Stress Fractures

Updated: Mar 09, 2022

Author: Stefanos F Haddad, MD; Chief Editor: Murali Poduval, MBBS, MS, DNB

Overview

Practice Essentials

The stress fracture, first described by Breithaupt in 1855,[1] is a common overuse injury seen in athletes and military recruits.[2, 3] The injury is usually seen in the lower extremities, but it has also been reported in the upper extremities and the ribs. The most common locations for stress fractures include the tibia, metatarsals, fibula, and navicular bones; less common locations include the femur, pelvis, and sacrum.

A stress fracture is caused by repetitive and submaximal loading of the bone, which eventually becomes fatigued and leads to a true fracture. The typical presentation is a complaint of increasing pain in the lower extremity during exercise or activity. The patient's history usually reveals a recent increase in either training volume or intensity.

The treatment of most stress fractures is relatively straightforward and includes decreased activity and immobilization; however, patients with some stress fractures, such as displaced femoral neck stress fractures[4] and fifth metatarsal base stress fractures, are more likely to have complications such as nonunion.[5, 6] These complications should be monitored closely because surgical intervention may be necessary.

Pathophysiology

Stress fractures result from recurrent and repetitive loading of bone. The stress fracture differs from other types of fractures in that in most cases, no acute traumatic event precedes the symptoms.

Normal bone remodeling occurs secondary to increased compressive or tensile loads or increased load frequency. In the normal physiologic response, minor microdamage of the bone occurs. This is repaired through remodeling. Stress fractures develop when extensive microdamage occurs before the bone can be adequately remodeled.[7, 8]

Often, the patient has a history of an increase or change in the character of activity or athletic workouts. Bones may be more prone to stress fractures if the bone is weakened, as in individuals with osteoporosis or those in whom weightbearing activities are increased.

The three factors that can predispose an individual to the development of stress fractures are as follows[9] :

Increase in the applied load
Increase in the number of applied stresses
Decrease in the surface area of the applied load

The applied load on the bone may be increased by decreasing the surface area across which the weight is distributed or by increasing the total weight that is applied to the bone. High-impact activities, such as jumping or performing plyometrics, running on a new surface, or practicing incorrect biomechanical movements or techniques, may increase the risk of stress fractures.

Oh et al proposed the following classification of stress fractures into four types, adding atypical fractures to the traditional three types[10] :

Fatigue fractures - These are due to overuse of bone with normal elastic resistance
Insufficiency fractures - These are due to everyday physiologic stress on fragile bone with poor elastic resistance
Pathologic fractures - These are due to bone weakness involving tumors
Atypical fractures

Etiology

Risk factors

Although stress fractures result from repeated loading, the exact contribution of training factors (eg, volume, intensity, and surface) has not been clearly established.[11] From what we do know, menstrual disturbances, caloric restriction, decreased bone density, muscle weakness, and leg-length differences are risk factors for stress fractures.[12, 13]

Myburgh reported that stress fractures were more common in athletes who had decreased bone density, lower dietary calcium intake, current menstrual irregularity, and less oral contraceptive use, when the athletes were matched for similar training volume and intensity.[14]

Nattiv and Armsey found that genetics, female sex, white ethnicity, low body weight, lack of weightbearing exercise, intrinsic and extrinsic mechanical factors, amenorrhea, oligomenorrhea, inadequate calcium and caloric intake, and disordered eating were additional risk factors for stress fractures.[15] A decreased testosterone level in male endurance athletes has also been implicated as a risk factor for stress fractures.[16, 17, 18, 19] Individuals found to have low bone mass and hormonal disturbances may require endocrinologic management.[20]

Schnackenburg et al did a matched control study on 19 female athletes with tibial stress fractures and found that stress fracture patients had lower tibial cross-sectional areas, lower trabecular bone mineral densities, and less cortical area, as well as decreased knee extension strength. They suggested that impaired bone quality of the posterior cortex and decreased muscle strength were associated with stress fractures in female athletes.[21]

Giladi identified two anatomic risk factors in military recruits. Recruits with stress fractures had significantly narrower tibiae and increased external rotation of the hip. These two variables were independent and cumulative, and when both risk factors were present, the stress-fracture morbidity was 45%.[22]

In a nationwide database analysis, Kale et al identified age and female sex as important risk factors for stress fractures.[23] A total of 41,257 stress fractures (30,555 in women and 10,702 in men) were included in the analysis. A greater proportion of female patients were older and had stress fractures of the foot, whereas a greater proportion of male patients were younger than 19 years and had metatarsal, hip, or tibial stress fractures.

There is some evidence that methotrexate therapy for rheumatic musculoskeletal disease can impair bone metabolism and thereby give rise to so-called methotrexate osteopathy, a condition characterized by a pathognomonic type of stress fractures with a band- or meander-shaped appearance along the growth plate.[24]

Activity and fracture location

Particular locations of stress fractures are commonly associated with particular activities (see Table 1 below).

Table 1. Epidemiologic Features of Stress Fractures According to Location and Activity (Open Table in a new window)

Location of Fracture	Activity Involved
Metatarsals, general	Football, basketball, gymnastics, ballet, military training[25]
Metatarsal, base of the second	Ballet
Metatarsal, fifth	Tennis,[26, 27] ballet
Sesamoids of the foot	Running, ballet, basketball, skating
Navicular	Sprinting,[28] jumping, basketball, football
Talus	Pole vaulting
Calcaneus	Military drills, running, aerobics
Fibula	Running, jumping, ballet, repeated heavy lifting[28]
Tibia	Running sports, dancing, ballet
Patella	Running, hurdling
Femoral neck	Distance running, military training[29]
Pubic rami	Military drills, distance running
Pars articularis	Gymnastics, ballet, cricket, volleyball, diving, football
Chest, ribs	Swimming,[30] golf,[31] rowing,[32] overhead throwing sports[33]
Sternum	Wrestling[34]
Ulna	Racquet sports, volleyball
Olecranon	Baseball, throwing sports

Epidemiology

Sex-related demographics

Studies of US military recruits revealed a higher percentage of stress fractures in female recruits than in male recruits.[2, 35, 36, 37] Bennell et al also found a 45% incidence of stress fractures in competitive female runners.[7] The women most at risk for stress fractures were those who restricted their food intake and those who had dysmenorrhea.

The triad of disordered eating, amenorrhea/oligomenorrhea, and osteoporosis may be extremely prevalent in female distance runners and ballet dancers,[38] as well as in other female athletes who believe that a low body weight or body-fat percentage provides a competitive advantage. This triple combination is commonly referred to as the so-called female athlete triad.[39]

The amenorrheic female athlete may experience a prolonged state of estrogen deficiency similar to that of a postmenopausal woman. The lower estrogen levels are associated with decreased bone density; even if normal menses returns, this bone loss may be irreversible in high school– and college-aged female athletes. Early identification of female athletes who are likely to develop the female athlete triad is important for the prevention of stress fractures and for maintaining overall future bone health.[39, 40]

Race-related demographics

In a study of military recruits, Markey found no difference in the incidence of stress fractures between recruits of various racial backgrounds.[41]

Presentation

History

With stress fractures, the typical complaint is that of an insidious onset of pain with activity or a complaint of pain in the affected extremity with repeated loading. Usually, the patient has no recent history of trauma to the affected area.

The pain subsides at rest, but symptoms return when the patient resumes the original activity. Local tenderness and swelling are often found at the fracture site. Early diagnosis is usually based on clinical findings, and several weeks may be required before the fracture site or new bone formation is visible on radiography.

The pain may occur only with weightbearing, and it may be reproducible with continued or prolonged activity. Some patients may associate a change in training equipment or training methods with the onset of symptoms.

Physical Examination

Common findings on physical examination may include tenderness or pain on palpation or percussion of the bone. Erythema or edema may be present at the site of the stress fracture. Loading or stress of the affected bone may also produce symptoms.

DDx

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.

Workup

Imaging Studies

Stress fractures may not show up on radiographs for the first 2-4 weeks after injury. (See the image below.) The first radiographic finding may be a localized periosteal reaction or an endosteal cortical thickening. The low sensitivity of radiography for stress fractures makes bone scanning, magnetic resonance imaging (MRI), and computed tomography (CT) the preferred tests for diagnosis.

$Fifth metatarsal stress fracture.$ Fifth metatarsal stress fracture.

Technetium-99m bone scan findings may be positive in the case of a stress fracture after 72 hours; however, a positive bone scan finding is nonspecific, and it may be indicative of another diagnosis, such as an infection or a neoplastic process. Conventional radiography and bone scanning have been compared for the initial detection of stress fractures; positive findings were reported in 96% of bone scans but on only 42% of radiographs.

MRI is also useful in the diagnosis of stress fractures. It provides information about bone integrity and fracture orientation, and it can demonstrate focal tissue damage and edema.

The MRI findings of stress fractures typically follow one of two patterns. In the first pattern, a hypointense bandlike fracture line is visible with surrounding bone or tissue edema. The second MRI pattern represents an amorphous stress fracture or response pattern. In this pattern, there is no obvious fracture line or band; instead, the fracture may have diffuse or scattered areas of hypointensity on T1-weighted images, with increased signal intensity on T2-weighted images.[42]

Short-tau inversion recovery (STIR) imaging sequences suppress the normal fat signal intensity in bone marrow, allowing better visualization of intramedullary bone.[43, 44, 45]

Wright et al carried out a systematic review of published studies with the aims of assessing the diagnostic accuracy of imaging modalities used to diagnose lower-extremity stress fractures and formulating evidence-based recommendations for clinical practice.[46] Reported sensitivities and specificities (with 95% confidence interval) for these modalities were as follows:

Conventional radiography - Sensitivity, 12% (0-29%) to 56% (39-72%); specificity, 88% (55-100%) to 96% (87-100%)
Nuclear scintigraphy - Sensitivity, 50% (23-77%) to 97% (90-100%); specificity, 33% (12-53%) to 98% (93-100%)
MRI - Sensitivity, 68% (45-90%) to 99% (95-100%); specificity, 4% (0-11%) to 97% (88-100%)
CT - Sensitivity, 32% (8-57%) to 38% (16-59%); specificity, 88% (55-100%) to 98% (91-100%)
Ultrasonography (US) - Sensitivity, 43% (26-61%) to 99% (95-100%); specificity, 13% (0-45%) to 79% (61-96%)

The investigators found MRI to be the most sensitive and specific imaging test for diagnosing stress fractures of the lower extremity.[46] They concluded that when MRI is available, nuclear scintigraphy is not recommended, because of its low specificity, high dosage of ionizing radiation, and other limitations. They also noted that radiography is likely to yield false-negative results at initial presentation, particularly in the early stages of fracture, and sometimes fails to identify an existing stress fracture at any time.

Grading

Several grading systems for stress fractures based on MRI or scintigraphic findings have been proposed for correlating imaging findings with clinical findings and providing treatment guidelines (see Table 2 below).[43]

Table 2. Grading of Stress Fractures According to Radiologic Findings^[43] (Open Table in a new window)

Grade	Radiographic Finding	Bone Scan Finding	MRI Finding
1	Normal	Poorly defined area	Increased activity on STIR image
2	Normal	More intense	Poor definition on STIR and T2-weighted images
3	Discrete line	Sharp area of uptake	No focal or fusiform cortical break on T1- and T2-weighted images
4	Fracture or periosteal reaction	More intense localized transcortical uptake	Fracture line on T1- and T2-weighted images

Treatment

Nonoperative Therapy

Most stress fractures can be treated conservatively by having patients stop or significantly decrease their activity for approximately 4-6 weeks, then gradually return to activity.[47, 48] (See Table 3 below.) Patients who experience pain with walking may be placed in a short leg cast with crutches, a walking boot, or a brace for 4-6 weeks. The use of pneumatic braces in the treatment and rehabilitation of tibial stress fractures also speeds the patient's return to training.[49]

Table 3. Healing Times for Various Stress Fractures*^[47] (Open Table in a new window)

Site of Stress Fracture	Percentage Healed at 2-4 wk, %	Percentage Healed at 1-2 mo, %	Percentage Healed at > 2 mo, %
Tibia, proximal third	0	43	57
Tibia, middle third	0	48	52
Tibia, distal third	0	53	47
Fibula	7	75	18
Metatarsals	20	57	23
Sesamoids	0	0	100
Femur, shaft	7	7	86
Femur, neck	0	0	100
Pelvis	0	29	75
Olecranon	0	0	100
*Adapted from Hulkko et al.[48] Findings were from a case series of 368 stress fractures in athletes, in which the healing times of stress fractures in different locations were assessed.

Surgical Care

Surgery for high-risk stress fractures

Nonunion of stress fractures is uncommon but can occur. These injuries should be closely followed up for early surgical intervention. High-risk stress fractures include stress fractures of the neck of the femur,[4] the anterior cortex of the tibia, the tarsal navicular, and the bases of the second and fifth[50] metatarsals.[47] Other high-risk stress fractures are stress fractures of the patella and medial malleolus.[51] Anterior-cortex stress fractures of the tibia are considered high-risk because the tensile forces across the anterior portion of the tibia can typically lead to delayed union or nonunion.

In contrast, low-risk stress fractures include most upper-extremity stress fractures, with the possible exception of fractures through the physis of the humeral head (Little League shoulder) and fractures through the medial epicondyle (Little League elbow), which may have complications due to the involvement of the growth plate. Other low-risk fractures include stress fractures of the ribs, pelvis, femoral shaft, fibula, calcaneus, and metatarsal shafts.

Prevention

Nutritional measures

Regarding fracture risk, Schwellnus and Jordaan found no benefit with calcium supplementation (500 mg/day) beyond the usual dietary intake in male military recruits.[52]

Biomechanical measures

The use of orthotic devices and shoe inserts has been studied as a preventive measure for lower-extremity stress fractures. Finestone and Milgrom both studied the use of semirigid orthoses, soft orthoses, or both in the boots of military recruits during basic training.[53, 54]

Finestone found that the incidence of lower-extremity stress fractures was lower in the group using semirigid orthoses (15.7%) or soft biomechanical orthoses (10.7%) than in the control group (27%).[53] Additionally, the recruits tolerated the soft biomechanical orthoses better than they did the semirigid orthoses.

In a prospective study of stress fractures, Milgrom et al studied the hypothesis that a shock-absorbing orthotic device worn within military boots decreases the incidence of stress fractures.[54] They demonstrated a statistically significant decrease in the incidence of femoral stress fractures in the orthotic device group. In military recruits who did develop stress fractures, the time of onset and the location of stress fractures did not differ between patients who wore the orthotic device and those who did not.

Gillespie and Grant reviewed the use of shock-absorbing insoles in four trials.[49] These insoles appeared to reduce the incidence of stress fractures and stress reactions of bone; however, incomplete data from one trial indicated that a reduction in the running distance and intensity may also have been a factor in preventing stress fractures.

Author

Stefanos F Haddad, MD Fellow in Hand and Upper Extremity Surgery, Rothman Institute

Stefanos F Haddad, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Society for Surgery of the Hand, New York State Society of Orthopaedic Surgeons

Disclosure: Nothing to disclose.

Coauthor(s)

Cory M Czajka, MD Orthopedic Surgeon, Capital Region Orthopedic Group

Cory M Czajka, MD is a member of the following medical societies: Orthopaedic Trauma Association

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.

Samuel Agnew, MD, FACS Associate Professor, Departments of Orthopedic Surgery and Surgery, Chief of Orthopedic Trauma, University of Florida at Jacksonville College of Medicine; Consulting Surgeon, Department of Orthopedic Surgery, McLeod Regional Medical Center

Samuel Agnew, MD, FACS is a member of the following medical societies: American Association for the Surgery of Trauma, American College of Surgeons, Orthopaedic Trauma Association, Southern Orthopaedic Association

Disclosure: Nothing to disclose.

Chief Editor

Murali Poduval, MBBS, MS, DNB Orthopaedic Surgeon, Senior Consultant, and Subject Matter Expert, Tata Consultancy Services, Mumbai, India

Murali Poduval, MBBS, MS, DNB is a member of the following medical societies: Association of Medical Consultants of Mumbai, Bombay Orthopedic Society, Indian Orthopedic Association, Indian Society of Hip and Knee Surgeons

Disclosure: Nothing to disclose.

Additional Contributors

John S Early, MD Foot/Ankle Specialist, Texas Orthopaedic Associates, LLP; Co-Director, North Texas Foot and Ankle Fellowship, Baylor University Medical Center

John S Early, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Medical Association, American Orthopaedic Foot and Ankle Society, Orthopaedic Trauma Association, Texas Medical Association

Disclosure: Received honoraria from AO North America for speaking and teaching; Received consulting fee from Stryker for consulting; Received consulting fee from Biomet for consulting; Received grant/research funds from AO North America for fellowship funding; Received honoraria from MMI inc for speaking and teaching; Received consulting fee from Osteomed for consulting; Received ownership interest from MedHab Inc for management position.

John M Martinez, MD Staff Physician, Kaiser Permanente

John M Martinez, MD is a member of the following medical societies: American Academy of Family Physicians, American College of Sports Medicine, American Medical Society for Sports Medicine

Disclosure: Nothing to disclose.

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