What is the recommended treatment for a patient with a shoulder stress fracture, considering potential underlying conditions such as osteoporosis?

Treatment for Shoulder Stress Fracture

For shoulder stress fractures, immediate cessation of the aggravating activity with a minimum of 6 weeks of complete rest from throwing or overhead activities is the cornerstone of treatment, followed by an additional 6 weeks of structured rehabilitation before any return to activity—totaling at least 3 months of modified activity. 1

Initial Management

Immediate Activity Modification

• Complete elimination of the causative activity (throwing, overhead sports, or repetitive shoulder loading) for a minimum of 6 weeks is mandatory. 1
• Non-weight bearing restrictions are not applicable to the shoulder, but all aggravating movements must cease until pain resolves. 2, 3
• Pain relief is the primary clinical indicator for progression—patients must be completely pain-free with activities of daily living before advancing rehabilitation. 2, 4

Pain Management

• Analgesics are appropriate for pain relief during the initial rest phase. 3
• Local tenderness over the proximal humerus (most common site in throwing athletes) should resolve before progressing treatment. 1

Diagnostic Considerations

Initial Imaging

• Plain radiographs should be obtained initially, though they are often negative in early stress fractures. 3
• If radiographs are negative but clinical suspicion remains high, MRI without IV contrast is the preferred advanced imaging modality due to superior sensitivity and specificity. 1

Follow-up Imaging Indications

• MRI without IV contrast should be obtained if symptoms persist or worsen despite appropriate conservative management, as this may indicate complications such as osteonecrosis or progression to complete fracture. 1
• Patients with osteoporosis or those on bisphosphonate therapy require closer monitoring with potential follow-up MRI, as they are especially prone to progression from incomplete to complete fractures. 1
• CT without IV contrast can identify delayed healing etiologies (such as osteoid osteoma) or suspected fracture completion if MRI is contraindicated. 1

Structured Rehabilitation Protocol

Phase 1: Rest and Initial Healing (Weeks 1-6)

• Absolute rest from throwing or overhead activities for 6 weeks minimum after diagnosis. 1
• Maintain cardiovascular fitness through lower extremity activities (cycling, running if tolerated) that do not stress the shoulder. 4
• Begin gentle range-of-motion exercises only after acute pain subsides, focusing on maintaining mobility without loading. 1

Phase 2: Strengthening Phase (Weeks 7-12)

• An additional 6 weeks of progressive strengthening without return to throwing activities is required. 1
• Implement a comprehensive strengthening program emphasizing:
  • Rotator cuff muscles (supraspinatus, infraspinatus, teres minor, subscapularis). 1
  • Periscapular muscles (serratus anterior, rhomboids, trapezius). 1
  • Core musculature to support the kinetic chain. 1
• Address capsular flexibility deficits that may contribute to abnormal mechanics. 1

Phase 3: Return to Activity (After Week 12)

• Gradual reintroduction of throwing or overhead activities only after completing the full 3-month protocol and achieving pain-free status. 1
• Work with coaching staff to review and correct any biomechanical flaws in throwing or overhead mechanics that contributed to the injury. 1
• Progressive increase in throwing volume and intensity, monitoring for any return of symptoms. 1

Special Populations and Risk Factors

Skeletally Immature Athletes

• Proximal humeral stress fractures in youth athletes (ages 11-16) represent "Little League shoulder"—a Salter-Harris type I injury to the proximal humeral physis. 1
• These injuries result from torsional overload during the late cocking phase of throwing. 1
• Radiographic widening of the proximal humeral physis may persist even after symptom resolution, emphasizing the need for prolonged rest. 1

Patients with Osteoporosis

• These patients require extended monitoring and potentially longer immobilization periods due to increased risk of progression to complete fracture. 1
• Consider evaluation of bone mineral density and treatment of underlying osteoporosis. 1
• Assess for nutritional deficiencies, particularly vitamin D and calcium intake. 2

Athletes on Bisphosphonate Therapy

• Higher risk for progression from incomplete to complete fracture requires more conservative management and closer follow-up. 1

Critical Pitfalls to Avoid

• Never allow premature return to throwing or overhead activities based on patient impatience or competitive pressures—the minimum 3-month protocol is non-negotiable. 1
• Do not progress rehabilitation based solely on imaging findings; clinical pain resolution must guide advancement. 1, 2
• Avoid neglecting biomechanical assessment and correction, as faulty mechanics are often the underlying cause and will lead to recurrence. 1
• Do not overlook associated conditions such as rotator cuff dysfunction, glenohumeral microinstability, or scapular dyskinesis that may have contributed to abnormal loading patterns. 1
• Female athletes and those with menstrual disturbances require evaluation for the female athlete triad (low energy availability, menstrual dysfunction, low bone density), as this significantly increases stress fracture risk. 4

When to Consider Surgical Consultation

• Surgical consultation is rarely needed for shoulder stress fractures but should be considered for:
  • Nonunion after appropriate conservative management. 3
  • Recurrent stress fractures despite addressing risk factors. 3
  • Complete fracture displacement. 2
  • Complications such as osteonecrosis identified on follow-up imaging. 1