Sections

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.^[38]

Short-tau inversion recovery (STIR) imaging sequences suppress the normal fat signal intensity in bone marrow, allowing better visualization of intramedullary bone.^{[39, 40, 41]}

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.^[42] 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.^[42] 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).^[39]

Table 2. Grading of Stress Fractures According to Radiologic Findings^[39] (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 & Management

Breithaupt. Zur pathologie des menschlichen fussed. Med Zeitung. 1855. 24:169.
Beck TJ, Ruff CB, Shaffer RA, Betsinger K, Trone DW, Brodine SK. Stress fracture in military recruits: gender differences in muscle and bone susceptibility factors. Bone. 2000 Sep. 27 (3):437-44. [Medline].
Hod N, Ashkenazi I, Levi Y, Fire G, Drori M, Cohen I, et al. Characteristics of skeletal stress fractures in female military recruits of the Israel defense forces on bone scintigraphy. Clin Nucl Med. 2006 Dec. 31 (12):742-9. [Medline].
DeLee JC, Evans JP, Julian J. Stress fracture of the fifth metatarsal. Am J Sports Med. 1983 Sep-Oct. 11 (5):349-53. [Medline].
Kavanaugh JH, Brower TD, Mann RV. The Jones fracture revisited. J Bone Joint Surg Am. 1978 Sep. 60 (6):776-82. [Medline].
Bennell KL, Malcolm SA, Thomas SA, Ebeling PR, McCrory PR, Wark JD, et al. Risk factors for stress fractures in female track-and-field athletes: a retrospective analysis. Clin J Sport Med. 1995 Oct. 5 (4):229-35. [Medline].
Uthgenannt BA, Kramer MH, Hwu JA, Wopenka B, Silva MJ. Skeletal self-repair: stress fracture healing by rapid formation and densification of woven bone. J Bone Miner Res. 2007 Oct. 22 (10):1548-56. [Medline].
Reeder MT, Dick BH, Atkins JK, Pribis AB, Martinez JM. Stress fractures. Current concepts of diagnosis and treatment. Sports Med. 1996 Sep. 22 (3):198-212. [Medline].
Bennell K, Matheson G, Meeuwisse W, Brukner P. Risk factors for stress fractures. Sports Med. 1999 Aug. 28 (2):91-122. [Medline].
Loud KJ, Micheli LJ, Bristol S, Austin SB, Gordon CM. Family history predicts stress fracture in active female adolescents. Pediatrics. 2007 Aug. 120 (2):e364-72. [Medline].
Popp KL, Hughes JM, Smock AJ, Novotny SA, Stovitz SD, Koehler SM, et al. Bone geometry, strength, and muscle size in runners with a history of stress fracture. Med Sci Sports Exerc. 2009 Dec. 41 (12):2145-50. [Medline].
Myburgh KH, Hutchins J, Fataar AB, Hough SF, Noakes TD. Low bone density is an etiologic factor for stress fractures in athletes. Ann Intern Med. 1990 Nov 15. 113 (10):754-9. [Medline].
Nattiv A, Armsey TD Jr. Stress injury to bone in the female athlete. Clin Sports Med. 1997 Apr. 16 (2):197-224. [Medline].
Opstad PK, Aakvaag A. Decreased serum levels of oestradiol, testosterone and prolactin during prolonged physical strain and sleep deprivation, and the influence of a high calorie diet. Eur J Appl Physiol Occup Physiol. 1982. 49 (3):343-8. [Medline].
Montain SJ, McGraw SM, Ely MR, Grier TL, Knapik JJ. A retrospective cohort study on the influence of UV index and race/ethnicity on risk of stress and lower limb fractures. BMC Musculoskelet Disord. 2013 Apr 12. 14:135. [Medline]. [Full Text].
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].
Chen YT, Tenforde AS, Fredericson M. Update on stress fractures in female athletes: epidemiology, treatment, and prevention. Curr Rev Musculoskelet Med. 2013 Jun. 6 (2):173-81. [Medline].
Moreira CA, Bilezikian JP. Stress Fractures: Concepts and Therapeutics. J Clin Endocrinol Metab. 2017 Feb 1. 102 (2):525-534. [Medline]. [Full Text].
Schnackenburg KE, Macdonald HM, Ferber R, Wiley JP, Boyd SK. Bone quality and muscle strength in female athletes with lower limb stress fractures. Med Sci Sports Exerc. 2011 Nov. 43 (11):2110-9. [Medline].
Giladi M, Milgrom C, Simkin A, Danon Y. Stress fractures. Identifiable risk factors. Am J Sports Med. 1991 Nov-Dec. 19 (6):647-52. [Medline].
Kurklu M, Ozboluk S, Kilic E, Tatar O, Ozkan H, Basbozkurt M. Stress fracture of bilateral tibial metaphysis due to ceremonial march training: a case report. Cases J. 2010 Jan 4. 3:3. [Medline].
Balius R, Pedret C, Estruch A, Hernández G, Ruiz-Cotorro A, Mota J. Stress fractures of the metacarpal bones in adolescent tennis players: a case series. Am J Sports Med. 2010 Jun. 38 (6):1215-20. [Medline].
Hetsroni I, Nyska M, Ben-Sira D, Mann G, Segal O, Maoz G, et al. Analysis of foot structure in athletes sustaining proximal fifth metatarsal stress fracture. Foot Ankle Int. 2010 Mar. 31 (3):203-11. [Medline].
Welck MJ, Hayes T, Pastides P, Khan W, Rudge B. Stress fractures of the foot and ankle. Injury. 2017 Aug. 48 (8):1722-1726. [Medline]. [Full Text].
Joshi A, Kc BR, Shah BC, Chand P, Thapa BB, Kayastha N. Femoral neck stress fractures in military personnel. JNMA J Nepal Med Assoc. 2009 Apr-Jun. 48 (174):99-102. [Medline].
Taimela S, Kujala UM, Orava S. Two consecutive rib stress fractures in a female competitive swimmer. Clin J Sport Med. 1995 Oct. 5 (4):254-6; discussion 257. [Medline].
Lee AD. Golf-related stress fractures: a structured review of the literature. J Can Chiropr Assoc. 2009 Dec. 53 (4):290-9. [Medline].
Karlson KA. Rib stress fractures in elite rowers. A case series and proposed mechanism. Am J Sports Med. 1998 Jul-Aug. 26 (4):516-9. [Medline].
Funakoshi T, Furushima K, Kusano H, Itoh Y, Miyamoto A, Horiuchi Y, et al. First-Rib Stress Fracture in Overhead Throwing Athletes. J Bone Joint Surg Am. 2019 May 15. 101 (10):896-903. [Medline].
Keating TM. Stress fracture of the sternum in a wrestler. Am J Sports Med. 1987 Jan-Feb. 15 (1):92-3. [Medline].
Bijur PE, Horodyski M, Egerton W, Kurzon M, Lifrak S, Friedman S. Comparison of injury during cadet basic training by gender. Arch Pediatr Adolesc Med. 1997 May. 151 (5):456-61. [Medline].
Scully TJ, Besterman G. Stress fracture--a preventable training injury. Mil Med. 1982 Apr. 147 (4):285-7. [Medline].
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].
Frusztajer NT, Dhuper S, Warren MP, Brooks-Gunn J, Fox RP. Nutrition and the incidence of stress fractures in ballet dancers. Am J Clin Nutr. 1990 May. 51 (5):779-83. [Medline].
Nattiv A, Agostini R, Drinkwater B, Yeager KK. The female athlete triad. The inter-relatedness of disordered eating, amenorrhea, and osteoporosis. Clin Sports Med. 1994 Apr. 13 (2):405-18. [Medline].
Rauh MJ, Barrack M, Nichols JF. Associations between the female athlete triad and injury among high school runners. Int J Sports Phys Ther. 2014 Dec. 9 (7):948-58. [Medline]. [Full Text].
Markey KL. Stress fractures. Clin Sports Med. 1987 Apr. 6 (2):405-25. [Medline].
Deutsch AL, Coel MN, Mink JH. Imaging of stress injuries to bone. Radiography, scintigraphy, and MR imaging. Clin Sports Med. 1997 Apr. 16 (2):275-90. [Medline].
Arendt EA, Griffiths HJ. The use of MR imaging in the assessment and clinical management of stress reactions of bone in high-performance athletes. Clin Sports Med. 1997 Apr. 16 (2):291-306. [Medline].
Moran DS, Evans RK, Hadad E. Imaging of lower extremity stress fracture injuries. Sports Med. 2008. 38 (4):345-56. [Medline].
Lee JK, Yao L. Stress fractures: MR imaging. Radiology. 1988 Oct. 169 (1):217-20. [Medline].
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. 2016 Jan. 44 (1):255-63. [Medline].
Brukner P, Bennell K. Stress fractures in female athletes. Diagnosis, management and rehabilitation. Sports Med. 1997 Dec. 24 (6):419-29. [Medline].
Hulkko A, Orava S. Stress fractures in athletes. Int J Sports Med. 1987 Jun. 8 (3):221-6. [Medline].
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 Apr 18. (2):CD000450. [Medline]. [Full Text].
Boden BP, Osbahr DC, Jimenez C. Low-risk stress fractures. Am J Sports Med. 2001 Jan-Feb. 29 (1):100-11. [Medline].
Schwellnus MP, Jordaan G. Does calcium supplementation prevent bone stress injuries? A clinical trial. Int J Sport Nutr. 1992 Jun. 2 (2):165-74. [Medline].
Finestone A, Giladi M, Elad H, Salmon A, Mendelson S, Eldad A, et al. Prevention of stress fractures using custom biomechanical shoe orthoses. Clin Orthop Relat Res. 1999 Mar. (360):182-90. [Medline].
Milgrom C, Giladi M, Kashtan H, Simkin A, Chisin R, Margulies J, et al. A prospective study of the effect of a shock-absorbing orthotic device on the incidence of stress fractures in military recruits. Foot Ankle. 1985 Oct. 6 (2):101-4. [Medline].

Media Gallery

Fifth metatarsal stress fracture.

of 1

Table 1. Epidemiologic Features of Stress Fractures According to Location and Activity

Location of Fracture	Activity Involved
Metatarsals, general	Football, basketball, gymnastics, ballet, military training^[21]
Metatarsal, base of the second	Ballet
Metatarsal, fifth	Tennis,^{[22, 23]} ballet
Sesamoids of the foot	Running, ballet, basketball, skating
Navicular	Sprinting,^[24] jumping, basketball, football
Talus	Pole vaulting
Calcaneus	Military drills, running, aerobics
Fibula	Running, jumping, ballet, repeated heavy lifting^[24]
Tibia	Running sports, dancing, ballet
Patella	Running, hurdling
Femoral neck	Distance running, military training^[25]
Pubic rami	Military drills, distance running
Pars articularis	Gymnastics, ballet, cricket, volleyball, diving, football
Chest, ribs	Swimming,^[26] golf,^[27] rowing,^[28] overhead throwing sports^[29]
Sternum	Wrestling^[30]
Ulna	Racquet sports, volleyball
Olecranon	Baseball, throwing sports

Table 2. Grading of Stress Fractures According to Radiologic Findings ^[39]

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

Table 3. Healing Times for Various Stress Fractures* ^[43]

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.^[44] 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.

Back to List

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.

Stress Fractures Workup

Imaging Studies

Grading

References

Tables

Contributor Information and Disclosures

What would you like to print?