Relative Risks
1. Women > Men
  1. Relative Risk = 3.5
2. White males > Black males
  1. Relative Risk = 4.7
3. White females > Black females
  1. Relative Risk = 8.5
Mechanisms of Injury
1. Weight bearing
2. Muscle forces
  1. Muscle strength increases faster than bone strength
3. Muscle Fatigue
Risk factors
1. Repetitive activity
  1. Sports (e.g. distance Running, track and field sport)
  2. Military recruits
2. Increases in intensity, frequency, and loading
  1. Too fast
  2. Too far
  3. Too soon
3. Biomechanical forces
  1. Over pronators or Supinators
  2. Hallux Valgus
  3. Genu Varum or genu valgus
  4. Leg Length Discrepancy
  5. External hip rotation
  6. Changes in foot gear or training surface
  7. Muscle Fatigue
4. Systemic Diseases that weaken bone
  1. Rheumatoid Arthritis
  2. Systemic Lupus Erythematosus
  3. Osteoarthritis
  4. Pyrophosphate arthropathy
  5. Renal Disease
  6. Osteoporosis (Female Athlete Triad)
  7. Joint Replacement
  8. Nutritional deficiency (e.g. dieting)
Common Stress Fracture Sites
1. Tibia Stress Fracture (50% of stress Fractures)
2. Metatarsal Stress Fracture (25% of stress Fractures)
3. Fibula Stress Fracture (10% of stress Fractures)
4. Tarsal Navicular Stress Fracture
5. Calcaneal Stress Fracture
6. Medial Malleolus Stress Fracture
7. Femoral Neck Stress Fracture
8. Femoral Shaft Stress Fracture
9. Pubic Ramus Stress Fracture
10. Pelvic Stress Fracture
  1. Seen almost exclusively in women
11. Lumbar Stress Fracture
12. Coracoid process Stress Fracture
13. Humerus Stress Fracture
14. Olecranon Stress Fracture
Symptoms
1. Deep ache following rapid training change
2. Pain progression
  1. Start: Pain after activity
  2. Next: Pain with activity
  3. Next: Pain with walking
  4. Last: Pain at rest
3. Night pain rarely occurs
  1. Consider another diagnosis
Signs
1. Fracture site intense localized pain
  1. Tenderness to palpation
  2. Compression induces pain
  3. Percussion of bone distant from symptomatic site
  4. Vibrating tuning fork (128 Hz) at suspected site
2. Specific Tests for leg or pelvis stress Fracture
  1. Hop Test
  2. Fulcrum test
Differential Diagnosis
1. Primary benign bone neoplasm
  1. Osteoid Osteoma
  2. Osteoblastoma
  3. Eosinophilic Granuloma
2. Infections
  1. Chronic or Subacute Osteomyelitis
3. Chronic Musculoskeletal Soft Tissue Injury
  1. Tendonitis
  2. Muscle Strain
  3. Chronic Compartment Syndrome
4. Metastatic Neoplasm
  1. Breast Cancer
  2. Prostate Cancer
5. Primary Malignant Bone Neoplasms
  1. Osteosarcoma
6. Nerve Compression Syndromes
  1. Tarsal Tunnel Syndrome
  2. Carpal Tunnel Syndrome
  3. Ulnar Tunnel Syndrome
7. Herniated Intervertebral Disc
8. Osteoarthritis
9. Hypertrophic Pulmonary Osteoarthropathy
Diagnostics (Start with XRay, THEN Bone scan...)
Management
1. Rest for 4-7 weeks (may require up to 3 months)
  1. Non-weight bearing until pain free while walking
    1. Tibia Stress Fracture
    2. Femoral Stress Fracture
2. Immobilization
  1. Short-leg casting Indications
    1. Non-compliance
    2. High-risk for non-union
      1. Navicular Stress Fracture
      2. Metatarsal Stress Fracture
  2. Pneumatic brace (Air cast)
    1. Support results in quicker recovery and less pain
    2. Indicated in tibial and fibular stress Fractures
3. Active rest (cross training)
  1. Goals
    1. Cardiovascular conditioning
    2. Flexibility
    3. Proprioception
    4. Strength
  2. Activities
    1. Swimming
    2. Pool Running with float vest
    3. Biking
    4. Stair climbing machines (later stages)
4. Surgery
  1. Indications
    1. High Risk Fractures for non-union
    2. Non-healing Fractures
  2. Specific high risk sites
    1. Tarsal Navicular Stress Fracture
    2. Proximal anterior Tibia Stress Fracture
    3. Base of fifth Metatarsal Stress Fracture
    4. Femoral Neck Stress Fracture
5. Experimental: Electromagnetic field devices
  1. Questionable efficacy
  2. High cost
Prevention
1. Do not increase Exercise intensity >10% per week
2. Stretch and warm-up before Exercise
3. Choose level Running surfaces
4. Shoes should be light weight and in good condition
5. Consider Orthotics for biomechanical factor correction
6. Shock-absorbing insoles may be beneficial
Reference
1. Simmons (1997) AAFP Sports Med Review
2. Sanderlin (2003) Am Fam Physician 68:1527
3. Buckwalter (1997) Am Fam Physician 56(1):175

Navigation Tree

Please see the Terms and Conditions. Please also see the privacy statement regarding advertising on this page. Although access to this page is not restricted, the information found here is intended for use by medical providers. Patients should address specific medical concerns with their physicians.

This page was written by Scott Moses, MD. This page was last revised before 5/10/08, prior to consistent tracking of revision date. This page was last published on 6/1/2008. Please send comments and questions to the editor. Contact information may be found on the page About the Family Practice Notebook. These pages are best viewed with Microsoft Internet Explorer 6.0.

Orthopedics Book

Approach

Miscellaneous

Type

Ankle Disorders Chapter related topics

Elbow Disorders Chapter related topics

Foot Disorders Chapter related topics

Forearm Disorders Chapter related topics

Hand Disorders Chapter related topics

Hip Disorders Chapter related topics

Knee Disorders Chapter related topics

Neurology Chapter related topics

Procedure Chapter related topics

Pulmonology Chapter related topics

Radiology Chapter related topics

Shoulder Disorders Chapter related topics

Thoracic Spine Disorders Chapter related topics

Wrist Disorders Chapter related topics

http://www.fpnotebook.com/

Stress Fracture

Navigation Tree