the athlete's program accordingly to permit progressively greater loading of the affected structure. Functional progression from walking to running to sport-specific skills permits the athlete to regain fitness and confidence prior to the resumption of training and competition. Additional recommendations for treatment are included in the following brief overviews of 4 common types of stress fracture.
Pars interarticularis stress fractures (ie, spondylolysis)
Stress fractures of the pars interarticularis are common in athletes who participate in sports demanding repetitive lumbar hyperextension, truncal rotation, or axial loading. Once considered a congenital variation, spondylolysis is probably an acquired condition in most cases. Genetic predisposition undoubtedly plays a role in the development of spondylolysis. For example, the prevalence of spondylolysis among the Inuit population is roughly 50%, and whites appear to be at greater risk for developing pars defects than African Americans. (See images below and Images 1-3.)
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 Images 1 and 3. 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 Images 1-2. 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.
Soler and Colderon found that while the prevalence of spondylolysis among a broad cross-section of elite Spanish athletes was similar to that found in the general population (8%), the highest prevalence (27%) was among athletes participating in the throwing track-and-field events (eg, javelin, discus, shot put). Roughly 17% of rowers and 14% of gymnasts were found to have spondylolysis. Approximately 13% of weightlifters were affected. The most common level of involvement was L5 (84%), followed by L4 (12%). More than one level was involved in only 3% of cases. The condition was bilateral approximately 78% of the time. Of the athletes found to have spondylolysis, 50-60% reported low back pain. Males and females appeared to be affected equally, although females were more likely to have associated spondylolisthesis than men. Other studies estimate the prevalence of spondylolysis among athletes from 15-63%, with the highest prevalence among weightlifters.
Clinically, symptomatic individuals typically report localized axial low back pain. The pain may be provoked by lumbar extension, particularly while bearing weight on the ipsilateral lower limb. Hamstring inflexibility is a common finding among individuals with spondylolysis. Curiously, young children diagnosed with pars defects tend to be asymptomatic.
The clinical diagnosis may be confirmed radiographically. Conventional radiography is often unrevealing, but, if present, the fracture line is usually best visualized on oblique views. Nascent or recently completed stress fractures of the pars may be detected by scintigraphy. Single-photon emission computed tomography (SPECT) is extremely sensitive and provides reasonable anatomic detail. MRI is also a justifiable first-line imaging procedure, and it offers the additional benefit of permitting concurrent evaluation of the lumbar intervertebral disks and other potential spinal pain generators. In their 2006 study, Sairyo and colleagues were able to correlate the presence of high water-weighted (T2) signal in the pedicle with the early stage of ipsilateral pars interarticularis stress injury as judged by CT, suggesting that MRI may permit early detection of stress injury and potentially enhance the outcome of treatment.5
Radiographically documented pars defects that are cold on bone scans probably represent remote injuries and have little chance of bony union. If symptomatic, individuals with cold defects may be treated with NSAIDs or other analgesics and should be instructed in a program of on-going home exercises to strengthen the muscle groups that provide dynamic stabilization of the lumbar spine.
The recommended treatment for acute spondylolysis has evolved considerably over the past decade and remains somewhat controversial. As with other stress fractures, the central tenet of treatment is relative rest with appropriate activity modification. Although some clinicians recommend bracing to minimize extension and resultant shear forces across the affected segment, some evidence from biomechanical studies indicates that lumbosacral bracing may actually increase intersegmental motion at the lumbosacral junction. Therefore, the prevailing opinion appears to be that bracing should be used only for individuals who remain symptomatic despite attempting to limit their activities, or for those who require a physical/tactile reminder to avoid provocative activities.
Once symptoms permit, the individual should begin a rehabilitation program of flexibility training and dynamic lumbar spinal stabilization. The program should emphasize pain-free functional progression. Once the athlete can perform sport-specific skills without symptoms, he or she may return to training and competition. Unilateral spondylolysis tends to have a more favorable clinical outcome than bilateral spondylolysis. For a more detailed discussion, see the article Lumbar Spondylolysis and Spondylolisthesis.
Femoral neck stress fracture
Stress fractures of the femoral neck6 can occur either on the superior or inferior aspect of the neck. Older individuals tend to develop fractures on the superior (or distraction) side of the neck, while younger people are more prone to fractures on the inferior (or compression) side of the neck. In both populations, the patient typically presents with activity-related pain in the groin, hip girdle, or anterior thigh. Physical examination may reveal pain with passive hip range of motion, particularly internal rotation. Conventional radiography and bone scanning are usually sufficient for the physician to confirm or exclude the diagnosis. However, MRI, with its sensitivity and high anatomic detail, is being used with increasing frequency. (See images below and Images 7-8.)
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 image of fracture shown in Image 7, in a 63-year-old man with metastatic thyroid carcinoma who 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.
For patients diagnosed with early stress reaction or a nondisplaced stress fracture of the femoral neck, treatment consists of avoidance of weight bearing on the affected lower limb until symptoms resolve. Subsequently, the individual is permitted to resume partial weight bearing as tolerated, progressing over time to unprotected weight bearing, to walking, and, finally, to running. Full functional progression may take months to complete. Serial radiographs obtained periodically help confirm that healing is progressing. If the patient is found to have a significant cortical defect or if the fracture is displaced, surgical fixation is required prior to beginning a program of rehabilitation.
Snyder et al, in a review of randomized and quasi-randomized, controlled trials, found evidence that the use of insoles can reduce the incidence of femoral and tibial stress fractures in soldiers during military training.7 It was uncertain from their investigation whether the same would be true for athletes.
Tibial stress fracture
The tibial shaft is the most common site of stress fractures. Unfortunately, shin pain is a frequent complaint among athletes and can result from a variety of causes, including tibial periostitis (ie, shin splints) and exertional compartment syndromes (a potentially serious condition). A careful history is helpful in distinguishing these entities. Pain that occurs early in the exercise program and then improves with ongoing activity suggests periostitis. Pain precipitated by exercise that worsens progressively with continued activity may herald a stress fracture. (See images below and Images 4 and 6.)
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 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.
Physical examination typically reveals localized tenderness over the medial aspect of the tibia. Tibial stress fractures may be more common among athletes with rigid cavus feet. Excessive subtalar pronation can also predispose an athlete to tibial stress fractures. The clinical diagnosis can be confirmed by conventional radiography, although one study suggests that this imaging modality shows evidence of stress fracture or periosteal reaction in only 10% of cases. Scintigraphy and/or MRI may be useful for confirming the suspected clinical diagnosis.
Treatment consists of activity restriction to minimize symptoms (ie, a period of non weight bearing may be necessary) before engaging in a program of increasingly demanding strengthening and conditioning exercise, leading to an eventual return to play in 8-12 weeks. Interestingly, 3 studies have demonstrated that use of a pneumatic leg brace allowed athletes to recover more quickly than athletes treated with activity restriction alone.8,9,10 It may be that compression of the leg's soft tissues helps to unload the tibia during weight-bearing activities, thereby minimizing further microdamage and facilitating bony repair.
Cortical stress fractures of the anterior tibial midshaft should be treated with care because they tend to heal more slowly (average of 6 mo) and are prone to delayed union or nonunion. In such cases, electromagnetic stimulation may potentially be helpful in promoting healing. Some authors recommend immobilization as initial therapy. Failure of nonoperative care warrants consideration of surgical intervention. Options include reamed intramedullary nailing and internal fixation with bone grafting. Postoperative recovery time averages 6 months.
Second metatarsal stress fracture
The metatarsals are the second most frequent stress fracture site and are especially common among military recruits, distance runners, and ballet dancers. The second metatarsal is injured most frequently, followed in order by metatarsals 3, 1, 4, and 5. Although the idea is somewhat controversial, foot structure may contribute to an individual's relative risk of developing lower limb overuse injuries in general and stress fractures in particular. (See image below and Image 5.)
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.
One prospective study of military recruits found that flat flexible feet were associated with a significantly higher rate of metatarsal stress fractures, while individuals with cavus feet were more prone to developing tibial stress fractures. The authors reasoned that flexible feet dissipate more GRF than do rigid cavus feet, thereby subjecting the intrinsic foot structures to greater loads and transmitting less GRF proximally than would a rigid cavus foot. The relative length of the first and second rays appears to have no relationship to the development of second metatarsal stress fractures.
The diagnosis of second metatarsal stress fracture can be made clinically, given an appropriate history of activity-related forefoot pain and the finding of focal tenderness over the second ray on palpatory examination. Treatment consists of relative rest, with return to play permitted once the individual can perform sport-specific skills without pain. Orthoses may be useful to help prevent recurrence of the injury. Custom-molded orthoses provide optimal support and may help correct biomechanical deficits, but studies have shown that over-the-counter shock absorbing insoles are equally effective in preventing lower limb stress injuries. Stress fractures at the base of the second metatarsal appear to be prone to delayed healing and may be treated best with a period of immobilization.
Medical Issues/Complications
Concern about complications is warranted when stress fractures are displaced or do not demonstrate adequate healing, despite time and appropriate interventions. Displaced stress fractures of the femoral neck, for example, have a high prevalence of complications, including avascular necrosis and pseudoarthrosis, due to the nature of the blood supply to the femoral neck. Other complications of stress fractures may include nonunion, malunion, posttraumatic arthrosis, and persistent disabling pain.11
Surgical Intervention
In most cases, stress fractures can be managed successfully with conservative measures. High-risk displaced stress fractures, however, require surgical intervention to ensure proper healing. Surgical procedures most typically involve open-reduction internal fixation and pinning of the associated fracture sites.12 Postoperative recovery time averages 6 months.
Consultations
Consider consultation with an orthopedic surgeon for high-risk stress fractures. Affected female athletes who exhibit signs of eating disorders may benefit from a consultation with dietitian, psychologist/psychiatrist, or both.
Medication
The goals of pharmacotherapy are to reduce patient discomfort, minimize associated morbidity, and to prevent complications.
Nonsteroidal anti-inflammatory drugs
Have analgesic, anti-inflammatory, and antipyretic activities. Mechanism of action is not known, but they may inhibit COX activity and prostaglandin synthesis. Other mechanisms may include inhibition of leukotriene synthesis, lysosomal enzyme release, lipoxygenase activity, neutrophil aggregation, and various cell membrane functions.
Celecoxib (Celebrex)
Inhibits primarily COX-2, which is considered an inducible isoenzyme, induced during pain and inflammatory stimuli. Inhibition of COX-1 may contribute to NSAID-related GI toxicity. At therapeutic concentrations, COX-1 isoenzyme is not inhibited, thus GI toxicity may be decreased. Seek lowest dose for each patient.
Adult
200 mg PO qd
Pediatric
Not established
Coadministration with fluconazole may cause increase in plasma concentrations because of inhibition of metabolism; coadministration with rifampin may decrease plasma concentrations
Documented hypersensitivity, sulfa allergies, and renal insufficiency
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Some authorities believe that anti-inflammatory drugs inhibit bone remodeling and fracture healing, and therefore recommend that these agents be used with caution in individuals with healing stress fractures; may cause fluid retention and peripheral edema; caution in compromised cardiac function, hypertension, and conditions predisposing to fluid retention; caution in severe heart failure and hyponatremia because may deteriorate circulatory hemodynamics; NSAIDs may mask usual signs of infection; caution in presence of existing controlled infections; evaluate symptoms and signs suggesting liver dysfunction or with abnormal LFT results
Ibuprofen (Motrin, Excedrin IB, Advil, Ibuprin)
DOC for patients with mild to moderate pain. Inhibits inflammatory reactions and pain by decreasing prostaglandin synthesis.
Adult
400 mg PO q4-6h, 600 mg PO q6h, or 800 mg PO q8h while symptoms persist; not to exceed 3.2 g/d
Pediatric
20-70 mg/kg/d PO divided tid/qid; start at lower end of dosing range and titrate; not to exceed 2.4 g/d
Coadministration with aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and, possibly, toxicity of NSAIDs; may decrease effect of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; may increase PT when taking anticoagulants (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently
Documented hypersensitivity; peptic ulcer disease, recent GI bleeding or perforation, renal insufficiency, or high risk of bleeding
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Pregnancy category D in third trimester of pregnancy; caution in congestive heart failure, hypertension, and decreased renal and hepatic function; caution in coagulation abnormalities or during anticoagulant therapy
Naproxen (Aleve, Anaprox, Naprelan, Naprosyn)
For relief of mild to moderate pain; inhibits inflammatory reactions and pain by decreasing activity of COX, which is responsible for prostaglandin synthesis.
NSAIDs decrease intraglomerular pressure and decrease proteinuria.
Adult
250-500 mg PO bid; may increase to 1.5 g/d for limited periods
Pediatric
<2 years: Not established
>2 years: 2.5 mg/kg/dose PO; not to exceed 10 mg/kg/d
Coadministration with aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and, possibly, toxicity of NSAIDs; may decrease effect of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; may increase PT when taking anticoagulants (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently
Documented hypersensitivity; peptic ulcer disease; recent GI bleeding or perforation; renal insufficiency
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Pregnancy category D in third trimester of pregnancy; acute renal insufficiency, interstitial nephritis, hyperkalemia, hyponatremia, and renal papillary necrosis may occur; patients with preexisting renal disease or compromised renal perfusion risk acute renal failure; leukopenia occurs rarely, is transient, and usually returns to normal during therapy; persistent leukopenia, granulocytopenia, or thrombocytopenia warrants further evaluation and may require discontinuation of drug
Analgesics
Pain control is essential to quality patient care. Analgesics ensure patient comfort, promote pulmonary toilet, and have sedating properties, which are beneficial for patients who have sustained trauma.
Acetaminophen (Tylenol, Feverall, Aspirin Free Anacin)
May be a reasonable alternative for symptom management in individuals who cannot tolerate NSAIDs or if the practitioner is concerned that NSAIDs may interfere with bone healing.
Adult
325-650 mg PO q4-6h
Pediatric
Not established
Rifampin can reduce analgesic effects; coadministration with barbiturates, carbamazepine, hydantoins, or isoniazid may increase hepatotoxicity
Documented hypersensitivity; known G-6-P deficiency
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Hepatotoxicity possible in chronic alcoholism following various dose levels; severe or recurrent pain or high or continued fever may indicate a serious illness; acetaminophen is contained in many OTC products, and combined use with these products may result in cumulative acetaminophen doses that exceed recommended maximum dose
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 |
| « Previous Page | Next Page » |
References
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. Feb 2005;33(2):272-6.
Brukner P, Bennell K, Matheson G. Stress Fractures. 1st ed. Melbourne, Australia: Blackwell Science Asia; 1999.
Bui-Mansfield LT, Thomas WR. Magnetic resonance imaging of stress injury of the cuneiform bones in patients with plantar fasciitis. J Comput Assist Tomogr. Jul-Aug 2009;33(4):593-6. [Medline].
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. Nov-Dec 2003;31(6):959-68. [Medline].
Sairyo K, Katoh S, Takata Y. MRI signal changes of the pedicle as an indicator for early diagnosis of spondylolysis in children and adolescents: a clinical and biomechanical study. Spine. Jan 15 2006;31(2):206-11.
Kuhn KM, Riccio AI, Saldua NS, et al. Acetabular retroversion in military recruits with femoral neck stress fractures. Clin Orthop Relat Res. Jul 9 2009;[Medline].
Snyder RA, Deangelis JP, Koester MC, et al. Does shoe insole modification prevent stress fractures? A systematic review. HSS J. Jun 9 2009;[Medline].
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. Jan-Feb 2000;20(1):28-33. [Medline].
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. May-Jun 1997;25(3):322-8. [Medline].
Whitelaw GP, Wetzler MJ, Levy AS, et al. A pneumatic leg brace for the treatment of tibial stress fractures. Clin Orthop. Sep 1991;(270):301-5. [Medline].
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. Apr 20 2009;[Medline].
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. Jul 30 2009;1(1):15. [Medline].
Arendt EA. Stress fractures and the female athlete. Clin Orthop. Mar 2000;(372):131-8. [Medline].
Bennell K, Brukner P. How Should You Treat a Stress Fracture?. Evidence-based Sports Medicine. 2002;491-517.
Bennell K, Matheson G, Meeuwisse W, Brukner P. Risk factors for stress fractures. Sports Med. Aug 1999;28(2):91-122. [Medline].
Buvanendran A, Reuben SS. COX-2 inhibitors in sports medicine: utility and controversy. Br J Sports Med. Nov 2006;40(11):895-6.
Callahan LR. Stress fractures in women. Clin Sports Med. Apr 2000;19(2):303-14. [Medline].
DiFiori JP. Stress fracture of the proximal fibula in a young soccer player: a case report and a review of the literature. Med Sci Sports Exerc. Jul 1999;31(7):925-8.
Donahue SW, Sharkey NA. Strains in the metatarsals during the stance phase of gait: implications for stress fractures. J Bone Joint Surg Am. Sep 1999;81(9):1236-44. [Medline].
Ellerin BE, Helfet D, Parikh S, et al. Current therapy in the management of heterotopic ossification of the elbow: a review with case studies. Am J Phys Med Rehabil. May-Jun 1999;78(3):259-71. [Medline].
Finestone A, Giladi M, Elad H, et al. Prevention of stress fractures using custom biomechanical shoe orthoses. Clin Orthop. Mar 1999;(360):182-90. [Medline].
Fredericson M, Ngo J, Cobb K. Effects of ball sports on future risk of stress fracture in runners. Clin J Sport Med. May 2005;15(3):136-41.
Green NE, Rogers RA, Lipscomb AB. Nonunions of stress fractures of the tibia. Am J Sports Med. May-Jun 1985;13(3):171-6. [Medline].
Ho ML, Chang JK, Chuang LY, et al. Effects of nonsteroidal anti-inflammatory drugs and prostaglandins on osteoblastic functions. Biochem Pharmacol. Sep 15 1999;58(6):983-90. [Medline].
Hofmann AA, Bloebaum RD, Koller KE. Does celecoxib have an adverse effect on bone remodeling and ingrowth in humans?. Clin Orthop Relat Res. Nov 2006;452:200-4.
Hoy G, Wood T, Phillips N. 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. Aug 2006;40(8):710-3; discussion 713.
Ivkovic A, Bojanic I, Pecina M. Stress fractures of the femoral shaft in athletes: a new treatment algorithm. Br J Sports Med. Jun 2006;40(6):518-20; discussion 520.
Johnson BA, Neylon T, Laroche R. Lesser metatarsal stress fractures. Clin Podiatr Med Surg. Oct 1999;16(4):631-42. [Medline].
Jones BH, Knapik JJ. Physical training and exercise-related injuries. Surveillance, research and injury prevention in military populations. Sports Med. Feb 1999;27(2):111-25. [Medline].
Jones BH, Thacker SB, Gilchrist J, et al. Prevention of lower extremity stress fractures in athletes and soldiers: a systematic review. Epidemiol Rev. 2002;24(2):228-47. [Medline].
Kaufman KR, Brodine SK, Shaffer RA, et al. The effect of foot structure and range of motion on musculoskeletal overuse injuries. Am J Sports Med. Sep-Oct 1999;27(5):585-93. [Medline].
Kibler WB. ACSM's Handbook for the Team Physician. Baltimore, Md: Williams & Wilkins; 1996.
Kibler WB, Herring SA, Press JM. Functional Rehabilitation of Sports and Musculoskeletal Injuries. Aspen Publishers: Gaithersburg, Md; 1998.
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. Jul 15 2006;31(16):E528-34.
Lauder TD, Dixit S, Pezzin LE, et al. The relation between stress fractures and bone mineral density: evidence from active-duty Army women. Arch Phys Med Rehabil. Jan 2000;81(1):73-9. [Medline].
Lippi G, Franchini M, Guidi GC. Non-steroidal anti-inflammatory drugs in athletes. Br J Sports Med. Aug 2006;40(8):661-2; discussion 662-3.
Maquirriain J, Ghisi JP. The incidence and distribution of stress fractures in elite tennis players. Br J Sports Med. May 2006;40(5):454-9; discussion 459.
Milgrom C, Simkin A, Eldad A, et al. Using bone''s adaptation ability to lower the incidence of stress fractures. Am J Sports Med. Mar-Apr 2000;28(2):245-51. [Medline].
Miller SF, Congeni J, Swanson K. Long-term functional and anatomical follow-up of early detected spondylolysis in young athletes. Am J Sports Med. Jun 2004;32(4):928-33.
Milner CE, Ferber R, Pollard CD. Biomechanical factors associated with tibial stress fracture in female runners. Med Sci Sports Exerc. Feb 2006;38(2):323-8.
Murnaghan M, Li G, Marsh DR. Nonsteroidal anti-inflammatory drug-induced fracture nonunion: an inhibition of angiogenesis?. J Bone Joint Surg Am. Nov 2006;88 Suppl 3:140-7.
Neal BC, Rodgers A, Clark T, et al. A systematic survey of 13 randomized trials of non-steroidal anti- inflammatory drugs for the prevention of heterotopic bone formation after major hip surgery. Acta Orthop Scand. Apr 2000;71(2):122-8. [Medline].
Orava S, Karpakka J, Hulkko A, et al. Diagnosis and treatment of stress fractures located at the mid-tibial shaft in athletes. Int J Sports Med. Aug 1991;12(4):419-22. [Medline].
Rauh MJ, Macera CA, Trone DW. Epidemiology of stress fracture and lower-extremity overuse injury in female recruits. Med Sci Sports Exerc. Sep 2006;38(9):1571-7.
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;CD000450.
Shaffer RA, Rauh MJ, Brodine SK. Predictors of stress fracture susceptibility in young female recruits. Am J Sports Med. Jan 2006;34(1):108-15.
Shikare S, Samsi AB, Tilve GH. Bone imaging in sports medicine. J Postgrad Med. Jul-Sep 1997;43(3):71-2. [Medline].
Simkin A, Leichter I, Giladi M, et al. Combined effect of foot arch structure and an orthotic device on stress fractures. Foot Ankle. Aug 1989;10(1):25-9. [Medline].
Sinha AK, Kaeding CC, Wadley GM. Upper extremity stress fractures in athletes: clinical features of 44 cases. Clin J Sport Med. Oct 1999;9(4):199-202. [Medline].
Soler T, Calderon C. The prevalence of spondylolysis in the Spanish elite athlete. Am J Sports Med. Jan-Feb 2000;28(1):57-62. [Medline].
Standaert CJ, Herring SA. How Should You Treat Spondylolysis in the Athlete?. Evidence-based Sports Medicine. 2002;239-265.
Stasinopoulos D. Treatment of spondylolysis with external electrical stimulation in young athletes: a critical literature review. Br J Sports Med. Jun 2004;38(3):352-4.
Stewart GW, Brunet ME, Manning MR, Davis FA. Treatment of stress fractures in athletes with intravenous pamidronate. Clin J Sport Med. Mar 2005;15(2):92-4.
Stovitz SD, Arendt EA. NSAIDs should not be used in treatment of stress fractures. Am Fam Physician. Oct 15 2004;70(8):1452, 1454. [Medline].
Torstveit MK, Sundgot-Borgen J. The female athlete triad: are elite athletes at increased risk?. Med Sci Sports Exerc. Feb 2005;37(2):184-93.
Välimäki VV, Alfthan H, Lehmuskallio E, et al. Risk factors for clinical stress fractures in male military recruits: a prospective cohort study. Bone. Aug 2005;37(2):267-73.
Van der Wall H, McLaughlin A, Bruce W, et al. Scintigraphic patterns of injury in amateur weight lifters. Clin Nucl Med. Dec 1999;24(12):915-20. [Medline].
Varner KE, Younas SA, Lintner DM, Marymont JV. Chronic anterior midtibial stress fractures in athletes treated with reamed intramedullary nailing. Am J Sports Med. Jul 2005;33(7):1071-6.
Wheeler P, Batt ME. Do non-steroidal anti-inflammatory drugs adversely affect stress fracture healing? A short review. Br J Sports Med. Feb 2005;39(2):65-9.
Further Reading
Related eMedicine articles:
Femoral Neck Stress and Insufficiency Fractures
Femoral Neck Fracture
Femur Injuries and Fractures
General Principles of Fracture Care
Metatarsals, Fractures
Pars Interarticularis Injury
Pelvis, Insufficiency Fractures
Stress Fracture [Radiology]
Stress Fractures
Clinical guidelines:
ACR Appropriateness Criteria® stress/insufficiency fracture, including sacrum, excluding other vertebrae. American College of Radiology - Medical Specialty Society. 1995 (revised 2008). 8 pages. NGC:007002
Clinical trials:
Bone Geometry, Strength, and Biomechanical Changes in Runners With a History of Stress Fractures
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
