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Stress Fractures. Kevin deWeber, MD, FAAFP, FACSM Director, Military Sports Medicine Fellowship USUHS/Ft. Belvoir 2011 (many slides courtesy Dave Haight , MD. Outline. Pathophysiology Risk Factors Associations Diagnosis General Treatment Treatment of High-Risk Cases.

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stress fractures

Stress Fractures

Kevin deWeber, MD, FAAFP, FACSM

Director, Military Sports Medicine Fellowship

USUHS/Ft. Belvoir


(many slides courtesy Dave Haight, MD

  • Pathophysiology
  • Risk Factors
  • Associations
  • Diagnosis
  • General Treatment
  • Treatment of High-Risk Cases
stress fracture stress frack chur
Stress fracture [stress frack-chur]
  • Break in a normal bone after it is subjected to repeated tensile or compressive stresses, none of which would be large enough individually to cause the bone to fail, in a person who is not known to have an underlying disease that would be expected to cause abnormal bone fragility.
insufficiency fracture in suh fish n see frack chur
Insufficiency Fracture[in-suh-fish-n-see frack-chur]
  • Fracture due to repeated compressive or tensile stresses in a bone whose mechanical strength is reduced due to a condition that is present either throughout the skeleton (osteoporosis, osteomalacia, osteogenesisimperfecta, etc.) or in a bony region (eg, demineralization in a limb due to disuse).
pathologic fracture path o lah jick frack chur
Pathologic fracture[path-o-lah-jickfrack-chur]
  • Fracture due to a localized loss of strength in a bone from a disease process immediately underlying the bone, eg, bone tumors , bone cysts, and infections.
  • 1% of general population get ‘em
  • 1-8% of collegiate team athletes get ‘em
  • Up to 31% of military recruits get ‘em
  • 13-52% of runners get ‘em
most common sites of stress fractures
Most Common Sites of Stress Fractures
  • Tibia - 39.5%
  • Metatarsals - 21.6%
  • Fibula - 12.2%
  • Navicular - 8.0%
  • Femur - 6.4%
  • Pelvis - 1.9%
  • OTHER – 10.4%



  • Change in load(force on the bone)
    • Small number of repetitions with large load
    • Large number of reps, usual load
    • Intermediate combination of increased load and repetition
  • Stress fracture: imbalance between bone resorption and formation
  • Wolff’s Law: change in external stress leads to change in shape and strength of bone
    • bone re-models in response to stress
  • ABRUPT increase in duration, intensity, frequency without adequate rest (re-modeling)
  • Microfracture -> continued load -> stress fracture
review of risk factor types
Review of Risk Factor Types
  • Intrinsic:
    • Gender, genetics
    • Anatomical malalignment/ biomechanical
    • Dietary
    • Muscle weakness/imbalance
  • Extrinsic
    • Training errors
    • Equipment mismatch
    • Technique errors
    • Environmental
  • Sports-imposed deficiencies
intrinsic risk factors for stress fractures
  • History of prior stress fracture
  • Low level of physical fitness
  • Female Gender
  • Menstrual irregularity
  • Diet poor in calcium and dairy
  • Poor bone health
  • Poor biomechanics
intrinsic risk factors cont
  • Prior stress fracture:
    • 6 x risk in distance runner and military recruits
    • 60% of track athletes have hx of prior stress fracture
    • One year recurrence: 13%
  • Poor Physical Fitness – [muscles absorb impact]
    • >1 cm decrease in calf girth
    • Less lean mass in LE
    • < 7 months prior strength tng
intrinsic risk factors cont13
  • Why female gender? [1.2-10x]
    • Higher rates of other risk factors
      • Poorer bone health, Menstrual irregularity, disordered eating
  • Poor bone health:
    • Supplementing female military recruits with Ca and Vit D reduced stress fracture incidence
      • Lappe J, Cullen D, Haynatzki G, et al.. J Bone Miner Res 2008
    • FamHx osteoporosis: 3x risk
intrinsic risk factors cont14
    • Shorter duration of foot pronation
    • Sub-talar joint control
    • Tibial striking torque
    • Early hindfooteversion
    • Pescavus (unproven)
    • Pesplanus (unproven)





extrinsic factors
  • Increasing volume and intensity
  • Footwear
    • Older shoes
    • Absence of shock absorbing inserts
  • Running Surface?: mixed results
    • Treadmill vs Track
  • Activity type
activity type associations
  • Ballet: spine, femur, metatarsal
  • Runners: tibia, MT
  • Sprinters: navicular
  • Long dist runner: femoral neck, pelvis
  • Baseball, tennis: humerus
  • Gymnasts: spine, foot, pelvis
  • Rowers, golfers: ribs
  • Hurdlers: patella
  • Rowers, Aerobics: sacrum
  • Bowling: pelvis
classic clinical history
Classic Clinical History
  • Gradual onset of pain over weeks to months
    • Initially pain only with activity
      • “can’t run through it”
    • Progresses to pain after activity
    • Eventually constant pain with ADLs
  • Change in training regimen
    • “too much too soon”
  • Change in equipment
    • Shoes, etc.
diagnosis take a good history
DIAGNOSIS: take a good History
  • Sports participation
  • Occupation
  • Significant change in training
    • Hills, surface, intensity
  • Dietary History: adequacy, Vit D, Calcium
  • Menstrual History
  • General Health
  • Past medical history
  • Medications
  • Family history (osteoporosis)
diagnosis examination
DIAGNOSIS: Examination


Digital Imaging”

  • Localized tenderness to palpation in a location known to commonly sustain stress fractures
  • Fulcrum test?
    • Neither sensitive nor specific
  • Hop test?
    • Neither sensitive nor specific
    • Risky in high risk fractures
  • Tuning fork?
    • 43% sensitive, 49% specific
diagnosis biomechanical evaluation
DIAGNOSIS: Biomechanical Evaluation
  • Leg length discrepancy
    • 70% incidence in patients w/ LE stress fractures
  • Joint range of motion and ligamentous stability
  • Muscle strength and flexibility
  • Limb alignment (eg, genuvarus or valgus)
  • Foot type (eg, pescavus or planus)
  • Gait analysis in shoes worn during physical activity
  • Core muscle strength (eg, abdominal, back, and hip musculature)
imaging x ray
  • Poor sensitivity
    • ~ 30% positive on initial examination
  • 4 Possible findings
    • Localized periostealelevation
    • Cortical thickening
    • Focal sclerosis
    • Radiolucent line
  • 10 - 20% never show up on plain films
imaging bone scan
Imaging: Bone Scan
  • Extremely sensitive
    • 95% show up after 1 day
  • Not very specific
    • up to 24% false-positive results (stress reaction)
  • Differentiate between acute and old lesions
  • Acute stress fracture: all three phases positive
  • Shin splint: delayed phase only
imaging ct scan
Imaging: CT scan
  • Excellent fracture line detail
  • More specific than bone scan
  • Useful for fracture age/non-union
    • Pars interarticularis, sesamoids, etc.
  • DOWNSIDE: high radiation dose
imaging mri
Imaging: MRI
  • Highly sensitive (= bone scan)
  • More specific than bone scan
    • still not perfect
  • Cost may be lower than bone scan some places
  • Non-invasive, no radiation
  • Sensitive for soft tissue injury
  • DOWN: less cortical bony detail than CT
imaging ultrasound
Imaging: Ultrasound
  • Useful if fracture superficial
  • Shows hematoma, hypervascularity, periosteal elevation, cortical defect
  • Metatarsal fractures: sensitivity 83%, specificity 76%
    • Balal F, Gandjbakhch F, Foltz V et al. J Rheumatol 2009
mri vs bone scan cjsm 2002
MRI vs. bone scan, CJSM 2002
  • MRI less invasive, provided more information than bone scan and recommended for initial diagnosis and staging of stress injuries
  • “Limited” MRI may be cheaper than bone scan at some institutions
radiation comparison

Study mSvrelative radiation

Plain film foot <0.01 < 1.5 days

Plain film CXR 0.02 2.4 days

Plain film pelvis 0.7 3.2 mo

Tech-99 bone scan 3 (150 CXR)1.2 yrs

CT L-spine 6 (300 CXR) 2.3 yrs

CT abd / pelvis 10 (500 CXR) 4.5 yrs

differential diagnosis
Differential Diagnosis
  • Muscle strains
  • Tendinopathy
  • Nerve entrapment
  • Medial tibial stress syndrome
  • Neoplasm
  • Infection
high risk stress fractures
  • Talus
  • Tarsal navicular
  • Proximal fifth metatarsal
  • Great toe sesamoid
  • Base of second metatarsal
  • Medial malleolus
  • Pars interarticularis
  • Femoral head
  • Femoral neck

(tension side)

  • Patella
  • Anterior cortex of tibia

(tension side)

general treatment for low risk stress fractures
    • Reduce pain
    • Promote healing
    • Prevent further bone damage
    • Rest from painful activities 6-8 weeks (or until pain-free for two to three weeks)
    • Cross-training (non-painful exercise)
    • Flexibility, strength balance
early treatment speeds recovery
Early Treatment Speeds Recovery!
  • Evaluation < 3 weeks of sx onset:
    • 10.4 weeks to RTP
  • Evaluation > 3 weeks
    • 18.4 weeks to RPT
    • Ohta-Fukushima M, Mutoh Y, Takasugi S, et al. J Sports Med Phys Fitness 2002
activity modification
  • Activity should be pain free
  • Approximate desired activity
    • Cycle
    • Swim
    • Walk
    • Elliptical
    • Deep water running
rehab exercise and biomechanical corrections
  • Muscle flexibility
  • Strength training
  • Excessive pronation, pescavus, pesplanus
  • Limb Length Discrepancy
  • Replace running shoes every…

<300 miles

other treatment modalities
Other Treatment Modalities
  • Ultrasound: unsure
    • 1 study no benefit, 2 studies + benefit
  • ECSWT: maybe—consider in high-risk sites
    • Worked in 1 small retrospective study
  • Medications:
    • Iloprost: 1 small retrospective study in subchondral stress fractures of knee
  • Capicitatively Coupled Electric Fields:
    • No benefit in recent RCT
high risk stress fractures38

High risk for

delayed union , nonunion,


  • Talus
  • Tarsal navicular
  • Proximal fifth metatarsal
  • Great toe sesamoid
  • Base of second metatarsal
  • Medial malleolus
  • Pars interarticularis
  • Femoral head
  • Femoral neck

(tension side)

  • Patella
  • Anterior cortex of tibia

(tension side)

high risk tibial stress fracture
High-Risk Tibial Stress Fracture
  • Anterior, middle-third stress fractures are very concerning
  • Tension side of bone
  • May present like shin splints
  • Seen more commonly in jumpers and leapers
  • If you see “dreaded black line” on x-ray, poor prognosis
management of high risk tibial stress fx
Management of High-Risk Tibial Stress Fx
  • 4-6 months of rest +/- immobilization
  • ? Therapeutic US or SWT
  • Surgery if not healing in 4-6 months
    • Intramedullary rod
mgmt of 5 th metatarsal stress fracture
Mgmt. of 5th Metatarsal Stress Fracture
  • Sxs <3 wks, neg x-rays:
    • Avoid WB activity; 5th MT unloader orthotic
  • Sxs > 3 wks or + x-rays
    • Cast, NWB x 6 wks OR
    • Screw fixation (faster RTP)
  • Non-union: Screw-it!
lumbar spondylolysis
Lumbar Spondylolysis
  • Stress fracture of the pars interarticularis
  • Caused by repetitive hyper-extension
  • Often develops in the teenage or pre-teen years
  • May be bilateral
sports associated with spondy
Sports Associated with Spondy
  • Football (offensive lineman)
  • Gymnastics
  • Wrestling
  • Diving
  • Tennis
  • Volleyball
physical exam spondy
Physical Exam- Spondy
  • Tenderness to palpation over spines > paraspinal muscles
  • Extension exacerbates pain

“Stork test”—not very sensitive

  • Tight hamstrings- cause or effect?
imaging suspected spondy
Imaging Suspected Spondy
  • AP & lateral x-rays
    • r/o other bony causes
    • Obliques don’t change management
  • Also order SPECT bone scan
    • MRI not as sensitive
  • CT with fine cuts: prognostic
    • Acute vs sclerotic
treatment spondy
Treatment- Spondy
  • Relative rest from painful activity
  • Physical Therapy referral
    • Williams flexion-based exercises:
  • Spine Surgeon referral
    • Anti-lordotic bracing
  • Brace 6 weeks - 6 months (controversial)
  • Return to activity in brace when pain-free
  • Surgery if fail treatment
femoral neck stress fracture
Femoral Neck Stress Fracture
  • Vague anterior or medial groin/hip pain
  • Early diagnosis critical
    • Anterior hip tenderness
    • Log-roll pain
    • Pain with straight-leg-raise
  • If x-rays negative, order MRI
    • Crutches/NWB until ruled out!
  • MRI diagnostic imaging of choice for femoral neck stress fractures
femoral neck palpation
Femoral Neck Palpation

Iliopsoas bursa

femoral neck stress fractures
Femoral Neck Stress Fractures
  • Compression side.
    • Inferior part of femoral neck
    • Less likely to become displaced
    • Complications possible
  • Treatment:
    • Fatigue line <50% neck width: Crutches/NWB until asymptomatic, then relative rest 4-6 wks
    • Fatigue line >50% neck width: surgical fixation
femoral neck stress fx
Femoral Neck Stress Fx
  • Tension side: HIGH-RISK
  • Superior cortex or

tension side of neck

  • High propensity to become displaced
  • Frequent complications
  • Treated acutely with internal fixation
tarsal navicular stress fx high risk
Tarsal Navicular Stress Fx: HIGH-RISK
  • Consider in: Sprinters, Jumpers, Hurdlers, Basketball, Football
  • Mean interval of 7 -12 months before diagnosis
  • Vague mid-foot medial arch pain
  • Foot cramping
tarsal navicular stress fx
Tarsal Navicular Stress Fx
  • X-rays usually negative
  • MRI or thin-cut CT better than bone scan
tarsal navicular stress fracture
Tarsal Navicular Stress Fracture
  • Meta-analysis 2010:
    • NWB cast better than WB
      • 6-8 weeks
      • Semirigid orthotic during subsequent ambulation
    • NWB trend better than surgery
      • Torg JS, Moyer J, Gaughan JP, Boden BP. Am J Sports Med 2010.
    • Nonunion/displacement: surgery
navicular stress fx return to play
Navicular Stress Fx Return to Play
  • After casting, if no tenderness at the “N” spot, then can gradually return
  • Reassess every 1-2 weeks, gradual return at 6 weeks if no symptoms
  • AFTER 6 weeks of protection, 6 weeks of PT for strength and flexibility prior to return to run!
  • Average return to play is 4-6 months
  • Follow up radiography not helpful for return to activity
sesamoid stress fracture
Sesamoid Stress Fracture
  • Risk: Sudden start-stop sports
  • Repetitive forced dorsiflexion
sesamoid stress fracture58
Sesamoid Stress Fracture
  • Tx: NWB x 6 weeks with cast to tip of great toe to prevent DF
  • Failure: Surgery (excision or grafting)
talus stress fracture
Talus Stress Fracture
  • Chronic pain after ankle sprain
  • Location of fx: body near lateral process
  • MRI or CT for best imaging
  • Tx: 6-8 wks NWB in cast
  • Failure to heal: Excision of lateral process
patella stress fracture
Patella Stress Fracture
  • Risk factors:
    • cerebral palsy, hurdlers
    • ACL reconstruction w/ BTB
  • Tx if x-rays neg:
    • Non-painful activity
  • Tx if x-rays + or high-demand athlete
    • K-wire fixation
femoral head stress fracture
Femoral Head Stress Fracture
  • Tx: NWB
  • Ortho referral; high rate of arthroplasty
medial malleolus stress fracture
Medial Malleolus Stress Fracture
  • Seen in runners and jumpers
  • Risk of non-union
  • Tx if x-rays neg and MRI w/o fx line:
    • SLWC or ankle brace; takes 4-5 MONTHS
    • High-level athlete: surgery (FASTER RTP)
  • Tx if x-rays + or non-union:
    • Surgery
orthopedic consultation
Orthopedic Consultation
  • High Risk Fracture sites
  • High Level Athlete/Laborer
  • Failed conservative therapy
prevention of stress fractures
  • Small incremental increases in training FITT
  • Shock absorbing shoe/boot inserts
  • Calcium 2000mg, Vit D 800 IU (27% decr.)
  • Increased dairy products
    • 62% decreased risk SF for each cup of skim milk
  • Modification of female recruit training:
    • Lower march speed
    • Softer surface
    • Individual step length/speed
    • Interval training instead of longer runs
  • ??: OCPs (sig increase in bone mineral density, no impact on stress fracture rate)
  • NO: HCP selection of military recruits’ running shoes based on foot morphology
    • 3 prospective studies by Knapik et al