From the Guidelines
Stress fractures should be managed with a multidisciplinary approach, prioritizing rest, pain management, and modification of risk factors to prevent progression to more serious fractures, as outlined in the 2024 update of the ACR Appropriateness Criteria for stress fractures 1. When managing stress fractures, it is essential to consider the location and type of fracture, as well as the patient's overall health and risk factors.
- High-risk stress fractures, such as those in the anterior tibial diaphysis, lateral femoral neck, and femoral head, require prompt identification and management to prevent complications like nonunion, delayed union, and avascular necrosis 1.
- Patients with osteoporosis, those on bisphosphonate therapy, and athletes are at high risk for fracture completion and require careful evaluation and management 1.
- Initial treatment typically involves rest from the activity that caused the fracture for 6-8 weeks, with gradual return to activity once pain subsides, as well as use of NSAIDs like ibuprofen (400-600mg every 6-8 hours) or naproxen (220-440mg twice daily) to manage pain and inflammation.
- Protective footwear or a walking boot may be necessary, and in some cases, crutches to reduce weight-bearing, while physical therapy exercises to strengthen surrounding muscles should begin after the initial healing period.
- Proper nutrition, especially adequate calcium (1000-1200mg daily) and vitamin D (600-800 IU daily), supports bone healing, and medical evaluation is essential if pain persists despite these measures, as some stress fractures may require surgical intervention 1.
From the Research
Definition and Causes of Stress Fractures
- Stress fractures are part of a continuum of changes in healthy bones in response to repeated mechanical deformation from physical activity 2.
- They occur when the activity produces excessive repetitive stress, causing osteoclastic processes in the bone to proceed at a faster pace than osteoblastic processes, thus weakening the bone and augmenting susceptibility to stress fractures 2.
- Stress fractures can be classified into two types: fatigue fractures and insufficiency fractures, with fatigue fractures being most common in runners and other athletes, and insufficiency fractures being common in elderly populations with osteoporosis 3.
Risk Factors and Incidence
- 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 overall stress fracture incidence is about three cases per 1,000 in active duty Servicemembers, but it is much higher among Army basic trainees: 19 per 1,000 for men and 80 per 1,000 for women 2.
Clinical Presentation and Diagnosis
- Individuals with stress fractures present with focal tenderness and local pain that is aggravated by physical activity and reduced by rest 2.
- A sudden increase in the volume of physical activity along with other risk factors is often reported 2.
- Simple clinical tests can assist in diagnosis, but more definitive imaging tests will eventually need to be conducted if a stress fracture is suspected 2.
- Plain radiographs are recommended as the initial imaging test, but magnetic resonance imaging has higher sensitivity and is more likely to detect the injury sooner 2, 4, 3.
Treatment and Prevention
- Treatment involves first determining if the stress fracture is of higher or lower risk; these are distinguished by anatomical location and whether the bone is loaded in tension (high risk) or compression (lower risk) 2.
- Low-risk stress fractures can be initially treated by reducing loading on the injured bone through a reduction in activity or by substituting other activities 2.
- Higher-risk stress fractures should be referred to an orthopedist 2.
- 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.
- Calcium and vitamin D supplementation might be helpful in preventing stress fractures, and bisphosphonates or teriparatide may accelerate fracture healing in special circumstances 5.