From the Guidelines
The treatment of stress fractures should primarily involve rest, activity modification, and gradual return to activity, as this approach allows for the natural healing process to occur while preventing further damage. The management of stress fractures can be divided into several key components, including:
- Rest and activity modification: The affected area should be rested for 6-8 weeks, with weight-bearing restrictions depending on the fracture location and severity, as noted in the 2024 update of the ACR Appropriateness Criteria for stress fractures 1.
- Pain management: This typically includes acetaminophen or NSAIDs like ibuprofen (400-600mg every 6-8 hours) for short periods, though NSAIDs should be used cautiously as they may delay bone healing.
- Use of supportive devices: For lower extremity fractures, crutches or a walking boot may be necessary to reduce stress on the affected area.
- Nutrition and supplements: Adequate calcium (1000-1200mg daily) and vitamin D (600-800 IU daily) intake is recommended to support bone healing.
- Gradual return to activity: This should begin only when the patient is pain-free, typically starting at 25% of previous activity level and increasing by 10-15% weekly if pain-free, as this allows the bone to adapt to increasing stress without risking further injury, as discussed in the context of stress fracture management 1.
From the Research
Treatment Options for Stress Fractures
- The primary treatment for stress fractures involves reducing loading on the injured bone through a reduction in activity or by substituting other activities 2, 3.
- Analgesics are appropriate to relieve pain, and pneumatic bracing can be used to facilitate healing 3.
- In some cases, nonweight-bearing crutches may be necessary for pain relief 3.
- Treatment options also include rest and cessation of the precipitating activity, with 'active rest' in which the athlete continues to exercise depending on the site of the fracture 4.
- Possible adjuncts to treatment include pneumatic braces and electromagnetic field therapy 4, 5.
High-Risk Stress Fractures
- Higher-risk stress fractures, distinguished by anatomical location and whether the bone is loaded in tension, should be referred to an orthopedist 2.
- Surgical consultation may be appropriate for patients with stress fractures in high-risk locations, nonunion, or recurrent stress fractures 3.
- Specific stress fractures that must be considered at-risk for complications of healing require immobilisation and may require surgery pending response to therapy 4.
Prevention and Risk Factors
- Investigated prevention strategies include modifications to physical training programs, use of shock absorbing insoles, vitamin D and calcium supplementation, modifications of military equipment, and leadership education with injury surveillance 2.
- Well-documented risk factors for stress fractures include female sex, white ethnicity, older age, taller stature, lower aerobic fitness, prior physical inactivity, greater amounts of current physical training, thinner bones, cigarette smoking, and inadequate intake of vitamin D and/or calcium 2.
- The use of non-steroidal anti-inflammatory drugs (NSAIDs), such as naproxen, may impair load-induced bone formation, reduce bone toughness, and diminish woven bone formation following stress fracture 6.