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Stress Fractures: Diagnosis, Treatment, and Prevention DEEPAK S. PATEL, MD, Rush-Copley Family Medicine Residency, Aurora, Illinois MATT ROTH, MD, The Toledo Hospital Primary Care Sports Medicine Fellowship, Toledo, Ohio NEHA KAPIL, MD, Rush-Copley Family Medicine Residency, Aurora, Illinois

Stress fractures are common injuries in athletes and military recruits. These injuries occur more commonly in lower extremities than in upper extremities. Stress fractures should be considered in patients who present with tenderness or edema after a recent increase in activity or repeated activity with limited rest. The differential diagnosis varies based on location, but commonly includes tendinopathy, compartment syndrome, and nerve or artery entrapment syndrome. Medial tibial stress syndrome () can be distinguished from tibial stress fractures by diffuse tenderness along the length of the posteromedial tibial shaft and a lack of edema. When is suspected, plain should be obtained initially and, if negative, may be repeated after two to three weeks for greater accuracy. If an urgent diagnosis is needed, triple-phase scintigraphy or magnetic resonance imaging should be considered. Both modalities have a similar sensitivity, but magnetic resonance imaging has greater specificity. Treatment of stress frac- tures consists of activity modification, including the use of nonweight- bearing crutches if needed for pain relief. Analgesics are appropriate to relieve pain, and pneumatic bracing can be used to facilitate healing. After the pain is resolved and the examination shows improvement, patients may gradually increase their level of activity. Surgical consul- tation may be appropriate for patients with stress fractures in high-risk locations, , or recurrent stress fractures. Prevention of stress fractures has been studied in military personnel, but more research is needed in other populations. (Am Fam Physician. 2011;83(1):39-46.

Copyright © 2011 American Academy of Family Physicians.) ILLUSTRATION DAVID BY KLEMM ▲ Patient information: tress fractures are common injuries who participate in sports involving throwing A handout on stress that begin with repetitive and exces- or other overhead motions.5 fractures, written by the authors of this article, is sive stress on the bone. This Persons who participate in repetitive, provided on page 47. to the acceleration of normal bone high-intensity training, such as athletes and S remodeling, the production of microfrac- military recruits, are at increased risk of tures (caused by insufficient time for the developing stress fractures.3-6 Recreational bone to repair), the creation of a bone stress runners who average more than 25 miles injury (i.e., stress reaction), and, eventually, per week are at increased risk of stress frac- a stress fracture.1,2 In contrast, pathological tures,4,7 as well as athletes who participate in (insufficiency) fractures occur under nor- track and field, basketball, soccer, or dance mal stress in bone weakened by a tumor, (Table 12-9).3,5 Women are at higher risk of infection, or osteoporosis.1,2 stress fracture than men,4 especially women The most common locations for stress frac- in the military,2 although there are conflict- tures are the (23.6 percent), tarsal navic- ing data among athletes.3,5 ular (17.6 percent), metatarsal (16.2 percent), Poor and lifestyle habits may fibula (15.5 percent), (6.6 percent), increase the risk of stress fracture. One (1.6 percent), and spine (0.6 percent).3,4 study found lower 25-hydroxyvitamin D Although less common, upper extrem- levels in Finnish male military recruits ity stress fractures can occur in persons with stress fractures.8 Women with the

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Evidence Clinical recommendations rating References Comments

Plain radiography should be the initial imaging modality to diagnose C 15 Consensus opinion stress fractures. Magnetic resonance imaging is preferred over bone scintigraphy for C 15 Consensus opinion the diagnosis of stress fractures because of greater specificity. Patients with tibial stress fracture may use a pneumatic compression A 20 Cochrane review device to reduce the time to resumption of full activity. Bone stimulators should not be used for the treatment of most stress B 24, 25 Good-quality randomized fractures. controlled trial Shock-absorbing orthotics and footwear modification may reduce B 20 Cochrane review lacking the occurrence of lower extremity stress injury. firm recommendation

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease- oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp. org/afpsort.xml.

female athlete triad (i.e., eating disorders, with limited rest.5-7,10 Pain is a common functional hypothalamic , and presenting symptom that can vary by loca- osteoporosis) are at higher risk of stress tion, such as knee pain with a proximal tibial fracture.9 A study of female military recruits injury, pain with a injury, demonstrated an increased risk of stress or groin pain with a .2,7 Spe- fracture with a history of smoking, exer- cifically, pain with ambulation is common cising less than three times per week, and (81 percent).10 On examination, patients usu- consuming more than 10 alcoholic drinks ally demonstrate focal tenderness (65.9 to per week before the start of basic training.6 100 percent) and edema (18 to 44 percent) at Additionally, 16.2 percent of white recruits the site of injury.4,10,11 who smoked and did not developed Although the hop test (i.e., single leg hop- a stress fracture.6 ping that produces severe localized pain) is often used and cited in texts as a diagnostic Diagnosis test for lower extremity fractures, no recent Stress fracture should be suspected in per- literature was found to validate its accuracy. sons with a drastic recent increase in physi- In some studies, a positive hop test was an cal activity or repeated excessive activity inclusion criterion4 or a common finding (70 to 100 percent 7,11) in patients with pre- sumed stress fractures, but was also noted Table 1. Risk Factors for Stress in nearly one-half (45.6 percent) of patients Fracture with suspected medial tibial stress syn- drome (shin splints).12 Another diagnostic Consuming more than 10 alcoholic drinks measure used often, but with little support- per week ing evidence, is the tuning fork test (i.e., Excessive physical activity with limited rest applying a tuning fork to the fracture site to periods produce focal pain). One small study found Female athlete triad (eating disorders, that the tuning fork test had a sensitivity amenorrhea, osteoporosis) of 75 percent, a specificity of 67 percent, a Female sex positive predictive value of 77 percent, and Low levels of 25-hydroxyvitamin D a negative predictive value of 63 percent for Recreational running (more than 25 miles 13 per week) tibial stress fractures. Smoking Diagnosing stress fractures can be chal- Sudden increase in physical activity lenging and warrants consideration of the Track (running sports) differential diagnosis, based on location (Table 23,6,7,14). The differential diagnosis Information from references 2 through 9. may include tendinopathy, compartment syndrome, and nerve or artery entrapment

40 American Family Physician www.aafp.org/afp Volume 83, Number 1 ◆ January 1, 2011 Stress Fractures Table 2. Risk Factors, , and Differential Diagnosis of Common Stress Fractures

Differential Fracture type Risk factors Signs and symptoms diagnosis Comments

Tibial Running, , Shin pain, focal tenderness Medial tibial stress Shin splints may cause pain along jumping, dancing, over anterior aspect of syndrome (shin the posteromedial border of the female athlete tibia, edema splints) distal tibia; no abnormalities will triad appear on radiography

Metatarsal Running, walking, Foot or ankle pain, focal Plantar fasciitis, Plantar fasciitis may cause pain or dancing, marching tenderness, swelling metatarsalgia, tenderness along the fascia Morton neuroma Metatarsalgia may cause tenderness on metatarsal heads Morton neuroma may cause pain (with compression) between the third and fourth metatarsals

Femoral or Running, walking, Groin pain, pain with Pathologic Urgent imaging is needed to identify sacral female athlete activity, pain with passive fracture, rectus underlying pathology triad, cycling hip range of movement femoris strain Localized tenderness and swelling (with sacral fracture only)

Spondylolysis Soccer, gymnastics, Tenderness, extension- Lumbar sprain, Most commonly associated with volleyball, related pain during pathologic L4 and L5 vertebrae; confirm dancing, football, “stork” test (single-leg fracture diagnosis with scintigraphy with weightlifting hyperextension/rotation) single-photon emission computed tomography14

Information from references 3, 6, 7, and 14.

Table 3. Imaging Modalities for Stress Fractures

Test Advantages Disadvantages

Plain radiography 4,11,15 Low cost, little radiation, wide availability Limited differential detail, poor initial sensitivity

Bone Low cost, high sensitivity Some radiation exposure, limited differential detail, may scinitigraphy10-12,16 be falsely positive if focal infection or tumor is present

Magnetic resonance Best differential detail, no radiation, equal or Highest cost imaging10,11,15,16 slightly better sensitivity than scintigraphy and higher specificity

Ultrasonography17 No radiation, low cost Limited availability, little differential detail, limited data on use in diagnosing stress fractures

Information from references 4, 10 through 12, and 15 through 17. syndrome. Medial tibial stress syndrome Imaging is a common condition that can be distin- Plain radiography should be the first imaging guished from tibial stress fractures by nonfo- modality considered because of its availabil- cal tenderness (diffuse along the mid-distal, ity and low cost (Table 3 4,10-12,15-17; Figure 1).15 posteromedial tibia) and a lack of edema.12 Plain radiography is usually negative initially The differential diagnosis may also include but is more likely to become positive over a variety of malignancies, such as osteosar- time (e.g., initial sensitivity of 10 percent4; coma and Ewing sarcoma.1 sensitivity of 30 to 70 percent after three

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Diagnosis and Treatment of Stress Fractures Pain with activity, recent increase in training, edema, or bone tenderness

Plain radiography

Positive Negative

Urgent diagnosis required?

No Yes

Avoid stress, repeat radiography in two to three weeks

Positive Negative

Clinical suspicion persists?

No Yes

Stress fracture likely ruled MRI or bone scintigraphy out; proceed with treatment

Positive Negative

High-risk fracture? Reconsider differential Figure 2. Radiography after two weeks of diagnosis distal fibular pain, edema, and tenderness. No Yes Note the sclerosis and periosteal/endosteal changes in the fibula. Treatment (Table 4): rest (stress avoidance), Consider referral to orthopedist activity modification, analgesics or sports medicine subspecialist Although computed tomography (CT) is regularly used for evaluation of bone pathol- Figure 1. Algorithm for the diagnosis and treatment of stress frac- tures. (MRI = magnetic resonance imaging.) ogy, its value is limited because of lower sensitivity and higher radiation exposure weeks11). If the initial radiography is negative than other imaging modalities.16 Thin-slice and an urgent diagnosis is not needed, repeat (16-detector) multisection CT has shown radiography may be performed after two to promise, but remains inferior to other three weeks. One algorithm used in the mili- modalities, such as scintigraphy and mag- tary advocates radiography two weeks after netic resonance imaging (MRI).18 the onset of symptoms (if symptoms persist), Triple-phase bone scintigraphy (Figure 3) with repeat radiography the following week was previously the confirmation test for stress before performing more advanced imaging.6 fracture in most studies3-5,7,10 because of its high With plain radiography, a faint lucency may sensitivity (74 to 100 percent10,16). With scin- be seen at first, although stress fractures are tigraphy, nonfocal radionuclide accumulation usually identified by subsequent indirect is less likely to be caused by stress fracture 11; findings: periosteal thickening or sclerosis, uptake that is spread diffusely along the tibia is cortical changes with initial decreased den- more consistent with medial tibial stress syn- sity (“gray cortex”), and, more commonly, drome.10,12 Scintigraphy may be falsely positive later callus formation, or endosteal thicken- in other cases of increased bone activity, such ing and sclerosis 5,11 (Figure 2). as focal infection and tumors.1 Scintigraphy

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Figure 3. Bone scintigram corresponding to the radiography in Figure 2. Confirms focal uptake in the right fibula con- sistent with a stress fracture. with single-photon emission CT is preferred for detection of early stress injury, although over MRI in patients with spondylolysis.14 both MRI and bone scintigraphy identified Despite limitations of cost and availability, the actual stress fractures. However, MRI MRI has replaced scintigraphy as the confir- may also identify reactive bone remodel- mation test used in most studies.10,11,16 MRI ing (interpreted as early stress injuries) and, has a sensitivity equal to or slightly better therefore, should be clinically correlated than scintigraphy, but with higher speci- for stress fracture.12,19 In a study of asymp- ficity (Table 3 4,10-12,15-17).10,11 For this reason, tomatic collegiate runners, 43 percent were an expert panel of the American College found to have stress injury on MRI.19 None of says that MRI may be consid- of the stress injuries progressed to stress frac- ered next when plain radiography is nega- tures, and all were resolved at the one-year tive.15 Because MRI provides greater detail follow-up.19 Another study of shin splints of surrounding tissue (Figure 4), it may be demonstrated similar bone stress changes on advantageous for evaluating the differential MRI, including 80 percent of diagnosis.15 One prospective study compared control patients.12 MRI, CT, and bone scintigraphy for evalua- Although musculoskeletal ultrasonogra- tion of early tibial bone stress injuries based phy is becoming more widely available, lim- on the premise that early detection could ited data exist for its use in diagnosing stress prevent stress fractures.16 MRI was superior fractures. One small prospective pilot study

A B

Figure 4. Magnetic resonance imaging. (A) Proximal tibial stress fracture (arrow). (B) Sagittal view of same fracture (arrow).

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found that ultrasonography had a sensitivity patients are pain free, they may increase of 83.3 percent, a specificity of 75.0 percent, a activity in a slow, graduated manner.4 positive predictive value of 58.8 percent, and Analgesics, such as acetaminophen and a negative predictive value of 91.7 percent for nonsteroidal anti-inflammatory drugs, may metatarsal stress fractures.17 The potential be considered for pain control. However, advantages of ultrasonography include low anti-inflammatories should be used with cost and no radiation exposure, but addi- caution, because some animal studies have tional studies are needed. shown that they may inhibit healing in sub- jects with traumatic fractures.23 Treatment Patients may require limited or full Depending on the injury, healing time for nonweight-bearing crutches to reduce pain. stress fractures can vary from four to 12 A Cochrane review pooling data from three weeks or longer from the time activity is small studies suggested that patients with restricted.4,5 Initial treatment should include tibial stress fracture who used a pneumatic reducing activity to the level of pain-free brace (e.g., a stirrup leg brace) showed a sig- functioning. Treatment should begin as nificant reduction in time to recommenc- soon as the injury is suspected, because ing full activity; however, more evidence delayed treatment has been correlated with is needed for confirmation.20 Pneumatic prolonged return to activity.5 Table 4 sum- compression walking boots may be used marizes general preventive measures and to reduce pain from lower extremity stress treatment options for stress fractures.4,20-23 fractures. and cross train- The patient can be examined every two to ing with non-aggravating activities may help three weeks to ensure pain-free functioning, maintain flexibility and strength, and car- monitor changes in symptoms, and evaluate diovascular fitness, respectively, during the improvement in provocative testing. When rest period.4 Bone stimulation via electrical or ultra- sonic impulses has been an area of growing Table 4. Summary of General Preventive interest, but evidence is currently lacking. A and Treatment Measures for Stress Fractures single randomized controlled trial (RCT) of 26 patients demonstrated no effect from low- Prevention intensity ultrasonic impulses in reducing Address modifiable risk factors (Table 1) healing time.24 Similarly, a single RCT of 50 Modify activity level or training patterns, and ensure adequate rest20 patients found no benefit from electrical field Consider daily supplementation of (2,000 mg) and stimulation in tibial stress fracture clinical (800 IU)21 healing.25 However, there is some evidence Address abnormal biomechanics if needed, and consider shock-absorbing for the use of stimulation in nonhealing 20 shoe inserts traumatic fractures, and it may also be con- Treatment sidered for recalcitrant stress fractures.26 Reduce activity to the level of pain-free functioning22 Certain stress fractures may to com- Consider acetaminophen, which may be favored over nonsteroidal anti- plications, including progression to complete inflammatory drugs23 fractures, development of , Stretch and strengthen supporting structures in rehabilitative program4 or delays in healing or nonunion. Examples Increase activity in graduated fashion after several weeks of rest and of these high-risk stress fractures include improved symptoms the superolateral femoral neck, patella, ante- Use pneumatic compression device (e.g., a stirrup leg brace, compression rior tibia, medial malleolus, talus, tarsal walking boots) or other biomechanical stress-relieving measures 22 (e.g., crutches) for lower-extremity stress fractures20 navicular, and the fifth metatarsal. High- Encourage cross training to maintain cardiovascular fitness4 risk stress fractures may warrant consulta- Consider for patients with recalcitrant or high-risk stress fractures22 tion with an orthopedist or sports medicine subspecialist. Information from references 4, and 20 through 23. In special circumstances, such as in com- petitive athletes during their sport’s season,

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patients may choose to modify their activity to Additionally, concerns with a decreased level of intensity (tolerable without include the potential for abnormal long- exacerbation), and delay complete rest until term bone deposition (especially in young the season is finished.22 In these situations, persons), potential teratogenic effects (U.S. athletes should be aware of the potential for and Drug Administration pregnancy prolonged recovery or the need for additional category C or D), and lack of approval for interventions, including surgery. this indication from the U.S. Food and Drug Administration.29 Prevention Data Sources: A PubMed search was completed in Clini- Although various methods have been pro- cal Queries using the following key terms: stress fracture, posed to prevent stress fractures (Table 4 4,20-23), MRI sensitivity of stress fracture, medial tibial stress, x-ray few have been validated in studies of appro- sensitivity stress fracture, hop test stress fracture, tuning fork test, fulcrum test, spondylolysis, dreaded black line, priate magnitude to justify definitive recom- and stress fracture treatment. The search included meta- mendations. Many preventive studies are analyses, randomized controlled trials, clinical trials, and conducted in military basic training, and their reviews. Also searched were the Agency for Healthcare usefulness in other populations is unknown. Research and Quality evidence reports, Bandolier, Clinical Evidence, the Cochrane database, Database of Abstracts Modification of training schedules may of Reviews of Effects, the Institute for Clinical Systems reduce the incidence of stress fractures, but Improvement, the National Guideline Clearinghouse data- specific training regimens may need indi- base, and the Trip database. Search date: March 1, 2010, vidualization.20 Two cluster randomized tri- with repeat searches in July 2010. als found that leg muscle stretching during warm-up before exercise had no significant The Authors effect on preventing stress fractures.20 DEEPAK S. PATEL, MD, FAAFP, is director of sports medi- Orthotics, such as shock-absorbing shoe cine at Rush-Copley Family Medicine Residency, in Aurora, inserts, were shown to be effective in reduc- Ill., and assistant professor at Rush Medical College in Chicago, Ill. He also practices family medicine and sports ing the occurrence of lower extremity stress medicine at Yorkville (Ill.) Primary Care. injury in military recruits.20 MATT ROTH, MD, is associate director of Sports Care at The Calcium and vitamin D metabolism and Toledo (Ohio) Hospital Primary Care Sports Medicine Fel- supplementation may play a role in the pre- lowship. He also practices family medicine and sports medi- vention of stress fracture, but the data are cine at Arrowhead Family Physicians in Maumee, Ohio. controversial. The intention-to-treat analy- NEHA KAPIL, MD, is a family medicine resident at Rush- sis of a double-blind RCT found a 20 percent Copley Family Medicine Residency in Aurora. lower incidence of stress fractures com- Address correspondence to Deepak Patel, MD, FAAFP, pared with placebo (5.3 versus 6.6 percent; Rush-Copley Family Medicine Residency, 2020 Ogden P = .0026) in female recruits who took a Ave., Ste. 325, Aurora, IL 60504 (e-mail: Deepak_S_Patel daily (2,000 mg) and @rsh.net). Reprint are not available from the authors. vitamin D supplement (800 IU).21 How- Author disclosure: Nothing to disclose. ever, after further analysis, the study lacked statistical significance in participants who REFERENCES completed the study per protocol (adjusted 1. Fayad LM, Kamel IR, Kawamoto S, Bluemke DA, Fras- odds ratio = 0.789; 95% confidence interval, sica FJ, Fishman EK. Distinguishing stress fractures from 21,27 pathologic fractures: a multimodality approach. Skel- 0.616 to 1.01; P = .0589). etal Radiol. 2005;34(5):245-259. Bisphosphonates have been proposed for 2. Niva MH, Mattila VM, Kiuru MJ, Pihlajamäki HK. Bone the prevention of stress fractures. However, stress injuries are common in female military train- an RCT in military recruits showed that ees: a preliminary study. Clin Orthop Relat Res. 2009; 467(11):2962-2969. prophylactic treatment with risedronate 3. Brukner P, Bradshaw C, Khan KM, White S, Crossley K. (Actonel; 30 mg daily for 10 days, followed by Stress fractures: a review of 180 cases. Clin J Sport Med. 30 mg weekly for the next 12 weeks) was not 1996;6(2):85-89. effective in reducing total stress fracture inci- 4. Matheson GO, Clement DB, McKenzie DC, Taunton JE, Lloyd-Smith DR, MacIntyre JG. Stress fractures in ath- dence, delaying the time to onset, or decreas- letes. A study of 320 cases. Am J Sports Med. 1987; ing the severity of stress fractures incurred.28 15(1):46-58.

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