From the Guidelines
The primary treatment for stress fractures involves immediate cessation of the causative activity, rest, and non-weight-bearing on the affected area for about 6-8 weeks, as evidenced by the most recent guidelines 1. When managing stress fractures, it is crucial to identify high-risk patients, such as those with osteoporosis or on bisphosphonate therapy, as they are more likely to experience fracture completion or complications 1. Key considerations in the treatment of stress fractures include:
- Identifying and modifying risk factors to prevent progression to complete fracture 1
- Recognizing high-risk stress fractures, such as those in the anterior tibial diaphysis, lateral femoral neck, and femoral head, which may require more aggressive management 1
- Implementing a non–weight-bearing regimen for low-risk stress fractures, such as medial compression-type femoral neck stress fractures 1
- Utilizing pain management strategies, including over-the-counter medications like acetaminophen or NSAIDs, and applying ice to reduce swelling and pain
- Gradually returning to activity, starting with low-impact exercises, once healing begins
- Ensuring proper nutrition, including adequate calcium and vitamin D intake, to support bone healing 1 It is essential to note that complete healing typically takes 6-12 weeks, depending on the location and severity of the fracture, and returning to activity too soon can lead to re-injury or chronic problems 1.
From the Research
Treatment Options for Stress Fractures
- Activity modification, including the use of nonweight-bearing crutches if needed for pain relief, is a common treatment approach for stress fractures 2
- Analgesics are appropriate to relieve pain, and pneumatic bracing can be used to facilitate healing 2
- Surgical consultation may be appropriate for patients with stress fractures in high-risk locations, nonunion, or recurrent stress fractures 2, 3
- Nonweight-bearing immobilization, often with a prolonged period away from sport, and a more methodic and careful reintroduction to athletic activity may be necessary for high-risk stress fractures 3
- Treatment modalities such as ultrasound and electromagnetic fields have been addressed in the literature, with an emphasis on literature support 4
Medication Considerations
- Regular use of nonsteroidal anti-inflammatory drugs (NSAIDs) such as naproxen may increase the risk of stress fracture and extend the healing time of these injuries 5, 6
- Naproxen has been shown to impair load-induced bone formation, reduce bone toughness, and diminish woven bone formation following stress fracture in mice 5
- A retrospective case-control study found that regular NSAID use increases stress fracture risk in the general population, with a strong correlation between regular ibuprofen/naproxen/celecoxib use and stress fracture incidence 6
High-Risk Stress Fractures
- Specific locations of high-risk stress fracture include the femoral neck (tension side), patella, anterior tibia, medial malleolus, talus, tarsal navicular, proximal fifth metatarsal, and great toe sesamoids 3
- These stress fractures require a more aggressive approach to evaluation, with imaging often necessary, to confirm early and accurate diagnosis and initiate immediate treatment 3
- Surgical intervention may be necessary for high-risk stress fractures 3