Stress Fractures

Ovid: Rockwood And Green’s Fractures In Adults

Editors: Bucholz, Robert W.; Heckman, James D.; Court-Brown, Charles M.; Tornetta, Paul
Title: Rockwood And Green’s Fractures In Adults, 7th Edition
> Table of Contents > Section One – General Principles: Basics > Fracture Types > 19 – Stress Fractures

Stress Fractures
David C. Teague
Much has changed in our understanding of stress
fractures since the likely initial description by Breithaupt in 1855 of
a syndrome of painful swollen feet among marching Prussian soldiers.27 It took until 1956 for the first report of the condition in athletes.58
Originally the domain of military recruits and military physicians,
recreational and competitive athletes with stress fractures now
commonly present to civilian practitioners. Athletic populations
involved in team and individual sports increasingly develop overuse
injuries, and stress fractures have been reported in most bones in the
Stress fracture incidences evade precise determination
in athletic populations because of a variability in training programs
and a lack of standardized reporting.166
Track and field teams have shown incidences ranging from 10% to 31%,
with lesser but substantial numbers noted for participants in
gymnastics, ballet, figure skating, basketball, crew, soccer, and
lacrosse.18,93 U.S. military recruits develop lower extremity stress fractures at a gender-dependent rate of up to 4% in men and 7% in women.4,80,95,103
By convention, stress fractures occur in normal bone
when that bone is subjected to abnormal or unaccustomed stresses. This
condition is distinct from insufficiency fractures, wherein normal
stresses applied to abnormal bone produce fracture.
Pathophysiology of Injury
Various forces exert loads on bone during all physical
activities. Ground and joint reaction forces as well as muscle forces
stress the bone by application of force across unit areas of bone.
These stresses yield local deformation or change in length, termed strain. Therefore, stress, a measure of the load applied, produces strain or bone deformation in a given direction.42
According to Wolff law, normal loads delivered to normal bone produce normal bone remodeling.44
This remodeling response to cyclic loading entails initial osteoclastic
bone resorption followed by osteoblastic new bone formation within
cortical bone as well as on the trabeculae of cancellous bone.33,39
The resorption process peaks at 3 weeks, but it takes 3 months to
adequately create the new bone to complete the remodeling cycle.70,96,158,176
When optimally loaded and with sufficient time for remodeling, bone
mass remains static, no stress fracture or injury ensues, and the bone
becomes stronger.70,71,110,158,186
However, repetitive loading, which outstrips the bone’s ability to
create new bone in the resorption tunnels and pits, engenders a
resorption-dominated accelerated remodeling process that actually
weakens the bone.41,71,96,110,120
Then, with continued repetitive loading, a positive feedback mechanism
develops in which increased mechanical usage stimulates bone turnover,
resulting in focally increased remodeling porosity and decreased bone
mass. This weakened site is thus more susceptible to further
microdamage, which will incite additional resorption. Ultimately,
stress fracture can result from continued loading superimposed onto the
focally decreased bone mass generated by progressively larger
resorption sites.162
Signs and Symptoms
A careful history of load-related pain often points to
the likely diagnosis of stress fracture. Most athletes can accurately


symptom progression and relate the gradual onset of vague pain over a
period of weeks during training. Symptoms are initially described as
mild and present only during the stress or activity.110
The symptoms very often occur during the first few weeks after an
increase in training volume or intensity, a change in technique or
surface, or an alteration of footwear. Any change in a previously
regimented training program may be the inciting historical event.42,83,120
For nonathletes, a recent unusual uptick in activity, like a vacation
with a great deal more walking than usual or a new aerobic exercise
program, may be described.62 If left
unchecked, the process may progress to persistent pain after training,
pain at rest, and even night pain. Pertinent historical questions
relate to potential risk factors. History of previous stress fractures
or other painful sites and the presence of eating disorders, leg length
discrepancy, or muscle imbalance should be evaluated. In the female
patient, age of menarche and presence of menstrual irregularities must
be considered. For athletes, training regimen alterations are usually
the root cause of the pain. For runners, the most common training
change is a significant increase in the distance run during a brief
period of training.150 Furthermore,
the potential impact to the patient must be assessed. For example, a
scholarship athlete may wish to make different treatment choices than a
weekend runner.

The hallmark physical finding is focal bone pain with
palpation and stressing, but findings vary depending on the location of
the stress fracture and the time from injury onset to presentation.
When the site is accessible, local swelling may be noted. Percussion of
the bone typically produces pain, but passive and active ranges of
motion of adjacent joints do not. The anatomic location of the pain can
help in the diagnosis. For example, femoral diaphyseal stress fractures
occur typically in the medial cortex, so lateral thigh pain is not
likely to be correlated with a stress fracture.62
Inaccessible sites require indirect physical tests for diagnosis. For
example, back pain produced by hip extension while standing on the
opposite leg may implicate stress fractures of the pars
Risk Factors
In general, the predominant risk factor for the
development of a stress fracture is an increase in training frequency
and intensity. However, work based on the concepts of Grimston and
Frost allows analysis of the factors that may lead to bone’s failure to
successfully adapt to the mechanical loads to which it is exposed.13,69,85
Mechanical competence of bone depends on properties like bone density
and geometry, all related to cellular activity. The theoretical
mechanosensory system of bone, classically considered to be Wolff law,
can be understood as a mechanostat that senses strain, compares it to a
given threshold, and initiates an adaptive cellular response.
Physiologic, mechanical, and pharmacologic factors generate mechanostat
responses by providing functional stimuli to the bone. Systemic
constraints on bone health such as genetics or eating disorders may
impede the bone’s ability to respond despite messages from the
In contrast to elderly patients with osteoporosis and
bone density measurements predictive of fragility fracture risks, the
majority of young active individuals have normal bone density.15
Little work points to any significant connection between bone density
and risk of stress fracture in men. Studies of male soldiers and
runners typically find no difference in tibial bone density between
those with and those without stress fractures.17,52,77 While not clearly causally related, low bone density may be a risk factor for women.12
A multivariate analysis showed a strong association between low femoral
neck bone density and risk of stress fracture in female military
recruits.111 An 8% lower bone
density at the tibia was identified in a subgroup of female track
athletes who developed tibial stress fractures.17
However, the bone density measures for these women were still higher
than those for similar less active nonathletes, perhaps suggesting that
the bone density required by athletes may be greater than that needed
by the general population. In summary, bone density measurement does
not appear to be a useful screening tool for stress fractures.12
Smaller bone size appears to predispose to stress fracture.13
In a prospective evaluation of more than 600 military recruits, an up
to 10% smaller tibial width and cross-sectional area was found among
those who developed stress fractures.10 Similar results for male runners are reported.52
Although bone geometry likely affects stress fracture development, no
practical imaging system yet allows this variable to be used as a
screening tool.
Activity that produces repetitive loading clearly can
lead to stress fracture development. Multiple factors influence the
clinical responses to bone loading.13
Most studies support the notion that poor baseline physical fitness
predisposes to stress fracture development when a significant increase
in activity occurs.49,165,192
However, well-conditioned athletes also develop stress fractures, so
other factors must be considered. Load magnitude and rate appear to
present the most significant stimulation of bone cellular dynamics, so
the training regimen of soldiers and athletes often merits scrutiny.13 Training modifications including rest periods,164,193 banning concrete as a training surface,83,151 use of running shoes,83,149 and restricting high-impact activities143,164,179
can reduce the incidence of stress fractures in military recruits.
Shock-absorbing boot inserts may lead to fewer stress injuries in
recruits, but comfort and compliance issues prevent strong conclusions.155
Surveys of athletes relate changes in training in more than 80% of them
before the onset of a stress fracture. Increased training volume is
related to higher stress fracture risks in ballet dancers and runners.38,98
The role of flexibility, either too much or not enough,
cannot be conclusively documented to contribute to stress fracture
development.13 Many investigators
have evaluated factors including joint mobility and laxity, and muscle
length. Only limited ankle dorsiflexion and increased hip external
rotation have been somewhat implicated in stress fracture development.77,78,91 Similarly, the contribution of foot structure to stress fracture risk is controversial.7,122,169
For example, some studies support an association in male military
recruits between high midfoot arch and greater risk of stress fracture.79,169 This correlation does not appear in all studies.130
The stress fracture-foot type relationship is likely variable depending
on which bone is involved. Leg length discrepancy actually appears to
increase the chance of stress fracture for military and athletic
individuals, but the risk is not specific to either the shorter or the
longer limb.17,38,68 The second metatarsal and second toe lengths do not correlate to risk of second metatarsal base stress fracture in dancers.55
Impact attenuation during training should alter the functional


stimuli transmitted to the bone. Conventionally, the training surface
is considered a factor in the development of stress fracture. Most
advise athletes to avoid training on hard, uneven surfaces, but no
clear scientific data support or refute this recommendation.13,109
Although ground reaction forces decrease with more compliant running
surfaces, these same surfaces may result in more or earlier muscle

No study demonstrates a correlation between a host of body size and composition factors and the incidence of stress fractures.13 Height, weight, body mass index, body girth and width, as well as many other variables, have been investigated.8,17,98,116
Even in military recruits, who display more variability in body size
than typical groups of similar athletes, no consistent associations
between stress fractures and body size and composition can be
While skeletal homeostasis is affected by multiple
endogenous hormones, sex hormones, primarily in women, appear to have
substantial impact on the stress fracture risks. No relationship
between lowered testosterone levels and stress fractures exists for
male athletes.170 Even when testosterone levels are decreased, they are typically within the range of normal for healthy adult men.88,117,171
Conversely, female athletes with menstrual irregularities uniformly are
found to have an increased risk for the development of stress
fractures. These women with menstrual disturbances present a two to
four times higher relative risk for stress fractures than eumenorrheic
athletes.12 Also, amenorrheic athletes are at a higher risk of developing multiple stress fractures.8 Yet use of oral contraceptives does not conclusively reduce the risk of stress fractures in these athletes.51,104
Lifetime menstrual history similarly yields information regarding the
risk of stress fracture, with the historically regular athletes
reporting a 20% less risk than those with very irregular menstrual
The mechanism that produces increased stress fracture
risk with menstrual disturbance is unclear and most certainly
multifactorial. Nevertheless, the association is unassailable and
frequently found presenting together with eating disorders and
osteopenia. This combination, known as the female athlete triad, mandates attention be directed to all facets of the patient’s condition.12,64,141 Eating disorders occur more commonly in female athletes than males.94,144 Even active duty female soldiers admit to an 8% prevalence of eating disorders.112
Disordered eating patterns appear to increase the risk of stress
fractures in ballet dancers and young adult female track athletes.16,72 Indeed, extreme weight-control behavior in college athletes doubles the risk of stress fracture.132 Lower dietary calcium intake may well be an independent risk factor, particularly for female runners with irregular menses.51,104
Stress fractures occur in people of all ages. The peak
incidence appears in late adolescence and early adulthood among
military recruits, competitive and recreational athletes, and dancers.14,19,81,92,95,122
Age is an important factor in determining the location of stress
fractures, but age does not appear to be an important factor in their
Imaging Modalities
The diagnosis of a stress fracture often requires no
imaging studies, especially when a careful history and a classic
physical exam combine to make the diagnosis with certainty. However,
several radiographic modalities are at the disposal of the clinician
for definitive documentation and differential evaluations. Plain
radiographs, bone scintigraphs, computed tomography (CT) scans, and
magnetic resonance (MR) images are now the routine studies used to
evaluate and diagnose stress fractures.
Plain Radiographs
Radiographs obtained very early in the stress fracture
process typically are not effective in demonstrating an abnormality.
Seldom do radiographic findings appear before 2 to 3 weeks from the
onset of symptoms. New periosteal bone formation, the classic
radiographic marker of a healing response, often does not appear until
3 months from symptom onset. Radiographic changes never appear for some
stress fractures in some patients.46
When changes are evident, several findings confirm the presence of a
stress fracture, rendering this modality poorly sensitive but highly
specific. Only 20% of bone scan foci positive for stress fractures
correlate with positive plain radiographic findings.127,196
The false-negative rate for radiographs approaches 100% for early Grade
I bone scan-positive lesions but drops to 24% for Grade III lesions,
demonstrating that stress fractures later in their course have more
ability to remodel and respond to the altered stresses, and the later
response often is apparent on plain radiographs.
Associated findings may include periosteal bone
formation, horizontal or oblique linear patterns of sclerosis,
endosteal callus, and a frank fracture line. The initial radiographic
sign of a progressing stress fracture is the so-called gray cortex,
which corresponds to a low-density cortical area affected by increased
osteoclastic bone resorption activity42 (Fig. 19-1).
As the process evolves in long bones, the stress fracture undergoes
marginal resorption and may yield an ovoid lucency within a thickened
area of cortical hyperostosis.29 A
late-stage stress fracture in cortical bone appears as a radiolucent
line with extension partially or completely across the cortex.
Similar-stage stress fractures in cancellous bone demonstrate a
fracture lucency oriented perpendicular to the trabeculae. Healing is
denoted by focal sclerosis in areas of cancellous bone, while
diaphyseal healing involves both periosteal and endosteal cortical
thickening.29 Plain films are most
likely to present positive findings in the fibula and metatarsals. The
x-ray beam should be centered over the painful, suspected bone. Plain
films typically are not helpful in discerning stress injuries to the
pars interarticularis. Some authors contend that plain films are
unlikely to yield positive results when investigating possible tibial
stress fractures, while others state the femur, pars interarticularis,
and tarsal bones are least likely to yield remarkable findings on
initial plain film investigation.29,46
When radiographic findings are conclusive, additional
studies are not required. If multiple sites of stress fracture are
possible based on history and physical exam, or if plain films do not
support the presumptive diagnosis of stress fracture, three-phase bone
scintigraphy has been the study of choice. Bone scan has long been
considered the most sensitive test for stress fracture, with
sensitivity approaching 100%.42,46 However, the sensitivity is not coupled with high specificity, so clinical features must be correlated.
Isotopes are atoms with identical atomic numbers but
different atomic weights, while a nuclide is the nucleus of a given
isotope. Nuclides or isotopes with differences in numbers of


and neutrons are unstable and give off particles or electromagnetic
radiation in their transition to stability; this is known as radioactive decay.
These materials are synonymously termed radionuclides or radioisotopes.
When used for diagnostic purposes, the materials are termed
radiopharmaceuticals and radiotracers.163

FIGURE 19-1 Imaging studies for a 20-year-old distance runner with bilateral proximal activity-related thigh pain. A. A plain radiograph demonstrates the gray cortex on the left femur (arrow) with minimal changes on the right. B.
Delayed spot image scintigraphic study shows Grade 3 increased activity
at the left proximal femur, while the right side demonstrates a
slightly less intense increased signal.
Technetium-99m methylene diphosphonate (99mTc
MDP) is the radioisotope usually used for bone scans. Gamma radiation
is emitted, and the whole body dose for a bone scan is about 0.13 to
0.19 rad. The bladder dose, where the radioactivity is concentrated in
the urine, is 2.62 to 3.90 rads—hence, the need for frequent voiding
during and after the scanning period.
99mTc MDP is available in good supply at low
cost, has a 6-hour half-life, and emits gamma energy at an ideal
frequency for gamma cameras used in diagnostic imaging.163
The radioisotope is administered as a bolus
intravenously. The mechanism of uptake in bone is not precisely
elucidated, but blood flow to the bone is a fundamental requirement. In
normal bone, uptake is in proportion to blood flow to the bone.
However, in abnormal situations like stress fractures that are
accompanied by high bone vascularity, factors other than bone blood
flow play a larger role in radiotracer uptake. New bone formation
proves to be the most important factor in the uptake, whereas bone
destruction without new bone formation yields no increase in uptake.29,163
Bone scintigraphy is performed in three phases—two early
and one delayed. The initial images acquired immediately after
radiotracer injection are representative of blood perfusion to bone and
soft tissue and correspond roughly to contrast angiography. The second
set of images, obtained approximately 2 to 5 minutes after injection
and termed the blood pool scans,
demonstrate radionuclide location in the soft tissues or extravascular
space. These images reflect the extent of hyperemia and capillary
permeability and generally correspond to the acuity and severity of the
injury. At 2 to 4 hours after injection, the delayed images document
radionuclide accumulation in the skeleton and, to a lesser extent, the
soft tissue. Over this time, 50% of the diphosphonate tracer is
postulated to be adsorbed on the hydroxyapatite matrix of bone, with
special affinity for new bone formation sites.46
Given a correlating history and physical exam, the
scintigraphic diagnosis of stress fracture is made by focal increased
uptake on the third-phase images. Stress fractures are positive on all
three phases, but periostitis develops positive foci only on the
delayed images.5,29,157
Other soft tissue injuries are positive only in the first two phases,
allowing some differentiation between bony and soft tissue pathology.
However, the lack of specificity remains a disadvantage of this
The typical list of conditions producing similar localized uptake
includes osteoid osteoma, other bony tumors, osteomyelitis, bony
infarct, and bony dysplasias. Due to its improved ability to
differentiate many of these conditions, MR imaging may be the
diagnostic method of choice in certain settings.
Radionuclide scans can be positive within hours of a bone injury.29
Acute stress fractures are positive on all three phases. As bony
healing proceeds, the initial phase perfusion scan normalizes first.
Within the ensuing few weeks, the blood pool second phase images return
to normal. Since bony remodeling continues for an extended period,
focal uptake on the delayed images resolves last. Uptake gradually
diminishes in intensity over a three to six month period, but some
increased uptake can last up to a year, even in uncomplicated stress
fractures with uneventful healing.5 Bone scans are not therefore particularly useful for monitoring healing and do not merit frequent repeating.
A grading system, based on the scintigraphic appearance,
allows classification into milder or more severe stress fractures,
recognizing that these stress injuries occur along a continuum of bony
involvement196 (Table 19-1).
The minimally symptomatic Grade 1 or Grade 2 stress fractures typically
resolve more quickly and completely. The grading system can assist in
prescribing the requisite rest and rehabilitation intervals29 (Fig. 19-1).
Single-photon emission computed tomography (SPECT) is used when lumbosacral stress fractures are suspected. The camera


rotates about the patient, generating three-dimensional images of
radioisotope uptake. This modality is particularly useful for
investigating suspected pars interarticularis and sacral stress

TABLE 19-1 Bone Scintigraphy and Magnetic Resonance Imaging Grading Scale


Bone Scan

Magnetic Resonance Imaging


Small, ill-defined cortical area of mildly increased activity

Periosteal edema: mild to moderate on fat-suppressed T2 or STIR images

Marrow: normal on T1 and fat-suppressed T2 or STIR images


Better-defined cortical area of moderately increased activity

Periosteal edema: moderate to severe on fat-suppressed T2 or STIR images

Marrow edema on fat-suppressed T2 or STIR images


Wide to fusiform, cortical medullary area of highly increased activity

Periosteal edema: moderate to severe on fat-suppressed T2 or STIR images

Marrow edema on T1 and fat-suppressed T2 or STIR images


Transcortical area of intensely increased activity

Periosteal edema: moderate to severe on fat-suppressed T2 or STIR images

Marrow edema on T1 and fat-suppressed T2 or STIR images

Fracture line clearly visible

STIR, short tau inversion recovery.

from Fredericson M, Bergman G, Hoffman KL, et al. Tibial stress
reaction in runners: correlation of clinical symptoms and scintigraphy
with a new magnetic resonance imaging grading system. Am J Sports Med

Magnetic Resonance Imaging
MR images provide identical sensitivity and superior
specificity compared with bone scintigraphy for the evaluation of
stress fractures.100,152
The improved specificity derives from the comprehensive anatomic
visualization provided from this modality, allowing for precise
localization of the injury and differentiation from other possible
conditions. The bony tissue, with comparatively few mobile protons, is
not represented in significant detail. Instead, MR imaging accentuates
reactive edema in the soft tissues and marrow surrounding a stress
injury. This soft tissue response is seen best in edema-sensitive
sequences like fat-suppressed T2-weighted and short tau inversion
recovery (STIR) scans. Areas of edema appear as high signal intensity
sites on these sequences.29,57
A grading system that corresponds to the scintigraphic
grading system addresses the typical progression of stress injury
documented on MR images66 (Table 19-1).
Earliest injuries demonstrate increased signal intensity first in the
periosteum, then also in the marrow on STIR and T2-weighted images,
while the T1 scans are normal. In Grade 3 injuries, decreased marrow
signal occurs with the T1 sequence, while the STIR and T2 sequences
yield even higher intensity marrow changes. Grade 4 stress fractures
feature a low signal fracture line on both sequences continuous with
the cortex and medullary space57,66 (Fig. 19-2).
Although plain radiographs and bone scintigraphs
accurately diagnose stress fractures in most patients, MR images are
increasingly advocated as the study of choice.29,46,81 MR imaging


involves no exposure to ionizing radiation and requires much shorter
imaging times than bone scintigraphy. The specificity of MR images
significantly exceeds that of scintigraphs.168
Thus, straightforward cases can be investigated reliably without MR
imaging, but more difficult diagnostic dilemmas or problematic cases
warrant MR imaging, which is now regarded as the overall best technique
for assessment.67,75,172

Coronal T1-weighted magnetic resonance image of a Grade 4 distal tibia
stress fracture with visible fracture line and surrounding marrow edema.
Computed Tomography
CT scans provide excellent bony anatomic detail. The
delineation of fracture line orientation is assisted with
three-dimensional CT information, which may improve treatment decisions
for certain bones such as the tarsal navicular.107,108
Longitudinal fracture lines in diaphyseal locations can also be
elucidated. Pars and sacral stress fractures are well characterized
with CT scans as well.42
Rationale of Initial Management
The fundamental principle of initial management is
modified rest to allow the bone remodeling process to equilibrate. The
inciting strain must be eliminated to break the cycle of accelerated
resorption, allowing new bone formation to catch up and adequately
repair the focus of stress fracture.42,150
Earlier initiation of rest, when the resorption-formation mismatch is
minimal, allows a brief period of activity restriction to suffice.126 For athletes, alternative training should continue provided regimens can be devised that unload the area of stress fracture.22 For nonathletes, a brief period of rest is usually well tolerated and adequate to reverse the process.
Different stress fracture sites mandate certain specific
management approaches, but the overarching message of activity
modification and rest applies to every site.60,99
During this first phase of treatment, remediable risk factors should be
addressed. The training errors or changes that precipitated the stress
fracture should be identified and corrected.110
Braces or other forms of immobilization are seldom needed. No
controlled study strongly supports adjunctive measures like external
electrical stimulation or ultrasound.9,11,26,122,153
For high-level athletes, early pool running programs prove highly
successful at maintaining baseline fitness during the rest phase.28,76
Second-phase rehabilitation begins when pain is substantially diminished or absent.42,150 For lower extremity injuries, this timeframe is roughly 2 weeks after painless walking is resumed.66,110
The training program emphasizes progressive aerobic conditioning with
specified rest times to permit bone compensation for the slowly
increasing strains.28,164
Provided the progression does not reproduce the patient’s pain,
activity reintroduction proceeds steadily. Cross-training is advisable
to reduce the likelihood of recurrence.28
Surgery is seldom contemplated or required for the management of most
stress fractures. No study proves or disproves an adverse link between
healing of stress fractures and use of nonsteroidal anti-inflammatory
drugs.189 A trial of prophylactic
treatment with risedronate failed to demonstrate a reduction in stress
fracture risk among infantry recruits.125
Lower Extremity
Femoral Neck
Early recognition of femoral neck stress fractures
prevents catastrophic consequences. Younger patients typically present
with inferior or medial neck lesions, commonly known as
compression-side stress fractures. Older patients are prone to
superior, tension-side fractures, and these are more likely to fail and
displace with continued activity.34,73,74
With either lesion, patients complain of activity-related diffuse groin
or anterior hip pain and have pain at the limits of hip rotation on
exam. MR images may be more accurate than scintigraphy in this region
and provide differential information for other causes of hip pain like
tendonitis, bone cysts, or avascular necrosis of the femoral head.168
Stage 1 or 2 injuries without a cortical crack are
treated with a modified rest protocol beginning with an initial period
of non-weight bearing until pain resolves. Stage 3 compression side
injuries, demonstrating a nondisplaced cortical crack, are still stable
and can be managed nonoperatively73,145 (Fig. 19-3).
Tension-sided stage 3 injuries, with a nondisplaced crack, can be
managed similarly with complete unloading and frequent clinical and
radiographic follow-up to document healing.50,73
However, because of the long-term functional consequences of a
displaced femoral neck fracture, some authors support stabilization
with cannulated screw fixation for this injury.61
Stage 4 injuries demonstrate widening of the cortical crack or even
frank displacement of the completed fracture. These injuries demand
operative stabilization. Nondisplaced complete fractures are stabilized
with multiple screws. Fluoroscopy-guided curettage of the tension side
fracture site has been advocated. In young people with displaced
fractures, emergent open reduction with internal fixation (ORIF) is
A recent series of displaced femoral neck stress fractures in military
recruits identified an association between delayed surgery and varus
malreduction and an increased risk of both avascular necrosis and poor
function.114 In older patients, consideration can be given to hip arthroplasty depending on the individual situation.
Femoral Shaft
In most athletes, femoral diaphyseal stress fractures occur proximally in the medial or posteromedial cortex87,93 (Fig. 19-1).


Vague activity-related anterior thigh pain is the typical complaint,
and vigorous stressing on physical exam can reproduce the pain.34 Some longitudinal stress fractures, parallel to the cortex, appear best in MR images.182 Other sites including the distal femoral supracondylar region are also susceptible to stress fractures.159
Femoral shaft lesions occur in sites of compressive stress, are stable,
and heal with modified rest protocols. Only catastrophic complete
failures require reamed intramedullary stabilization.

Coronal T1-weighted pelvis magnetic resonance image of a 50-year-old
female runner demonstrates a Grade 3 left compression-side femoral neck
stress fracture. The darker marrow signal represents edema.
Tibial stress fractures are the most commonly reported among the many lower extremity stress fractures.122
Other overuse injuries may simultaneously present or require
elimination from the differential diagnosis. Inflammation of the
aponeurotic tenoperiosteal origins of the tibialis posterior and soleus
muscles and of the fascial attachments to the posterior medial border
of the tibia produces pain previously termed shin splints and now
characterized as medial tibial stress syndrome.6,177
Pain from this inflammatory situation typically occurs along the medial
border of the tibia, improves after warm-up, and is worse in the
morning. Exertional compartment syndromes of the anterior or deep
posterior compartments present with muscle aching and subjective
tightness that increase shortly after exercise begins. No bony
tenderness usually accompanies this condition. Tibial stress fracture
pain is progressive, with a gradual onset exacerbated by exercise and
made worse with impact, ultimately occurring while simply walking, or
even at rest or at night. Tenderness is localized and bony.31
The majority of tibial stress fractures are
posteromedial compression injuries and occur usually in the proximal or
distal thirds.21,31 When a fracture has developed, a transverse orientation is typical (Fig. 19-2), but longitudinal stress fractures also are reported.102
These fractures respond well to cessation of the repetitive loading
activity, which almost always is distance running, along with complete
leg rest using crutches until the pain subsides.31
Some work suggests adjunctive treatment with a pneumatic brace may
facilitate earlier functional return to activity by accelerating the
initial time to pain-free walking, but other investigators have not
demonstrated a benefit.3,155,178,190 Pulsed ultrasound and capacitively coupled electrical stimulation treatments do not significantly reduce the healing time.9,156 Surgery is not required for this condition, but return to activity can take up to 3 months.150
The more unusual but significantly more vexing tibial
stress fracture appears in the middle third of the anterior cortex.
This tension-side injury results from repetitive stress of jumping or
leaping, as seen in basketball players and ballet dancers. Bone pain is
easily demonstrated, and palpable periosteal thickening may be present
if the process is chronic. These fractures frequently progress to
nonunion, and complete fractures are also reported.21,84 In chronic cases, a transverse, wedge-shaped defect in the anterior cortex, dubbed the dreaded black line, is often seen in conjunction with cortical hypertrophy150 (Fig. 19-4). Tissue obtained from these sites demonstrates limited healing potential, consistent with a pseudarthrosis.138,154
Initial conservative treatment requires prolonged modified rest, with or without cast or brace immobilization.180
However, even over 4 to 6 months, many of these fractures with chronic
changes and anterior fissures or cracks will remain symptomatic and
nonunited. Some authors have shown healing benefits from adjunctive
electrical stimulation or ultrasound in nonoperative protocols,11,26,153 while others demonstrate no benefits from these modalities.84 Transverse drilling of the nonunion sites reportedly stimulates healing and speeds time to return to activity.110,138,150
Reamed intramedullary nailing works well for recalcitrant cases and now
has some support as the initial treatment of choice for the anterior
cortical stress fracture nonunion.45,146,187 Following nail fixation, return to sport within 4 months is typical, although failure to unite and knee problems are reported.142,187
A small series touts anterior tension band plating for this lesion in
elite female athletes, with return to full activity at 10 weeks.23
Lateral radiograph of the left tibia of a collegiate track athlete
demonstrates anterior cortical hypertrophy and the dreaded black line
of an anterior tension-side stress fracture.
Medial Malleolus
Participants in repetitive running and jumping
activities are at risk for the development of medial malleolus stress
fractures characterized by bony tenderness and ankle effusion. The
typically vertically oriented fracture line originates at the junction
between the malleolus and plafond directly above the medial border of
the talus, which is postulated to be the cyclic force transmitter.21,167
For grade 1 and 2 injuries, impact avoidance in a cast or pneumatic
brace achieves return to function in 6 to 8 weeks. For grade 3 and 4
stress fractures, similar conservative measures are appropriate, but
healing may take 4 to 5 months. More aggressive intervention is also
supported depending on the injury chronicity and the demands of the
patient. Drilling


may enhance healing.139
Screw fixation for displaced fractures, nonunion, and chronic cases and
in elite performers allows early motion and may promote earlier return
to activity.21,31

Tarsal Navicular
Repetitive running and jumping activity places
sprinters, hurdlers, middle-distance runners, football players,
basketball players, ballet dancers, and other athletes at risk for
tarsal navicular stress fracture.36,122 The insidious onset of vague medial arch pain usually accompanies dorsal navicular tenderness to palpation.30
The stress fracture occurs in the sagittal plane in the relatively
avascular central third of the bone, originating at the proximal dorsal
articular surface and extending in a plantar distal direction.21,184 Plain radiography often fails to demonstrate the navicular stress fracture.106
Although bone scintigraphy is sensitive, CT or MR imaging provides
specific information regarding fracture completeness and orientation21 (Fig. 19-5).
Among patients with an early diagnosis, 6 weeks of non-weight-bearing cast immobilization yields high union rates.107,184
Conversely, less than 25% of patients treated with weight-bearing
immobilization heal, and the risk of delayed union and recurrence is
also much higher.40,59,65,107,115,137,184
Following the initial period of strict non-weight bearing, graduated
return to activity is pursued provided the physical exam reveals no
navicular tenderness.30 In cases of displaced fractures, delayed unions, and nonunions, surgical stabilization is undertaken.21
Regardless of chronicity, some authors recommend ORIF when imaging
confirms extension of the stress fracture into the body of the
navicular.161 Compression screw
fixation alone usually provides adequate stability. Often the dorsal
cortex is not visibly disrupted, so placing supplemental bone graft may
require more extensive dissection except in cases of complete,
displaced stress fractures or nonunions.65,115
Non-weight bearing after fixation is advised. Surgical and conservative
management leads to good results, but most patients note slight
long-term pain and functional loss even after return to activity.148
T1-weighted magnetic resonance image of the right ankle of a collegiate
basketball player shows a navicular stress fracture (arrow) originating
at the talonavicular joint surface.
Metatarsal stress fractures are common in distance runners and ballet dancers.30
The second metatarsal neck is the most likely site for stress fracture,
but all metatarsals are susceptible. Gradually worsening forefoot pain
exacerbated by running or dancing herald the diagnosis, especially when
accompanied by focal bony tenderness. For short-lived complaints,
initiation of modified rest without imaging studies usually leads to
symptom resolution. For uncertain diagnoses or chronic complaints,
imaging modalities provide clarification. A second metatarsal plantar
base stress fracture previously recognized only in female ballet
dancers appears to be secondary to the en pointe position and responds to rest and activity modification.82,136
This stress fracture site has now been reported in nondancer athletes,
and 50% of the patients in those small series required surgery for
Stress fracture of the proximal diaphysis of the fifth
metatarsal, common in basketball players, often are slow to heal, and
can demonstrate high recurrence rates.97,183
The problematic site is in the proximal 1.5 cm of the diaphysis, where
cortical hypertrophy commonly occurs in running and jumping athletes,
rendering the zone relatively avascular with a narrow medullary canal.54 Treatment choices are predicated on the stage of the lesion as described by Torg and colleagues.183,185
Patients with acute fractures often acknowledge a 2- to 3-week
prodromal history of activity-related lateral foot pain. These acute
injuries show clear fracture lines with no medullary sclerosis and
little or no cortical hypertrophy. Healing in most acute fractures
ensues with a 6- to 8-week course of non-weight-bearing cast
immobilization.1,48,185,195 Closed treatment with full weight bearing appears to predispose to nonunion and refracture.97
Surgical management of acute stress fractures, especially in athletes,
is recommended by some to avoid prolonged healing. Sliding bone graft
procedures53,86,194 and intramedullary compression screw fixation56,101 techniques usually result in satisfactory healing within 3 months.128
Patients with a history of previous injury and recurrent
symptoms will have radiographic evidence of delayed union or nonunion.
Delayed unions demonstrate a wider fracture completely through the
medial and lateral cortices with some medullary sclerosis (Fig. 19-6).
A very wide gap with periosteal new bone formation and complete
medullary sclerosis characterizes the appearance of established
nonunions.183,185 Delayed unions may heal with prolonged non-weight-bearing cast immobilization, but functional recovery often requires 6 months.185,195
Most active patients with delayed union and virtually all with an
established nonunion recover faster with surgical management. Torg185 advises sclerotic bone débridement and inlay bone


grafting. Others propose a sliding bone graft53 or compression screw fixation56,113,147 (Fig. 19-6). For those averse to surgery, electrical stimulation has been shown to be effective.90

FIGURE 19-6 Middle-aged recreational runner with several-month history of worsening activity-related lateral foot pain. A.
Intermediate delayed union fifth metatarsal stress fracture with a
complete fracture, some widening of the cortical gap, and moderate
medullary sclerosis. B. Radiographic
appearance 3 months following medullary drilling, bone grafting,
compression screw stabilization, and initial period of non-weight
Other Sites
Stress fractures are reported in most of the remaining
bones in the lower extremity. Rare patellar stress fractures, usually
transverse but occasionally longitudinal, respond to extension
immobilization for 4 weeks followed by progressive rehabilitation.31,121,181
Runners and jumpers are susceptible to this injury. Failure to improve
and acute displacement are indications for open management with tension
band stabilization.140 Fibular
stress fractures occur typically in runners 1 to 2 inches above the
ankle joint line, are much less common than tibial injuries, and
usually respond to modified rest protocols.110,129 Talar neck and body stress fractures are rare, but talar head stress lesions appear in military recruits.173
Nonoperative management produces healing with only mild residual
symptoms. Stress fractures of the lateral process of the talus are
encountered on occasion, and a 6-week period of non-weight-bearing
produces control of symptoms.30,110 Surgical stabilization or excision may be considered for recalcitrant or displaced cases.20,24
Calcaneal stress fractures typically occur transversely through the
tuberosity in soldiers, runners, ballet dancers, and jumpers.30,174Conservative
treatment measures are always sufficient. Similarly, a few reports of
cuboid and cuneiform stress fractures describe successful modified rest
treatment protocols.105,119
Some calcaneal stress fractures occur in isolation, but most calcaneal
and other tarsal stress fractures are associated with at least one
other foot stress injury best diagnosed by MR imaging.133,174
Upper Extremity
Stress fractures in non-weight-bearing bones result from
repetitive strains associated with recurrent loading activities like
rowing, swimming, and throwing. The possibility of stress fracture
should be considered in athletes primarily involved in upper extremity
sports who complain of the gradual onset bony pain associated with the
activity. Physical examination typically reveals bony tenderness to
palpation and stressing. Imaging modalities are useful for clarifying
the diagnosis. Modified rest and training technique corrections or
alterations almost always result in early healing and return to
Stress fractures of the ribs occur not uncommonly in
competitive rowers, typically anterolaterally between the fourth and
ninth ribs.59 Most humerus stress
fractures occur in baseball pitchers, although other reports detail
occurrence in athletes ranging from tennis players to weight lifters.37
All of these athletes can be managed with modified rest and gradual
resumption of activity. One report describes progression of humerus
stress fractures to spontaneous shaft fractures in men in a baseball
league.25 The risk factors for
complete fracture include age over 30 years, a prolonged layoff from
pitching before resumption of participation, no regular exercise
program, and prodromal arm pain.
In older adolescents and young adults involved in
throwing sports or gymnastics, the presentation of gradually increasing
elbow pain with activity mandates consideration of an olecranon stress
fracture.37 Some patients who
complain less of prodromal symptoms and more of acute elbow pain
related to a particularly strong throwing effort may have tip avulsion
fractures involving up to the proximal third of the olecranon. Surgical
excision of the fractured tip allows early return to sport.135
Patients with classical stress fractures complain of longer duration
pain that recurs when throwing resumes. These fractures are usually
transverse and in the middle third of the olecranon. Among baseball
players, the olecranon is the most common site for stress fracture.
Adolescent gymnasts can also develop this stress fracture.118 For nondisplaced fractures, immobilization and progressive return to activity are recommended. When displaced


or delayed in healing, tension band fixation is effective.118,135,191

Stress fractures of the ulna may occur in baseball and
softball pitchers, tennis players, weight-lifters, and volleyball
players. Repetitive strains from underhanded softball pitching and
twohanded tennis backhand strokes are representative of the typical
inciting stresses. The athletes complain of bony pain with activity and
even after the activity. Depending on the stage of injury, radiographs
may demonstrate periosteal bone formation or a small cortical fracture.
All reports document healing with modified rest for 4 to 6 weeks and
progressive resumption of activity.35,37
Stress injuries to the distal radial physis are common in young gymnasts,43
but radial shaft stress fractures in young adults are less common.
Bilateral radial shaft stress fractures have been seen in a gymnast who
doubled her weekly training time.2
Athletes in any sport who begin a high-stress weight program are at
risk for developing a radial stress reaction. The typical modified rest
protocol should be instituted for the radius. If weight training is the
inciting stress but the athlete’s primary sport does not repetitively
load the radius, continued participation in the sport usually presents
no additional risk.
Repetitive strains to the metacarpals, particularly the second and fifth, can lead to stress fracture.134
Patients describe a change in training volume and technique. Tennis
players may be susceptible at the second metacarpal because the racquet
provides a fulcrum.131 Rest from the
activity will yield healing and return to sport within 4 weeks,
provided technique errors and training overload are altered.
Stress fractures of the pubic rami occur not uncommonly
in female distance runners, most of whom have associated risk factors,
as well as female military recruits.89
When present, groin pain prevents further training, and single leg
stance reproduces the pain. Deep palpation of the bone in these
characteristically thin individuals typically elicits significant pain.
Plain films and bone scintigraphs are usually diagnostic. An 8- to
12-week modified training regimen allows graduated return to activity.134
Sacral stress fractures predominantly develop in female
distance runners but are also reported in their male counterparts.
Female military conscripts show dramatically increased risks for this
site.123 Most have prodromal low
back and buttock pain. Physical exam demonstrates localized tenderness
to palpation and stress of the sacroiliac region. SPECT scanning has
been the investigation of choice, but MR imaging now provides more
specificity. Implementation of initial protected weight bearing
followed by a progressive activity regimen reliably leads to uneventful
The author thanks Doug Beall, MD,
and Weyton Tam, MD, for providing the figures in this chapter, and
Sheila M. Algan, MD; W. Bentley Edmonds, MD; Don McGinnis, MD; and
Brock Schnebel, MD, for providing cases and sports medicine expertise.
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