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Stress Fractures Main

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Other Names

  • Stress Reaction
  • Stress fracture


  • This page acts as the main page for all stress fractures


  • First reported by Breithaupt, a Prussian military surgeon, in 1855[1]


  • Stress fractures represent between 0.7% and 20% of all sports medicine injuries[2]
    • Wentz et al estimate 2% of all sports injuries in athletes[3]
    • In runners, stress fractures represent 16% of all injuries
  • The most common site overall is the tibia[4]
  • Estimated that 80-95% of stress fractures occur in the lower extremities
  • Breakdown of extremity[5]
    • Tibia (23.6%)
    • Tarsal navicular (17.6%)
    • Metatarsals (16.2%)
    • Femur (6.6%)
    • Pelvis (1.6%).



  • Occur as a result of repetitive submaximal mechanical load across the bone
  • Universally, there will be a sudden increase in training intensity, duration and/or frequency
  • Inadequate rest is also frequently cited
  • Training surface, footwear are also factors
  • Early detection is important
    • Increased awareness has been shown to improve early detection

Bone Remodeling

  • Bone remodels due to mechanical stress
  • Bone absorption exceeds mechanical repair and formation during remodeling
  • Wolff's Law: Rate and remodeling depends on number, frequency of loading cycles
  • Continued loading may propagate microfractures into stress fractures
  • Vast majority of cases occur in individuals with normal bone and excessive forces
  • Starts with a "crack" but can propagate with inadequate healing time


  • Fatigue fracture: repetitive stress on abnormal bone
  • Insufficiency fracture: repetitive stress on abnormal bone

Risk Factors

Clinical Features


  • Onset is universally insidious
  • Localized pain related to activity and worsened by activity
  • Early in disease state, pain occurs towards the end of exercise
  • Can progress to pain with less activity and eventually with normal ambulation/ rest
  • Eventually pain can even occur at night

Physical Examination

  • Typically point tender on bone depending on the area affected
  • May have soft tissue swelling, erythema or bony callus

Special Tests


Upper Extremity

Torso/ Pelvis

Lower Extremity



  • Poor sensitivity[13]
    • Early stages as low as 10%, periosteal elevation not seen for 2-3 weeks
    • At follow up ranges from 30-70%
  • Findings when abnormal
    • Periosteal elevation
    • Cortical thickening
    • Sclerosis
    • Fracture line
  • Natural history
    • Gray cortex sign: subtle loss of cortical density in early stages
    • Increasing sclerosis or cortical thickening along the fracture site
    • Periosteal reaction and elevation may take up to two weeks
    • Fracture line


  • Study of choice
    • Sensitivity, specificity and accuracy rated as high as 100%[14]
    • Can also evaluate soft tissue lesions
  • Findings
    • Increased signal intensity
    • Periosteal edema and soft tissue edema
    • Bone marrow edema in a band-like pattern
    • T1 hypointense fracture line in high-grade injury

Bone Scan/ Nuclear Medicine

  • 91m Technetium-methylene diphosphonate bone scintigraphy
  • Sensitive (74-84%), not specific (33%)[15]
  • Has fallen out of use in favor of MRI
  • False positives: due to increased bone metabolism (tumors, infections)[16]
  • Doesn't distinguish well between stress fracture and stress reaction[17]

CT Scan

  • Single Photon Emission Computed Tomography (SPECT)
  • Findings are similar to radiographs
    • Sclerosis, new bone formation, periosteal reaction, fracture lines
  • Useful for
    • Sacrum and pubic stress fractures as MRI has reduced sensitivity
    • Differentiate stress fracture from bony malignancy, osteomyelitis


  • Growing but less well defined utility in the diagnosis of stress fractures
  • In a case-control study of MRI-confirmed metatarsal stress fractures[18]
    • Sensitivity 83%, specificity 76%
  • Also useful to evaluate other surrounding soft tissue structures

Laboratory Evaluation

  • May not be necessary in first time stress fractures
  • If the athlete has had a previous stress fracture, consider the following:
    • Complete Blood Count
    • ESR (Erythrocyte Sedimentation Rate)
    • CRP (C-reactive Protein)
    • Kidney function tests
    • Liver function tests
    • Calcium levels
    • Albumin
    • Vitamin D level
    • Hormone Profile (females)
    • Thyroid studies
    • Parathyroid hormone (PTH)
    • Phosphorous
    • Alkaline Phosphatase



  • Among army recruits, a reduction in running distance resulted in fewer injuries and lower injury severity[19]
  • Among female long distance runners, increased calcium, vitamin D, and protein intake correlated with increased bone mineral density and protection from stress fractures[20]
    • Potassium intake was associated with increased bone mineral density only
  • Insoles reduced stress fractures in the military population [21]

Nonoperative: General

  • Depends on location, imaging
  • Early intervention to prevent propagation and full cortical break
  • Cessation of all provocative activities
    • Must decide whether to make patient weight-bearing or non-weight bearing
  • Conservative management
    • Reduced weight bearing
    • Splinting
    • Activity modification

Nonoperative: Medications

    • One study found delayed stress fracture healing[22]
    • Meta-analysis: no significant risk of nonunion with nonsteroidal anti-inflammatory exposure[23]
    • Overall, NSAIDS are controversial and typically not recommended
  • Bisphosphonates
    • Use is not supported by any strong evidence for treatment or prophylaxis[24][25]
    • One case series showed accelerated recovery among 5 runners
  • Vitamin D
    • Deficiency should be suspected in elderly patient stress fractures
  • Calcium
  • Calcitonin
    • Role in stress fractures is unknown
  • Raloxifene
    • Role in stress fractures is unknown
  • Strontium Ranelate
    • Role in stress fractures is unknown
  • Teriparatide
    • Role in stress fractures is unknown

Treatment Modalities


Rehab and Return to Play


  • Gradual resumption of activities

Return to Play

  • Slow, controlled return to play once pain free

Prognosis and Complications


  • Some fractures are high risk for propagation
    • Require prompt treatment, careful monitoring to prevent progression
  • High Risk
    • Anterior tibial diaphysis
    • Lateral femoral neck
    • Patella
    • Medial malleolus
    • Navicular
    • Fifth metatarsal base
    • Proximal second metatarsal
    • Sesamoids (great toe tibial)
    • Talus
    • Femoral head
  • Low Risk
    • Posteromedial tibial
    • Metatarsals
    • Calcaneus
    • Cuboid
    • Cuneiform
    • Fibula
    • Medial femoral neck
    • Femoral shaft
    • Pelvis


  • Premature return to sport
    • Associated with recurrence, progression
  • Full cortical break
  • Re-fracture
  • Inability to return to sport

See Also


  1. Breithaupt ZVR . Pathologie monschuchew fusser. Med Zeittung 1855;24:169, 170–5
  2. Fredericson M, Bergman AG, Hoffman KL, Dillingham MS. Tibial stress reaction in runners. Correlation of clinical symptoms and scintigraphy with a new magnetic resonance imaging grading system. Am J Sports Med. 1995;23(4):472–481.
  3. Wentz L , Liu PY , Haymes E , Ilich JZ . Females have a greater incidence of stress fractures than males in both military and athletic populations: a systemic review. Mil Med 2011;176:420–30
  4. Brukner P, Bradshaw C, Khan K.et al Stress fractures: a review of 180 cases. Clin J Sport Med 1996685–89
  5. Kahanov, Leamor, et al. "Diagnosis, treatment, and rehabilitation of stress fractures in the lower extremity in runners." Open access journal of sports medicine 6 (2015): 87.
  6. Wright AA Taylor JB Ford KR Siska L Smoliga JM. Risk factors associated with lower extremity stress fractures in runners: A systematic review with meta‐analysis. Br J Sports Med.
  7. Warden SJ Burr DB Brukner PD. Stress fractures: Pathophysiology, epidemiology, and risk factors. Curr Osteoporos Rep. 2006;4(3):103‐109.
  8. Zeni AI, Street CC, Dempsey RL, Staton M. Stress injury to the bone among women athletes. Phys Med Rehabil Clin N Am. 2000;11(4):929-947
  9. Rousière, Mickaël, André Kahan, and Chantal Job-Deslandre. "Postpartal sacral fracture without osteoporosis." Joint Bone Spine 68.1 (2001): 71-73.
  10. Friberg O. Leg length asymmetry in stress fractures: clinical and radiological study. J Sports Med Phys Fitness. 1982;22(4):485-488
  11. Simkin A, Leichter I, Giladi M, Stein M, Milgrom C. Combined effect of foot arch structure and an orthotic device on stress fractures. Foot Ankle. 1989;10(1):25-29
  12. Burge MR, Lanzi RA, Skarda ST, Eaton RP. Idiopathic hypogonadotropic hypogonadism in a male runner is reversed by clomiphene citrate. Fertil Steril. 1997;67(4):783-785
  13. Fredericson, Michael, et al. "Stress fractures in athletes." Topics in Magnetic Resonance Imaging 17.5 (2006): 309-325.
  14. Shin A Y, Morin W D, Gorman J D, Jones S B, Lapinsky A S. The superiority of magnetic resonance imaging in differentiating the cause of hip pain in endurance athletes. Am J Sports Med. 1996;24:168–176.
  15. Gaeta M, Minutoli F, Scribano E, et al. CT and MR imaging findings in athletes with early tibial stress injuries: comparison with bone scintigraphy findings and emphasis on cortical abnormalities. Radiology. 2005;235(2):553-561
  16. Matheson GO, Clement DB, McKenzie DC, Taunton JE, Lloyd-Smith DR, Macintyre JG. Scintigraphic uptake of 99mTc at non-painful sites in athletes with stress fractures: the concept of bone strain. Sports Med. 1987;4(1):65-75
  17. Monteleone GP. Stress fractures in the athlete. Orthop Clin North Am. 1995;26(3):423-432
  18. Banal F, Gandjbakhch F, Foltz V, et al. Sensitivity and specificity of ultrasonography in early diagnosis of metatarsal bone stress fractures: a pilot study of 37 patients. J Rheumatol. 2009;36(8):1715-1719
  19. Rudzki SJ. Injuries in Australian Army recruits: part I. Decreased incidence and severity of injury seen with reduced running distance. Mil Med. 1997;162(7):472-476
  20. Nieves JW, Melsop K, Curtis M, et al. Nutritional factors that influence change in bone density and stress fracture risk among young female cross-country runners. PM R. 2010;2(8):740-750
  21. 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;(2):CD000450.
  22. Li J, Waugh LJ, Hui SL, Burr DB, Warden SJ. Low-intensity pulsed ultrasound and nonsteroidal anti-inflammatory drugs have opposing effects during stress fracture repair. J Orthop Res. 2007;25(12):1559-1567
  23. Dodwell ER, Latorre JG, Parisini E, et al. NSAID exposure and risk of nonunion: a meta-analysis of case-control and cohort studies. Calcif Tissue Int. 2010;87(3):193-202
  24. Milgrom C, Finestone A, Novack V, et al. The effect of prophylactic treatment with risedronate on stress fracture incidence among infantry recruits. Bone. 2004;35(2):418-424
  25. Stewart GW, Brunet ME, Manning MR, Davis FA. Treatment of stress fractures in athletes with intravenous pamidronate. Clin J Sport Med. 2005;15(2):92-94
  26. Rue JP, Armstrong DW 3rd, Frassica FJ, Deafenbaugh M, Wilckens JH. The effect of pulsed ultrasound in the treatment of tibial stress fractures. Orthopedics. 2004;27(11):1192-1195
Created by:
John Kiel on 13 June 2019 07:23:58
Last edited:
6 May 2024 00:58:18