Further Outpatient Care
Treatment of stress fractures typically is performed in an outpatient setting. Patients may benefit from physical therapy to maintain overall fitness, thereby minimizing time lost from training and competition once the individual has been cleared to return to their previous activity level. The physical therapist may also assist in identifying intrinsic risk factors that might have contributed to the onset of the stress injury. See Physical Therapy.
Further Inpatient Care
Most stress fractures are treated successfully in an outpatient setting using conservative measures. Inpatient care is necessary only for individuals who undergo surgical intervention for the treatment of more severe displaced fractures or in an effort to treat a nonhealing fracture. If hospitalized, some patients who have been ordered to restrict weight bearing through the affected limb may benefit from consultation with a physical therapist to ensure safe ambulation. If the patient's symptoms or treatment interfere with his or her ability to independently perform aspects of daily care, a consultation with an occupational therapist may be indicated.
Deterrence
The optimal treatment for stress fractures is prevention. Ideally, coaches, athletes, trainers, and team physicians should invest themselves in a program of injury prevention that is appropriate to the sport or activity. Features common to such programs include thorough preparticipation physical examinations to screen for risk factors (see Causes); prescription of "prehabilitation" exercises designed to enhance strength, endurance, and coordination; and close monitoring of athletes for early signs that may alert the attentive clinician to an incipient overuse injury.
Stress fractures can be largely prevented with proper conditioning and preseason training. Athletes must use proper equipment and wear appropriate shoes to avoid developing stress fractures. For certain foot structures, taping techniques or the use of orthotic inserts can prevent overloading of soft tissues and bone. Nutritional supplementation and increasing calcium intake also contribute to overall bone health and thereby decrease the likelihood of developing stress fractures.
The cornerstone of secondary prevention of bony stress injury is a thorough assessment of potentially modifiable intrinsic and extrinsic risk factors unique to the athlete.
A relationship between a diminished vitamin D status and increased risk of stress fracture has been established. [17, 18, 43] A serum 25 hydroxy-vitamin D level below 75.8 nmol/L was determined to be a significant risk factor. [43, 44, 45, 46] Supplementation with 2,000 mg of calcium and 800 IU of vitamin D resulted in an approximately 20% lower incidence of stress fractures. [44]
Complications
Complications of stress fracture may include avascular necrosis, nonunion, malunion, posttraumatic arthrosis, and persistent disabling pain.
Prognosis
The prognosis for recovery is dependent on the location and severity of the fracture and on the age and underlying condition and associated comorbidities of the affected athlete. Most stress fracture carry a favorable prognosis for full recovery when appropriate treatment has been provided.
Patient Education
Patient education is important in both the prevention and treatment of stress fractures. Athletes need to be educated on proper conditioning programs that decrease their chances of developing stress fractures. For example, the preseason training program should be structured to gradually increase the frequency and intensity of exercise and to avoid sudden increases in training load that might overwhelm the skeleton's intrinsic ability to recover and repair.
Once diagnosed with a stress fracture, the affected individual must be made to understand the importance of a period of relative rest/activity modification. Athletes should review their training history for evidence of significant training errors or overload and adjust the training program accordingly. Educating the patient in an outpatient program of progressive muscle strengthening and conditioning will enable the athlete to return safely to his or her sport once their bony stress injury has healed.
For patient education resources, see the Breaks, Fractures, and Dislocations Center and Sports Injury Center, as well as Repetitive Motion Injuries.
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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.
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Same patient as in the above image. 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.
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Same patient as in the above 2 images. 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.
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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.
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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.
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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.
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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.
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Enlarged view of the fracture shown in the above image. 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.
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This case involves a 16-year-old female basketball player with a 2-year history of left foot pain refractory to casting and reduced weight bearing. Bone scanning revealed a focal area of delayed uptake lateral to the left first metatarsal phalangeal joint, which corresponded to a bipartite sesamoid on plain films. Courtesy of Michael Spieth, MD, and Nandita Bhattacharjee, MD, MHA; Marshfield Clinic Department of Radiology.
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Sesamoid stress fractures are prone to nonunion, and sesamoidectomy is indicated for patients who do not respond to conservative management. Some clinicians recommend bone grafting as an alternative to complete or partial sesamoidectomy. Courtesy of Michael Spieth, MD, and Nandita Bhattacharjee, MD, MHA; Marshfield Clinic Department of Radiology.
