How to evaluate a patient with suspected stress fractures on physical assessment, considering their medical history, physical activity, and demographics?

Physical Assessment of Suspected Stress Fractures

Begin with focused point tenderness over bone and pain on loading the affected bone—these are the hallmark physical examination findings that should prompt imaging workup. 1, 2

Key Physical Examination Findings

Primary Clinical Indicators

• Localized bony point tenderness at the suspected fracture site is the most consistent physical finding and should be systematically assessed by palpating along the entire length of suspect bones 1, 2
• Pain on loading the bone through weight-bearing, hopping on one leg, or applying axial compression/percussion forces directly to the bone 1, 2
• Edema or soft tissue swelling overlying the tender area, which distinguishes stress fracture from medial tibial stress syndrome (shin splints) that presents with diffuse tenderness without focal edema 3
• Inability to bear weight for 4 steps immediately after injury (particularly relevant for lower extremity fractures) 4

Location-Specific Examination Techniques

For hip/pelvis stress fractures:

• Assess for intractable lower back or pelvic pain with loss of mobility 5
• Test for pain exacerbation with weight-bearing activities 5
• Palpate for focal tenderness over the femoral neck, pubic rami, or sacrum 5

For lower extremity fractures:

• Perform single-leg hop test (inability or severe pain indicates high suspicion) 3
• Apply tuning fork test (128 Hz) over the suspected site—pain with vibration suggests stress fracture 2
• Assess for focal versus diffuse tenderness (diffuse posteromedial tibial tenderness = shin splints, not stress fracture) 3

For patellar involvement:

• Test straight leg raise against gravity (inability suggests patellar fracture) 4
• Palpate for defect in the patella 4
• Assess for large knee effusion/hemarthrosis with ballotable patella 4

Critical History Elements to Obtain

Training and Activity Assessment

• Recent increase in training distance, intensity, or frequency—the most common precipitating factor 1, 3
• Change in running surface (concrete vs. track vs. grass) 1
• New or different footwear 1
• Limited rest periods between training sessions 3
• Sport-specific patterns: javelin throwers/baseball pitchers (olecranon), runners (proximal femur/tibia), basketball players (tarsal navicular) 5

Risk Factor Screening

For female athletes, systematically screen for the female athlete triad: 1, 6

• Menstrual irregularities or amenorrhea
• Eating disorders or restrictive eating patterns
• History of previous stress fractures

For all patients: 5

• Osteoporosis or low bone mineral density
• History of radiation therapy to the affected area
• Long-term bisphosphonate use
• Pregnancy status (particularly third trimester or postpartum for pelvic/sacral fractures) 5

Distinguishing Stress Fractures from Mimics

Medial Tibial Stress Syndrome (Shin Splints)

• Diffuse tenderness along the posteromedial tibial shaft (>5 cm length) versus focal point tenderness 3
• Absence of focal edema (stress fractures have localized swelling) 3

Other Differential Considerations

• Tendinopathy: Pain with specific tendon loading maneuvers, tenderness along tendon course rather than bone 3
• Compartment syndrome: Pain with passive stretch, tense compartment on palpation 3
• Nerve/artery entrapment: Neurologic symptoms, vascular changes 3

Common Pitfalls to Avoid

• Do not rely on absence of swelling to rule out stress fracture—early stress fractures may have minimal visible edema 2
• Do not dismiss the diagnosis based on ability to bear weight—many stress fractures allow partial weight-bearing initially 3
• Do not confuse muscle strain with stress fracture—if clinical suspicion exists for stress fracture despite muscle symptoms, proceed with stress fracture imaging algorithm 7
• Do not overlook bilateral examination—stress fractures can be bilateral, particularly in military recruits and runners 3
• Do not delay imaging in high-risk locations (femoral neck, anterior tibial cortex, tarsal navicular, fifth metatarsal base)—these require urgent diagnosis due to complication risk 5

Immediate Management Based on Physical Findings

If physical examination is highly suggestive (point tenderness + pain on loading + edema):

• Initiate non-weight-bearing or protected weight-bearing immediately 3
• Immobilize in full extension if patellar fracture suspected 4
• Order plain radiographs as first imaging study (even though sensitivity is only 15-35% initially) 5
• Plan for repeat radiographs in 10-14 days or MRI without contrast if urgent diagnosis needed 5

For pregnant patients with suspected pelvic/hip/sacral stress fracture:

• Proceed directly to MRI without contrast (skip initial radiographs due to radiation concerns) 5