What is the appropriate workup for a patient with recurrent stress fractures?

From the Guidelines

The appropriate workup for a patient with recurrent stress fractures typically starts with radiographs in at least two planes as the initial imaging study.

Initial Imaging

• Radiographs are the least expensive and most widely available imaging modality, and should be obtained in every patient suspected of having a stress fracture 1.
• Early radiographic findings are often nonspecific, but over time, patients develop more specific radiographic findings, such as linear sclerosis perpendicular to the trabeculae 1.

Next Steps

• If radiographs are negative or indeterminate, and the patient is at high risk for fracture completion (e.g. osteoporosis, bisphosphonate therapy, or athlete), the next imaging study may be a Tc-99m bone scintigraphy (bone scan) or other advanced imaging modalities 1.
• Certain stress fractures are considered high risk based on a tendency for nonunion or delayed union, and may require more urgent evaluation and management, such as the anterior tibial diaphysis, lateral femoral neck and femoral head, patella, medial malleolus, navicular, fifth metatarsal base, proximal second metatarsal, tibial hallux sesamoid, and talus 1.

Clinical Considerations

• Correlation of clinical history, pattern, and site recognition with radiographic findings is usually specific, and certain athletic activities often result in specific sites of fatigue fracture 1.
• Stress fractures are frequently occult on initial radiographs, with conventional radiographs having a sensitivity of 15% to 35% 1, and bone scintigraphy may show stress fractures days to weeks earlier than radiographs in many instances 1.

From the Research

Diagnosis of Stress Fractures

• The diagnosis of stress fractures is based on history and diagnostic imaging, which include radiographs, ultrasound, therapeutic ultrasound, computed tomography, and bone scans 2
• Magnetic resonance imaging is still the gold standard for diagnosis of stress fractures 2
• Plain radiography should be obtained initially, and if negative, may be repeated after two to three weeks for greater accuracy 3
• If an urgent diagnosis is needed, triple-phase bone scintigraphy or magnetic resonance imaging should be considered 3

Treatment of Stress Fractures

• Treatment of stress fractures consists of activity modification, including the use of nonweight-bearing crutches if needed for pain relief 3
• Analgesics are appropriate to relieve pain, and pneumatic bracing can be used to facilitate healing 3
• After the pain is resolved and the examination shows improvement, patients may gradually increase their level of activity 3
• Surgical consultation may be appropriate for patients with stress fractures in high-risk locations, nonunion, or recurrent stress fractures 3

Prevention of Stress Fractures

• Prevention of stress fractures with training periodization and nutritional assessment is essential, especially in females 2
• Reduced bone mineral density is an independent risk factor for delayed union, and prevention strategies should focus on maintaining adequate bone mineral density 2
• Calcium and vitamin D supplementation might be helpful in preventing stress fractures, especially in individuals with low dietary calcium and vitamin D intake 4

Risk Factors for Stress Fractures

• Risk factors for stress fractures include reduced bone mineral density, low energy intake, and menstrual disturbances in women 4
• Other risk factors include biomechanical predisposition, training methods, and other factors such as diet, muscle strength, and flexibility 5
• Postmenopausal women are particularly at risk of stress fractures due to the increasing prevalence of osteoporosis 2