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Stress Fractures: Diagnosis, Treatment, and Prevention DEEPAK S 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 (shin splints) can be distinguished from tibial stress fractures by diffuse tenderness along the length of the posteromedial tibial shaft and a lack of edema. When stress fracture is suspected, plain radiography 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 bone 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, nonunion, 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 BY DAVID 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 leads 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 tibia (23.6 percent), tarsal navic- ing data among female athletes.3,5 ular (17.6 percent), metatarsal (16.2 percent), Poor nutrition and lifestyle habits may fibula (15.5 percent), femur (6.6 percent), increase the risk of stress fracture. One pelvis (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 Downloaded from the American Family Physician Web site at www.aafp.org/afp. Copyright © 2010 American Academy of Family Physicians. For the private, noncommer- January cial1, 2011use of ◆one Volume individual 83, user Number of the Web 1 site. All other rights reserved.www.aafp.org/afp Contact [email protected] for copyright questionsAmerican and/or permission Family requests. Physician 39 Stress Fractures SORT: KEY RECOMMENDATIONS FOR PRACTICE 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 amenorrhea, 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, hip pain with a femoral neck injury, demonstrated an increased risk of stress or groin pain with a pelvic fracture.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 exercise 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, Signs and Symptoms, and Differential Diagnosis of Common Stress Fractures Differential Fracture type Risk factors Signs and symptoms diagnosis Comments Tibial Running, walking, 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
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