II. Epidemiology: 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

III. Mechanisms of Injury

  1. Weight bearing
  2. Muscle forces
    1. Muscle Strength increases faster than bone strength
  3. Muscle Fatigue

IV. Risk factors

  1. Repetitive activity
    1. Military recruits
    2. Sports (e.g. distance Running, track and field sport)
      1. Running (>25 miles per week)
      2. Track and Field
      3. Basketball
      4. Soccer
      5. Dance
  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)
      1. Vitamin D Deficiency
  5. Other Associated risk factors
    1. Tobacco abuse
    2. Alcohol >10 drinks per week
    3. Female Athlete Triad

V. Pathophysiology: Common Stress Fracture Sites

  1. Tibia Stress Fracture (23% of Stress Fractures)
  2. Metatarsal Stress Fracture (16% of Stress Fractures)
  3. Fibula Stress Fracture (15% of Stress Fractures)
  4. Tarsal Navicular Stress Fracture
  5. Calcaneal Stress Fracture
  6. Medial Malleolus Stress Fracture
  7. Femoral Neck Stress Fracture (6%)
  8. Femoral Shaft Stress Fracture
  9. Pubic Ramus Stress Fracture
  10. Pelvic Stress Fracture (1-2%)
    1. Seen almost exclusively in women
  11. Lumbar Stress Fracture
  12. Coracoid process Stress Fracture
  13. Humerus Stress Fracture
  14. Olecranon Stress Fracture

VI. 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 (at presentation in 81% of patients)
    4. Last: Pain at rest
  3. Night pain rarely occurs
    1. Consider another diagnosis

VII. Signs

  1. Fracture site intense localized pain
    1. Tenderness to palpation (present in most cases)
    2. Edema at Fracture site may be present
    3. Compression induces pain
    4. Percussion of bone distant from symptomatic site
    5. Vibrating tuning fork (128 Hz) at suspected site
      1. Mediocre Test Sensitivity and Specificity
      2. Lesho (1997) Mil Med 162(12): 802-3 [PubMed]
  2. Specific Tests for leg or pelvis Stress Fracture
    1. Fulcrum Test
    2. Hop Test
      1. Poor Specificity (common finding in Shin Splints)
      2. Batt (1998) Med Sci Sports Exerc 30(11): 1564-71 [PubMed]

VIII. 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 to bone
    1. Breast Cancer
    2. Prostate Cancer
  5. Primary Malignant Bone Neoplasms
    1. Osteosarcoma
    2. Ewing Sarcoma
  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

IX. Imaging

  1. Overall imaging approach (preferred)
    1. Step 1: XRay negative and Stress Fracture suspicion persists
    2. Step 2: Repeat XRay in 2-3 weeks is negative and Stress Fracture suspicion persists
    3. Step 3: Obtain MRI (preferred) or bone scan
  2. Imaging modalities
    1. Stress Fracture XRay
    2. Stress Fracture Bone Scan
    3. Stress Fracture CT
    4. Stress Fracture MRI
    5. Ultrasound is being investigated for specific Stress Fracture sites (e.g. Metatarsal Stress Fracture)
      1. Banal (2009) J Rheumatol 36(8): 1715-9 [PubMed]

X. Management

  1. Rest for 4-7 weeks (may require up to 3 months)
    1. Activity should be pain-free only
    2. Non-weight bearing until pain free while walking
      1. Tibia Stress Fracture
      2. Femoral Stress Fracture
  2. Analgesia
    1. Acetaminophen is preferred over NSAIDS
      1. NSAIDS may delay healing
  3. Immobilization
    1. Short-leg Casting or CAM-Walker 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
  4. Active rest (cross training)
    1. Consider formal rehabilitation program with physical therapy for strength and Stretching
    2. Goals
      1. Cardiovascular conditioning
      2. Flexibility
      3. Proprioception
      4. Strength
    3. Activities
      1. Swimming
      2. Pool Running with float vest
      3. Biking
      4. Stair climbing machines (later stages)
  5. 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
  6. Experimental: Electromagnetic field devices
    1. Questionable efficacy
    2. High cost

XI. 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
  7. Osteoporosis Prevention (unclear efficacy)
    1. Consider calcium supplement 1000 mg orally daily
    2. Consider Vitamin D 800 IU orally daily

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Ontology: Stress Fractures (C0016664)

Definition (MSH) Fractures due to the strain caused by repetitive exercise. They are thought to arise from a combination of MUSCLE FATIGUE and bone failure, and occur in situations where BONE REMODELING predominates over repair. The most common sites of stress fractures are the METATARSUS; FIBULA; TIBIA; and FEMORAL NECK.
Concepts Injury or Poisoning (T037)
MSH D015775
ICD10 M84.3
SnomedCT 23382007, 240197007, 269322004, 208682007, 157252004, 208743001, 263253007
English Fatigue Fracture, Fatigue Fractures, Fracture, Fatigue, Fractures, Fatigue, Fractures, March, Fractures, Stress, March Fracture, March Fractures, Fracture, March, Fracture, Stress, [Q] Stress fracture, stress fracture (diagnosis), stress fracture, [Q]Stress fracture, Stress fracture (disorder), Stress fracture NOS, Stress reaction, Fractures, Stress [Disease/Finding], stress fractures, march fractures, Fatigue fractures, fracture of metatarsal bone(s) march fracture, March fracture (diagnosis), Fatigue fracture, Stress fracture, March fracture, March fracture (disorder), Stress fracture (morphologic abnormality), fatigue fracture, march fracture, fatigue; fracture, fracture; fatigue, fracture; march fracture, fracture; stress, march fracture; fracture, stress; fracture, Stress Fractures, Stress Fracture, Fracture;stress
Italian Frattura da sforzo, Frattura da marcia, Fratture da fatica, Fratture da marcia, Fratture da stress
Swedish Utmattningsfrakturer
Japanese ストレスコッセツ, コウグンコッセツ, 過労性骨折, 骨折-疲労, ストレス骨折, 疲労骨折, 行軍骨折, 骨折-ストレス, 骨折-行軍, 骨折-過労性
Czech fraktury z přetěžování, fraktury stresové, Pochodová zlomenina, Únavová zlomenina
Finnish Rasitusmurtumat
Russian MARSHEVAIA STOPA, MARSHEVYE PERELOMY, PERELOMY UTOMLENIIA, STRESSOVYE PERENAPRIAZHENIIA, PERELOMY, PERELOMY USTALOSTNYE, UTOMLENIIA PERELOMY, МАРШЕВАЯ СТОПА, МАРШЕВЫЕ ПЕРЕЛОМЫ, ПЕРЕЛОМЫ УСТАЛОСТНЫЕ, ПЕРЕЛОМЫ УТОМЛЕНИЯ, СТРЕССОВЫЕ ПЕРЕНАПРЯЖЕНИЯ, ПЕРЕЛОМЫ, УТОМЛЕНИЯ ПЕРЕЛОМЫ
Spanish Fractura de la marcha, Fracturas de la Marcha, Fracturas por Tensión, (Q)fractura por sobrecarga, fractura por estrés, fractura de esfuerzo, fractura por sobrecarga (trastorno), Stress fracture, fractura por fatiga, fractura por marcha (trastorno), fractura por marcha, fractura por sobrecarga (anomalía morfológica), fractura por sobrecarga, Fractura por sobrecarga, Fracturas por Estrés, Fracturas por Fatiga
French Fracture de marche, Fracture de fatigue, Fractures de stress, Fractures de fatigue
Dutch marsfractuur, fractuur; marsfractuur, fractuur; stress, fractuur; vermoeidheid, marsfractuur; fractuur, stress; fractuur, vermoeidheid; fractuur, stressfractuur, Fracturen, stress-, Fractuur, stress-, Marsfractuur, Stressfracturen, Stressfractuur, Vermoeidheidsfractuur
German Marschfraktur, Belastungsfraktur, Frakturen, Marsch-, Marschfrakturen, Ermüdungsbrüche, Ermüdungsfrakturen, Frakturen-, Ermüdungs-, Frakturen, Streß-, Streßfrakturen
Portuguese Fractura da marcha, Fraturas por Fadiga, Fraturas por Stress Mecânico, Fraturas por Estresse Físico, Fractura de fadiga, Fraturas de Estresse, Fraturas de Fadiga, Fraturas de Marcha
Polish Złamania przeciążeniowe
Hungarian March-fractura, Fáradásos törés
Norwegian Marsjfraktur, Marsjbrudd, Tretthetsbrudd, Stressfraktur, Trøtthetsbrudd