Stress Fractures Differential Diagnoses

Updated: Mar 09, 2022
  • Author: Stefanos F Haddad, MD; Chief Editor: Murali Poduval, MBBS, MS, DNB  more...
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Diagnostic Considerations

Differential diagnoses for stress fractures are varied and depend on location, symptoms, history, and physical examination.

Shin splints (medial tibial stress syndrome) are a common source of complaints of midtibial pain, especially in runners. Although the complaints of pain from shin splints are similar to those expressed by patients with stress fractures of the tibia, the two conditions may be differentiated on the basis of the history and physical examination findings.

Most athletes report a crescendo-type pain with stress fractures, as the pain increases through individual workouts and from one workout to the next. Shin splint pain, however, tends to be present at the start of activity in those athletes who are symptomatic. Physical examination of an athlete with shin splints should reveal tenderness to palpation over a wide region of the tibia and the tibialis muscle, whereas the pain from stress fractures tends to be localized to a specific area on the tibia.

Contusions typically present with ecchymosis and swelling, as well as a history of a traumatic injury.

True fractures also tend to have an obvious history, with a traumatic event being recalled by the patient with acute onset of pain.

Muscle strains may be acute or chronic. Chronic muscle strains can be differentiated from stress fractures by the location and by factors that exacerbate or worsen the injury.

Costochondritis or rib pain may mimic the pain seen in stress fractures of the ribs. A high index of suspicion should be maintained for rib stress fractures in athletes who participate in rowing sports, such as crew rowing. The pain of costochondritis may be more diffuse or widespread than the pain from stress fractures of the ribs; however, multiple stress fractures of the ribs can occur.

Exertional compartment syndrome is most commonly seen in the lower extremities. A history of swelling in the legs with athletic activity may indicate the presence of a compartment syndrome. Increased intracompartmental pressures measured with a catheter transducer would suggest compartment syndrome.

Nerve entrapment syndromes can also mimic stress fractures, but with entrapment syndromes, numbness is also often a complaint.

Peripheral nerve injuries or neuropathies such as the following often require consideration in the differential diagnosis:

  • Posterior tibial nerve injury
  • Common peroneal nerve injury
  • Saphenous nerve injury
  • Sural nerve injury

Popliteal artery entrapment syndrome is another cause of lower-extremity pain. The typical history is one of increased pain or swelling with exercise. The pain tends to be more diffuse than the pain associated with stress fractures. Measurement of ankle blood pressures before and during exercise or an angiogram may help with the diagnosis.

Morton neuroma is an irritation of one of the interdigital nerves of the foot that is often seen in long-distance runners. The pain is usually localized just proximal to the second, third, or fourth toes, and it is worse when the forefoot is squeezed laterally and medially.

Metatarsalgia presents as foot pain and may be mistaken for a stress fracture of the metatarsals. The pain of metatarsalgia usually resolves quicker than the pain from a stress fracture once treatment is initiated. Bone scans may show diffuse uptake, but they do not usually show the significant uptake seen with stress fractures. Freiberg infarction (necrosis of the second metatarsal epiphysis in female adolescents) should be considered.