Stress fractures: definition, diagnosis and treatment Work performed at the Sports Traumatology Center, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, SP, Brazil.

ABSTRACT

Stress fractures were first described in Prussian soldiers by Breithaupt in 1855. They occur as the result of repeatedly making the same movement in a specific region, which can lead to fatigue and imbalance between osteoblast and osteoclast activity, thus favoring bone breakage. In addition, when a particular region of the body is used in the wrong way, a stress fracture can occur even without the occurrence of an excessive number of functional cycles. The objective of this study was to review the most relevant literature of recent years in order to add key information regarding this pathological condition, as an updating article on this topic.

Keywords:
Stress fracture/epidemiology; Stress fracture/physiopathology; Stress fracture/diagnosis; Stress fracture/classification; Stress fracture/treatment

RESUMO

A fratura por estresse foi descrita inicialmente em soldados prussianos por Breithaupt em 1855 e ocorre como o resultado de um número repetitivo de movimentos em determinada região que pode levar a fadiga e desbalanço da atuação dos osteoblastos e osteoclastos e favorecer a ruptura óssea. Além disso, quando usamos uma determinada região do corpo de maneira errônea, a fratura por estresse pode ocorrer mesmo sem que ocorra um número excessivo de ciclos funcionais. O objetivo deste estudo é revisar a literatura mais relevante dos últimos anos para agregar as principais informações a respeito dessa patologia em um artigo de atualização do tema.

Palavras chave:
Fraturas por estresse/epidemiologia; Fraturas por estresse/fisiopatologia; Fraturas por estresse/diagnóstico; Fraturas por estresse/classificação; Fraturas por estresse/tratamento

Introduction

Stress fractures were first described in Prussian soldiers by Breithaupt in 1855.11. Breithaupt MD. Zur pathologie des menschlichen fusses. To the pathology of the human foot. Med Zeitung. 1855;24:169.,22. Devas MB. Stress fractures of the tibia in athletes of 'shin soreness. J Bone Joint Surg Br. 1958;40(2):227-39.and33. Schneiders AG, Sullivan SJ, Hendrick PA, Hones BDGM, Mcmaster AR, Sugden BA, et al. The ability of clinical tests to diagnose stress fractures: a systematic review and meta- analysis. J Orthop Sports Phys Ther. 2012;42(9):760-71. They were named "march fractures" and their characteristics were confirmed 40 years later with the advent of radiography.11. Breithaupt MD. Zur pathologie des menschlichen fusses. To the pathology of the human foot. Med Zeitung. 1855;24:169.and22. Devas MB. Stress fractures of the tibia in athletes of 'shin soreness. J Bone Joint Surg Br. 1958;40(2):227-39. In 1958, Devas made the first report on stress fractures in athletes.11. Breithaupt MD. Zur pathologie des menschlichen fusses. To the pathology of the human foot. Med Zeitung. 1855;24:169.,22. Devas MB. Stress fractures of the tibia in athletes of 'shin soreness. J Bone Joint Surg Br. 1958;40(2):227-39.and33. Schneiders AG, Sullivan SJ, Hendrick PA, Hones BDGM, Mcmaster AR, Sugden BA, et al. The ability of clinical tests to diagnose stress fractures: a systematic review and meta- analysis. J Orthop Sports Phys Ther. 2012;42(9):760-71.

This injury occurs as a result of high numbers of occurrences of cyclical overloading of intensity lower than the maximum bone strength, on non-pathological bone tissue.44. Fayad LM, Kamel IR, Kawamoto S, Bluemke DA, Frassica FJ, Fishman EK. Distinguishing stress fractures from pathologic fractures: a multimodality approach. Skelet Radiol. 2005;34(5):245-59.,55. Niva MH, Mattila VM, Kiuru MJ, Pihlajamäki HK. Bone stress injuries are common in female military trainees: a preliminary study. Clin Orthop Relat Res. 2009;467(11):2962-9.and66. Carmont RC, Mei-Dan O, Bennell LK. Stress fracture management: current classification and new healing modalities. Oper Tech Sports Med. 2009;17:81-9.

These fractures may be the final stage of fatigue or insufficiency of the bone affected.66. Carmont RC, Mei-Dan O, Bennell LK. Stress fracture management: current classification and new healing modalities. Oper Tech Sports Med. 2009;17:81-9. Fatigue fractures occur after formation and accumulation of microfractures in normal bone trabeculae. On the other hand, fractures resulting from bone insufficiency occur in bone that is mechanically compromised and generally presents low bone mineral density.66. Carmont RC, Mei-Dan O, Bennell LK. Stress fracture management: current classification and new healing modalities. Oper Tech Sports Med. 2009;17:81-9. In both situations, imbalance between the bone that is formed and remodeled and the bone that it reabsorbed will result in discontinuity of the bone at the site affected.77. Patel DS, Roth M, Kapil N. Stress fractures: diagnosis, treatment, and prevention. Am Fam Physician. 2011;83(1):39-46.and88. Evans RK, Antczak AJ, Lester M, Yanovich R, Israeli E, Moran DS. Effects of a 4-month recruit training program on markers of bone metabolism. Med Sci Sports Exerc. 2008;40 11 Suppl.:S660-70. The aim here was to present an updating article on this topic and condense the main information obtained through the most important studies published over the last few years.

Epidemiology

Population

Runners, soldiers and dancers are the main victims of stress fractures.66. Carmont RC, Mei-Dan O, Bennell LK. Stress fracture management: current classification and new healing modalities. Oper Tech Sports Med. 2009;17:81-9.,99. Cosman F, Ruffing J, Zion M, Uhorchak J, Ralston S, Tendy S, et al. Determinants of stress fractures risk in United States Military Academy cadets. Bone. 2013;55(2):359-66.and1010. Bennell KL, Malcolm SA, Thomas SA, Wark JD, Brukner PD. The incidence and distribution of stress fractures in competitive track and field athletes. A twelve-month prospective study. Am J Sports Med. 1996;24(2):211-7.

Anatomical region

All the bones of the human body are subject to fracturing caused by stress. This stress is closely related to the daily practice that athletes undertake. The predominance of stress fractures in the lower limbs, over fractures in the upper limbs, reflects the cyclical overloading that is typically exerted on bones that bear the body weight, in comparison with bones that do not have this function.33. Schneiders AG, Sullivan SJ, Hendrick PA, Hones BDGM, Mcmaster AR, Sugden BA, et al. The ability of clinical tests to diagnose stress fractures: a systematic review and meta- analysis. J Orthop Sports Phys Ther. 2012;42(9):760-71.Stress fractures are mostly commonly diagnosed in the tibia, followed by the metatarsals (especially the second and third metatarsals) and by the fibula.33. Schneiders AG, Sullivan SJ, Hendrick PA, Hones BDGM, Mcmaster AR, Sugden BA, et al. The ability of clinical tests to diagnose stress fractures: a systematic review and meta- analysis. J Orthop Sports Phys Ther. 2012;42(9):760-71.and1111. Royer M, Thomas T, Cesini J, Legrand E. Stress fractures in 2011: practical approach. Joint Bone Spine. 2012;79 Suppl. 2:S86-90. Stress fractures in the axial skeleton are infrequent and are mainly located in the ribs, pars interarticularis, lumbar vertebrae and pelvis.1111. Royer M, Thomas T, Cesini J, Legrand E. Stress fractures in 2011: practical approach. Joint Bone Spine. 2012;79 Suppl. 2:S86-90.,1212. Snyder RA, Koester MC, Dunn WR. Epidemiology of stress fractures. Clin Sports Med. 2006;25(1):37-52.and1313. Iwamoto J, Takeda T. Stress fractures in athletes: review of 196 cases. J Orthop Sci. 2003;8(3):273-8.

Types of sport

Runners present greatest incidence of stress fractures in long bones such as the tibia, femur and fibula, and also present fractures in the bones of the feet and sacrum.1111. Royer M, Thomas T, Cesini J, Legrand E. Stress fractures in 2011: practical approach. Joint Bone Spine. 2012;79 Suppl. 2:S86-90.and1212. Snyder RA, Koester MC, Dunn WR. Epidemiology of stress fractures. Clin Sports Med. 2006;25(1):37-52. Types of sport in which the upper limbs are used, such as Olympic gymnastics,1414. Daffner RH, Pavlov H. Stress fractures: current concepts. Am J Roentgenol. 1992;159(2):245-52.tennis, baseball and basketball may result in fractures due to stress. The bone most affected is the ulna, especially in its proximal portion, while the distal extremity of the humerus is also affected.66. Carmont RC, Mei-Dan O, Bennell LK. Stress fracture management: current classification and new healing modalities. Oper Tech Sports Med. 2009;17:81-9.,1111. Royer M, Thomas T, Cesini J, Legrand E. Stress fractures in 2011: practical approach. Joint Bone Spine. 2012;79 Suppl. 2:S86-90.and1313. Iwamoto J, Takeda T. Stress fractures in athletes: review of 196 cases. J Orthop Sci. 2003;8(3):273-8. Stress fractures occur mainly in the ribs in golfers and rowers1111. Royer M, Thomas T, Cesini J, Legrand E. Stress fractures in 2011: practical approach. Joint Bone Spine. 2012;79 Suppl. 2:S86-90.and1313. Iwamoto J, Takeda T. Stress fractures in athletes: review of 196 cases. J Orthop Sci. 2003;8(3):273-8. Jumpers, bowlers and dancers present greatest risk of injury to the lumbar spine and pelvis.1111. Royer M, Thomas T, Cesini J, Legrand E. Stress fractures in 2011: practical approach. Joint Bone Spine. 2012;79 Suppl. 2:S86-90.

Sex

Among athletes, the difference in the incidence of stress fractures between men and women is minimal. It is believed that the intensity and type of controlled training for each athlete and the physical preparation that already exists diminish the impact of the training program.99. Cosman F, Ruffing J, Zion M, Uhorchak J, Ralston S, Tendy S, et al. Determinants of stress fractures risk in United States Military Academy cadets. Bone. 2013;55(2):359-66.and1515. Johnson AW, Weiss CB Jr, Wheeler DL. Stress fractures of the femoral shaft in athletes - more common than expected: a new clinical test. Am J Sports Med. 1994;22(2):248-56.In the military population, the incidence of stress fractures among females is greater than among men.1616. Jones BH, Bovee MW, Harris JM, Cowan DN. Intrinsic risk factors for exercise- related injuries among male and female army trainees. Am J Sports Med. 1993;21(5):705-10.and1717. Pester S, Smith PC. Stress fractures in the lower extremities of soldiers in basic training. Orthop Rev. 1992;21(03): 297-303.

Physiopathology

Six to eight weeks after a sudden and non-gradual increase in the intensity of an athlete's or new patient's physical activity, this cyclical and repetitive physiological overloading may lead to the appearance of microfractures and may not allow the bone tissue to have sufficient time to undergo remodeling and adapt to the new condition, and thus to repair the microlesion.44. Fayad LM, Kamel IR, Kawamoto S, Bluemke DA, Frassica FJ, Fishman EK. Distinguishing stress fractures from pathologic fractures: a multimodality approach. Skelet Radiol. 2005;34(5):245-59.,55. Niva MH, Mattila VM, Kiuru MJ, Pihlajamäki HK. Bone stress injuries are common in female military trainees: a preliminary study. Clin Orthop Relat Res. 2009;467(11):2962-9.,66. Carmont RC, Mei-Dan O, Bennell LK. Stress fracture management: current classification and new healing modalities. Oper Tech Sports Med. 2009;17:81-9.,1010. Bennell KL, Malcolm SA, Thomas SA, Wark JD, Brukner PD. The incidence and distribution of stress fractures in competitive track and field athletes. A twelve-month prospective study. Am J Sports Med. 1996;24(2):211-7.,1818. Bolin D, Kemper A, Brolinson G. Current concepts in the evaluation and management of stress fractures. Curr Rep Sport Med. 2005;4(6):295-300.and1919. Mori S, Burr DB. Increasing intracortical remodelling following fatigue damage. Bone. 1993;14(2):103-9. The load applied is considered to be insufficient to cause an acute fracture, but the combination of overloading, repetitive movements and inadequate recovery time make this a chronic injury.1111. Royer M, Thomas T, Cesini J, Legrand E. Stress fractures in 2011: practical approach. Joint Bone Spine. 2012;79 Suppl. 2:S86-90. Elastic deformation occurs initially, and this progresses to plastic deformity until it finally results in microfracturing. If this is not treated, it will evolve to complete fracturing of the bone affected.1010. Bennell KL, Malcolm SA, Thomas SA, Wark JD, Brukner PD. The incidence and distribution of stress fractures in competitive track and field athletes. A twelve-month prospective study. Am J Sports Med. 1996;24(2):211-7. The bone repair process in stress fractures differs from the process in cases of common acute fractures and only takes place through bone remodeling, i.e.reabsorption of the injured cells and replacement with new bone tissue take place. 1919. Mori S, Burr DB. Increasing intracortical remodelling following fatigue damage. Bone. 1993;14(2):103-9.

Markey also proposed that the muscle mass acts toward dispersing and sharing impact loads on the bone tissue.2020. Raasch WG, Hergan DJ. Treatment of stress fractures: the fundamentals. Clin Sports Med. 2006;25(1):29-36.Therefore, when fatigue, weakness or muscle unpreparedness occur, this protective action is lost and the risk of bone tissue lesions increases.1616. Jones BH, Bovee MW, Harris JM, Cowan DN. Intrinsic risk factors for exercise- related injuries among male and female army trainees. Am J Sports Med. 1993;21(5):705-10.and2020. Raasch WG, Hergan DJ. Treatment of stress fractures: the fundamentals. Clin Sports Med. 2006;25(1):29-36.

Risk factors

The factors associated with increased risk of development of stress fractures can be divided into extrinsic and intrinsic factors. This makes stress fractures multifactorial and difficult to control.88. Evans RK, Antczak AJ, Lester M, Yanovich R, Israeli E, Moran DS. Effects of a 4-month recruit training program on markers of bone metabolism. Med Sci Sports Exerc. 2008;40 11 Suppl.:S660-70.,99. Cosman F, Ruffing J, Zion M, Uhorchak J, Ralston S, Tendy S, et al. Determinants of stress fractures risk in United States Military Academy cadets. Bone. 2013;55(2):359-66.,2020. Raasch WG, Hergan DJ. Treatment of stress fractures: the fundamentals. Clin Sports Med. 2006;25(1):29-36.,2121. Korpelainen R, Orava S, Karpakka J, Siira P, Hulkko A. Risk factors for recurrent stress fracture in athletes. Am J Sports Med. 2001;29(3):304-10.,2222. Joy EA, Campbell D. Stress fractures in the female athlete. Curr Sports Med Rep. 2005;4(6):323-8.and2323. Gardner LI Jr, Dziados JE, Jones BH, Brundage JF, Harris JM, Sullivan R, et al. Prevention of lower extremity stress fractures: a controlled trial of a shock absorbent insole. Am J Public Health. 1988;78(12):1563-7.Extrinsic factors relate to sports movements, nutritional habits, equipment used and the type of ground.88. Evans RK, Antczak AJ, Lester M, Yanovich R, Israeli E, Moran DS. Effects of a 4-month recruit training program on markers of bone metabolism. Med Sci Sports Exerc. 2008;40 11 Suppl.:S660-70.,99. Cosman F, Ruffing J, Zion M, Uhorchak J, Ralston S, Tendy S, et al. Determinants of stress fractures risk in United States Military Academy cadets. Bone. 2013;55(2):359-66.,1414. Daffner RH, Pavlov H. Stress fractures: current concepts. Am J Roentgenol. 1992;159(2):245-52.,2020. Raasch WG, Hergan DJ. Treatment of stress fractures: the fundamentals. Clin Sports Med. 2006;25(1):29-36.,2121. Korpelainen R, Orava S, Karpakka J, Siira P, Hulkko A. Risk factors for recurrent stress fracture in athletes. Am J Sports Med. 2001;29(3):304-10.,2222. Joy EA, Campbell D. Stress fractures in the female athlete. Curr Sports Med Rep. 2005;4(6):323-8.and2323. Gardner LI Jr, Dziados JE, Jones BH, Brundage JF, Harris JM, Sullivan R, et al. Prevention of lower extremity stress fractures: a controlled trial of a shock absorbent insole. Am J Public Health. 1988;78(12):1563-7.

Abrupt increases in the intensity and volume of training are often enough for lesions to develop.66. Carmont RC, Mei-Dan O, Bennell LK. Stress fracture management: current classification and new healing modalities. Oper Tech Sports Med. 2009;17:81-9.,99. Cosman F, Ruffing J, Zion M, Uhorchak J, Ralston S, Tendy S, et al. Determinants of stress fractures risk in United States Military Academy cadets. Bone. 2013;55(2):359-66.,1010. Bennell KL, Malcolm SA, Thomas SA, Wark JD, Brukner PD. The incidence and distribution of stress fractures in competitive track and field athletes. A twelve-month prospective study. Am J Sports Med. 1996;24(2):211-7.and1111. Royer M, Thomas T, Cesini J, Legrand E. Stress fractures in 2011: practical approach. Joint Bone Spine. 2012;79 Suppl. 2:S86-90. Equipment such as footwear that has low impact absorption, is worn out (more than six months of use) or is a bad fit for the athlete's foot may cause injuries.88. Evans RK, Antczak AJ, Lester M, Yanovich R, Israeli E, Moran DS. Effects of a 4-month recruit training program on markers of bone metabolism. Med Sci Sports Exerc. 2008;40 11 Suppl.:S660-70.and2323. Gardner LI Jr, Dziados JE, Jones BH, Brundage JF, Harris JM, Sullivan R, et al. Prevention of lower extremity stress fractures: a controlled trial of a shock absorbent insole. Am J Public Health. 1988;78(12):1563-7. The quality of the training track may also be a risk factor, when it is uneven, irregular or very rigid.1717. Pester S, Smith PC. Stress fractures in the lower extremities of soldiers in basic training. Orthop Rev. 1992;21(03): 297-303.and2424. Milgrom C, Finestone A, Levi Y, Simkin A, Ekenman I, Mendelson S, et al. Do high impact exercises produce higher tibial strains than running? Br J Sports Med. 2000;34(3):195-9. Lastly, if the athlete's fitness level is insufficient for the sports movement or functional technique, this may lead to injury, sometimes without the number of repetitions having been very high.88. Evans RK, Antczak AJ, Lester M, Yanovich R, Israeli E, Moran DS. Effects of a 4-month recruit training program on markers of bone metabolism. Med Sci Sports Exerc. 2008;40 11 Suppl.:S660-70.and2525. Patel RD. Stress fractures: diagnosis and management in the primary care settings. Pediatr Clin N Am. 2010;81:9-27.

The intrinsic factors relate to possible anatomical variations, muscle conditions, hormonal states, gender, ethnicity or age.88. Evans RK, Antczak AJ, Lester M, Yanovich R, Israeli E, Moran DS. Effects of a 4-month recruit training program on markers of bone metabolism. Med Sci Sports Exerc. 2008;40 11 Suppl.:S660-70.,99. Cosman F, Ruffing J, Zion M, Uhorchak J, Ralston S, Tendy S, et al. Determinants of stress fractures risk in United States Military Academy cadets. Bone. 2013;55(2):359-66.,2020. Raasch WG, Hergan DJ. Treatment of stress fractures: the fundamentals. Clin Sports Med. 2006;25(1):29-36.,2121. Korpelainen R, Orava S, Karpakka J, Siira P, Hulkko A. Risk factors for recurrent stress fracture in athletes. Am J Sports Med. 2001;29(3):304-10.and2222. Joy EA, Campbell D. Stress fractures in the female athlete. Curr Sports Med Rep. 2005;4(6):323-8.

Many studies have mistakenly considered that only female gender is a risk factor for stress factors to appear.1111. Royer M, Thomas T, Cesini J, Legrand E. Stress fractures in 2011: practical approach. Joint Bone Spine. 2012;79 Suppl. 2:S86-90.,1616. Jones BH, Bovee MW, Harris JM, Cowan DN. Intrinsic risk factors for exercise- related injuries among male and female army trainees. Am J Sports Med. 1993;21(5):705-10.and2626. Shaffer RA, Rauh MJ, Brodine SK, Trone DW, Macera CA. Predictors of stress fracture susceptibility in young female recruits. Am J Sports Med. 2006;34(1):108-15. In reality, hormonal, nutritional, biomechanical and anatomical alterations are the true factors that favor appearance of stress fractures in women.1111. Royer M, Thomas T, Cesini J, Legrand E. Stress fractures in 2011: practical approach. Joint Bone Spine. 2012;79 Suppl. 2:S86-90.and2424. Milgrom C, Finestone A, Levi Y, Simkin A, Ekenman I, Mendelson S, et al. Do high impact exercises produce higher tibial strains than running? Br J Sports Med. 2000;34(3):195-9.

Age also cannot be considered to be a risk factor in isolation for stress fractures.1111. Royer M, Thomas T, Cesini J, Legrand E. Stress fractures in 2011: practical approach. Joint Bone Spine. 2012;79 Suppl. 2:S86-90.,2323. Gardner LI Jr, Dziados JE, Jones BH, Brundage JF, Harris JM, Sullivan R, et al. Prevention of lower extremity stress fractures: a controlled trial of a shock absorbent insole. Am J Public Health. 1988;78(12):1563-7.and2727. Milgrom C, Finestone A, Shlamkovitch N, Rand N, Lev B, Simkin A, et al. Youth is a risk factor for stress fracture: a study of 783 infantry recruits. J Bone Joint Surg Br. 1994;76(1):20-2. Studies conducted in the United States have attempted to evaluate the incidence of these injuries among white and black athletes, without observing any significant differences.1111. Royer M, Thomas T, Cesini J, Legrand E. Stress fractures in 2011: practical approach. Joint Bone Spine. 2012;79 Suppl. 2:S86-90.and1313. Iwamoto J, Takeda T. Stress fractures in athletes: review of 196 cases. J Orthop Sci. 2003;8(3):273-8. In a military population, the incidence among whites was twice as high as among blacks, without any difference between the sexes. This was attributed to bone density and its biomechanics.2424. Milgrom C, Finestone A, Levi Y, Simkin A, Ekenman I, Mendelson S, et al. Do high impact exercises produce higher tibial strains than running? Br J Sports Med. 2000;34(3):195-9.

There is an inverse relationship between bone mineral density and the risk of stress fractures.88. Evans RK, Antczak AJ, Lester M, Yanovich R, Israeli E, Moran DS. Effects of a 4-month recruit training program on markers of bone metabolism. Med Sci Sports Exerc. 2008;40 11 Suppl.:S660-70.,1010. Bennell KL, Malcolm SA, Thomas SA, Wark JD, Brukner PD. The incidence and distribution of stress fractures in competitive track and field athletes. A twelve-month prospective study. Am J Sports Med. 1996;24(2):211-7.and2828. Valimaki VV, Alfthan H, Lehmuskallio E, Loyttyniemi E, Sahi T, Suominen H, et al. Risk factors for clinical stress fractures in male military recruits: a prospective cohort study. Bone. 2005;37(2):267-73. Inadequate nutritional intake may alter bone metabolism and predispose toward appearance of stress fractures.88. Evans RK, Antczak AJ, Lester M, Yanovich R, Israeli E, Moran DS. Effects of a 4-month recruit training program on markers of bone metabolism. Med Sci Sports Exerc. 2008;40 11 Suppl.:S660-70.,1010. Bennell KL, Malcolm SA, Thomas SA, Wark JD, Brukner PD. The incidence and distribution of stress fractures in competitive track and field athletes. A twelve-month prospective study. Am J Sports Med. 1996;24(2):211-7.and2929. Myburg KH, Hutchins J, Fataar AB, Hough SF, Noakes TD. Low bone density is an etiologic factor or stress fractures in athletes. Ann Intern Med. 1990;113(10):754-9.

Low levels of physical and muscle conditioning are also an important risk factor for the genesis of this problem.66. Carmont RC, Mei-Dan O, Bennell LK. Stress fracture management: current classification and new healing modalities. Oper Tech Sports Med. 2009;17:81-9.,88. Evans RK, Antczak AJ, Lester M, Yanovich R, Israeli E, Moran DS. Effects of a 4-month recruit training program on markers of bone metabolism. Med Sci Sports Exerc. 2008;40 11 Suppl.:S660-70.,1010. Bennell KL, Malcolm SA, Thomas SA, Wark JD, Brukner PD. The incidence and distribution of stress fractures in competitive track and field athletes. A twelve-month prospective study. Am J Sports Med. 1996;24(2):211-7.,3030. Nieves JW, Melsop K, Curtis M. Nutritional factors that influence change in bone density and stress fracture risk among young female cross- country runners. PMR. 2010;2(8):740-50.and3131. Popp KL, Hughes JM, Smock AJ, Novotny SA, Stovitz SD, Koehler SM, et al. Bone geometry, strength, and muscle size in runners with a history of stress fracture. Med Sci Sports Exerc. 2009;41(12):2145-50. Furthermore, rigid pes cavus, discrepancy of the lower limbs, short tibia, genu valgum, increased Q angle, body mass index lower than 21 kg/m2 and short stature should also be taken into consideration in analyzing the risk factors for stress fractures.66. Carmont RC, Mei-Dan O, Bennell LK. Stress fracture management: current classification and new healing modalities. Oper Tech Sports Med. 2009;17:81-9.,88. Evans RK, Antczak AJ, Lester M, Yanovich R, Israeli E, Moran DS. Effects of a 4-month recruit training program on markers of bone metabolism. Med Sci Sports Exerc. 2008;40 11 Suppl.:S660-70.,99. Cosman F, Ruffing J, Zion M, Uhorchak J, Ralston S, Tendy S, et al. Determinants of stress fractures risk in United States Military Academy cadets. Bone. 2013;55(2):359-66.,2121. Korpelainen R, Orava S, Karpakka J, Siira P, Hulkko A. Risk factors for recurrent stress fracture in athletes. Am J Sports Med. 2001;29(3):304-10.and3232. Giladi M, Milgrom C, Simkin A, Danon Y. Stress fractures: identifiable risk factors. Am J Sports Med. 1991;19(6):647-52.

Some studies have also suggested that stiffness of the feet, alterations to the plantar arch and limitations of dorsiflexion due to shortening of the sural triceps may be risk factors.88. Evans RK, Antczak AJ, Lester M, Yanovich R, Israeli E, Moran DS. Effects of a 4-month recruit training program on markers of bone metabolism. Med Sci Sports Exerc. 2008;40 11 Suppl.:S660-70.,1010. Bennell KL, Malcolm SA, Thomas SA, Wark JD, Brukner PD. The incidence and distribution of stress fractures in competitive track and field athletes. A twelve-month prospective study. Am J Sports Med. 1996;24(2):211-7.and3333. Manioli A 2nd, Graham B. The subtle cavus foot: the under pronator: a review. Foot Ankle Int. 2005;26(3):256-63. Runners whose hindfoot presents eversion, particularly with excessive pronation, and athletes with a pronounced high arch have a risk of developing stress fractures that is up to 40% higher.1010. Bennell KL, Malcolm SA, Thomas SA, Wark JD, Brukner PD. The incidence and distribution of stress fractures in competitive track and field athletes. A twelve-month prospective study. Am J Sports Med. 1996;24(2):211-7.,2121. Korpelainen R, Orava S, Karpakka J, Siira P, Hulkko A. Risk factors for recurrent stress fracture in athletes. Am J Sports Med. 2001;29(3):304-10.,3333. Manioli A 2nd, Graham B. The subtle cavus foot: the under pronator: a review. Foot Ankle Int. 2005;26(3):256-63.and3434. Pohl MB, Mullineaux DR, Milner CE, Hamill J, Davis IS. Biomechanical predictors of retrospective tibial stress fractures in runners. J Biochem. 2008;41(6):1160-5. Moreover, hyperpronation of the forefoot predisposes toward increased risk of stress fractures in the fibula.3535. Maitra RS, Johnson DL. Stress fractures. Clinical history and physical examination. Clin Sports Med. 1997;16(2): 259-74. Stress fractures in the second metatarsal have been correlated with presence of Morton's neuroma, hypermobility of the first metatarsal and a relative increase in the length of the second metatarsal.2020. Raasch WG, Hergan DJ. Treatment of stress fractures: the fundamentals. Clin Sports Med. 2006;25(1):29-36.and3333. Manioli A 2nd, Graham B. The subtle cavus foot: the under pronator: a review. Foot Ankle Int. 2005;26(3):256-63.Although use of orthoses and footwear that is more appropriate theoretically decreases the incidence of stress fractures, the number of studies in the literature remains insufficient to sustain this theory.1010. Bennell KL, Malcolm SA, Thomas SA, Wark JD, Brukner PD. The incidence and distribution of stress fractures in competitive track and field athletes. A twelve-month prospective study. Am J Sports Med. 1996;24(2):211-7.and3434. Pohl MB, Mullineaux DR, Milner CE, Hamill J, Davis IS. Biomechanical predictors of retrospective tibial stress fractures in runners. J Biochem. 2008;41(6):1160-5.

Other authors have also considered that the following are risk factors: smoking, physical activity of frequency less than three times a week and consumption of more than 10 doses of alcoholic drink per week.66. Carmont RC, Mei-Dan O, Bennell LK. Stress fracture management: current classification and new healing modalities. Oper Tech Sports Med. 2009;17:81-9.

Physical examination

Physical examination of stress fractures is very sensitive but unspecific.2020. Raasch WG, Hergan DJ. Treatment of stress fractures: the fundamentals. Clin Sports Med. 2006;25(1):29-36.and3636. Fredericson M, Wun C. Differential diagnosis of leg pain in the athlete. J Am Podiatr Med Assoc. 2003;93(4):321-4. Patients present increased sensitivity, pain and edema at the lesion location after an abrupt and/or repetitive increase in physical activity with insufficient rest intervals for physiological tissue recovery.66. Carmont RC, Mei-Dan O, Bennell LK. Stress fracture management: current classification and new healing modalities. Oper Tech Sports Med. 2009;17:81-9. Initially, the pain is reduced and alleviated through rest and this allows unimpaired physical activity. However, if the aggressive movement is maintained, the injury will progress, thus resulting in increased pain and limitation of practicing this movement.99. Cosman F, Ruffing J, Zion M, Uhorchak J, Ralston S, Tendy S, et al. Determinants of stress fractures risk in United States Military Academy cadets. Bone. 2013;55(2):359-66.and2020. Raasch WG, Hergan DJ. Treatment of stress fractures: the fundamentals. Clin Sports Med. 2006;25(1):29-36. Information regarding any previous fractures, weight, height, body mass index and its changes over the last 12 months, menstrual and puberty history and nutritional evaluations is important for identifying possible intrinsic risk factors for injury during physical examinations.1010. Bennell KL, Malcolm SA, Thomas SA, Wark JD, Brukner PD. The incidence and distribution of stress fractures in competitive track and field athletes. A twelve-month prospective study. Am J Sports Med. 1996;24(2):211-7.

Clinical tests such as use of therapeutic ultrasound and tuning forks are also useful in diagnostic investigations on stress fractures.33. Schneiders AG, Sullivan SJ, Hendrick PA, Hones BDGM, Mcmaster AR, Sugden BA, et al. The ability of clinical tests to diagnose stress fractures: a systematic review and meta- analysis. J Orthop Sports Phys Ther. 2012;42(9):760-71. When used directly on the site of the suspected lesion, they may trigger or worsen the pain because of the great local osteoclastic reabsorption, which results in injury to the periosteum.33. Schneiders AG, Sullivan SJ, Hendrick PA, Hones BDGM, Mcmaster AR, Sugden BA, et al. The ability of clinical tests to diagnose stress fractures: a systematic review and meta- analysis. J Orthop Sports Phys Ther. 2012;42(9):760-71.and3737. Romani WA, Perrin DH, Dussault RG, Ball DW, Kahler DM. Identification of tibial stress fractures using therapeutic continuous ultrasound. J Orthop Sports Phys Ther. 2000;30(8):444-52. In addition, the skipping rope test (hop test) can be used: this consists of asking the patient to hop on the spot while putting weight on the limb that is under investigation. The test is positive when it triggers strong or incapacitating pain in the region injured.66. Carmont RC, Mei-Dan O, Bennell LK. Stress fracture management: current classification and new healing modalities. Oper Tech Sports Med. 2009;17:81-9.and3838. Ishibashi Y, Okamura Y, Otsuka H, Nishizawa K, Sasaki T, Toh S. Comparison of scintigraphy and magnetic resonance imaging for stress injuries of bone. Clin J Sport Med. 2002;12(2):79-84.

Some laboratory tests may be useful in investigating stress fractures: serum levels of calcium, phosphorus, creatinine and 25(OH)D3. Nutritional markers should be requested in the presence of clinical conditions of weight loss and anorexia. Hormonal levels (FSH and estradiol) should be investigated when there is a history of dysmenorrhea.1010. Bennell KL, Malcolm SA, Thomas SA, Wark JD, Brukner PD. The incidence and distribution of stress fractures in competitive track and field athletes. A twelve-month prospective study. Am J Sports Med. 1996;24(2):211-7.

Imaging examinations

Imaging examinations are fundamental for diagnosing, prognosing and following up stress fractures.66. Carmont RC, Mei-Dan O, Bennell LK. Stress fracture management: current classification and new healing modalities. Oper Tech Sports Med. 2009;17:81-9.

Simple radiography (X-ray) is the initial imaging examination because of its ease of access and low cost.44. Fayad LM, Kamel IR, Kawamoto S, Bluemke DA, Frassica FJ, Fishman EK. Distinguishing stress fractures from pathologic fractures: a multimodality approach. Skelet Radiol. 2005;34(5):245-59.,1313. Iwamoto J, Takeda T. Stress fractures in athletes: review of 196 cases. J Orthop Sci. 2003;8(3):273-8.,3636. Fredericson M, Wun C. Differential diagnosis of leg pain in the athlete. J Am Podiatr Med Assoc. 2003;93(4):321-4.,3838. Ishibashi Y, Okamura Y, Otsuka H, Nishizawa K, Sasaki T, Toh S. Comparison of scintigraphy and magnetic resonance imaging for stress injuries of bone. Clin J Sport Med. 2002;12(2):79-84.,3939. Sterling JC, Edelstein DW, Calvo RD, Webb R. Stress fractures in the athlete. Diagnosis and management. Sports Med. 1992;14(5):336-46.,4040. Bennell K, Brukner P. Preventing and managing stress fractures in athletes. Phys Ther Sport. 2005;6:171-80.,4141. Fredericson M, Bergman AG, Hoffman KL, Dillingham MS. Tibial stress reaction in runners. Correlation of clinical symptoms and scintigraphy with a new magnetic resonance imaging grading system. Am J Sports Med. 1995;23(4): 472-81.and4242. Strauch WB, Slomiany WP. Evaluating shin pain in active patients. J Musculoskelet Med. 2008;25:138-48. However, it has a high false-negative rate, given that the alterations caused by stress fractures only appear on such examinations at a late stage (two to four weeks after the start of the pain), which may delay the diagnosis.66. Carmont RC, Mei-Dan O, Bennell LK. Stress fracture management: current classification and new healing modalities. Oper Tech Sports Med. 2009;17:81-9.,1414. Daffner RH, Pavlov H. Stress fractures: current concepts. Am J Roentgenol. 1992;159(2):245-52.,1818. Bolin D, Kemper A, Brolinson G. Current concepts in the evaluation and management of stress fractures. Curr Rep Sport Med. 2005;4(6):295-300.and4343. Shin AY, Morin WD, Gorman JD, Jones SB, Lapinski AS. The superiority of magnetic resonance imaging in differentiating the cause of hip pain in endurance athletes. Am J Sports Med. 1996;24(2):168-76. Initially, a subtle weak radiolucent area can be observed directly on the bone tissue affected and/or sclerosis, periosteal thickening, cortical changes comprising diminished cortical bone density (gray cortex) and/or appearance of a delicate fracture line. Finally, an attempt by the organism to form a bone callus is observed, with endosteal thickening and sclerosis, which are the commonest findings.66. Carmont RC, Mei-Dan O, Bennell LK. Stress fracture management: current classification and new healing modalities. Oper Tech Sports Med. 2009;17:81-9.,1010. Bennell KL, Malcolm SA, Thomas SA, Wark JD, Brukner PD. The incidence and distribution of stress fractures in competitive track and field athletes. A twelve-month prospective study. Am J Sports Med. 1996;24(2):211-7.,1414. Daffner RH, Pavlov H. Stress fractures: current concepts. Am J Roentgenol. 1992;159(2):245-52.,3838. Ishibashi Y, Okamura Y, Otsuka H, Nishizawa K, Sasaki T, Toh S. Comparison of scintigraphy and magnetic resonance imaging for stress injuries of bone. Clin J Sport Med. 2002;12(2):79-84.and4444. Dixon S, Newton J, Teh J. Stress fractures in the young athlete: a pictorial review. Curr Probl Diagn Radiol. 2011;40(1): 29-44. The sign known as the dreaded black line occurs in the anterior cortical bone of the tibia and suggests the presence of a fracture with a poor prognosis and a high probability of evolution to a complete fracture because of its location in a region of bone tension and poor vasclarization.4444. Dixon S, Newton J, Teh J. Stress fractures in the young athlete: a pictorial review. Curr Probl Diagn Radiol. 2011;40(1): 29-44.

Computed tomography (CT) is used mainly when there is a contraindication against using magnetic resonance imaging.4343. Shin AY, Morin WD, Gorman JD, Jones SB, Lapinski AS. The superiority of magnetic resonance imaging in differentiating the cause of hip pain in endurance athletes. Am J Sports Med. 1996;24(2):168-76.,4444. Dixon S, Newton J, Teh J. Stress fractures in the young athlete: a pictorial review. Curr Probl Diagn Radiol. 2011;40(1): 29-44.,4545. Zukotynski K, Curtis C, Grant FD, Micheli L, Treves ST. The value of SPECT in the detection of stress injury to the pars interarticularis in patients with low back pain. J Orthop Surg Res. 2010;5:13.and4646. Sofka CM. Imaging of stress fractures. Clin Sports Med. 2006;25(1):53-62.Chronic and quiescent lesions may be more evident in this examination than on magnetic resonance imaging or bone scintigraphy because they present low bone turnover.4646. Sofka CM. Imaging of stress fractures. Clin Sports Med. 2006;25(1):53-62.Single photon emission CT (SPECT) has been particularly more useful in investigating stress fractures involving the dorsal spine, and specifically in pars interarticularis (spondylolysis).66. Carmont RC, Mei-Dan O, Bennell LK. Stress fracture management: current classification and new healing modalities. Oper Tech Sports Med. 2009;17:81-9.,4545. Zukotynski K, Curtis C, Grant FD, Micheli L, Treves ST. The value of SPECT in the detection of stress injury to the pars interarticularis in patients with low back pain. J Orthop Surg Res. 2010;5:13.and4646. Sofka CM. Imaging of stress fractures. Clin Sports Med. 2006;25(1):53-62.

Nuclear medicine using triple-phase scintigraphy (technetium-99 m) presents significant sensitivity (74-100%) to bone remodeling and shows imaging alterations three to five days after the start of symptoms.33. Schneiders AG, Sullivan SJ, Hendrick PA, Hones BDGM, Mcmaster AR, Sugden BA, et al. The ability of clinical tests to diagnose stress fractures: a systematic review and meta- analysis. J Orthop Sports Phys Ther. 2012;42(9):760-71.,66. Carmont RC, Mei-Dan O, Bennell LK. Stress fracture management: current classification and new healing modalities. Oper Tech Sports Med. 2009;17:81-9.,4141. Fredericson M, Bergman AG, Hoffman KL, Dillingham MS. Tibial stress reaction in runners. Correlation of clinical symptoms and scintigraphy with a new magnetic resonance imaging grading system. Am J Sports Med. 1995;23(4): 472-81.,4242. Strauch WB, Slomiany WP. Evaluating shin pain in active patients. J Musculoskelet Med. 2008;25:138-48.and4747. Brukner P, Bennell K. Stress fractures in female athletes. Diagnosis, management and rehabilitation. Sports Med. 1997;24(6):419-29. The radiopharmaceutical becomes concentrated in the regions affected and detects areas of bone remodeling, microfractures of the trabecular bone, periosteal reaction and formation of bone callus.4646. Sofka CM. Imaging of stress fractures. Clin Sports Med. 2006;25(1):53-62.

Magnetic resonance imaging (MRI) is the most sensitive and specific imaging examination for diagnosing stress fractures. It is recommended by the American College of Radiology as the preferred examination in the absence of radiographic alterations.66. Carmont RC, Mei-Dan O, Bennell LK. Stress fracture management: current classification and new healing modalities. Oper Tech Sports Med. 2009;17:81-9. The abnormalities caused by the fracture can be identified one to two days after the start of the symptoms,66. Carmont RC, Mei-Dan O, Bennell LK. Stress fracture management: current classification and new healing modalities. Oper Tech Sports Med. 2009;17:81-9.,1010. Bennell KL, Malcolm SA, Thomas SA, Wark JD, Brukner PD. The incidence and distribution of stress fractures in competitive track and field athletes. A twelve-month prospective study. Am J Sports Med. 1996;24(2):211-7.,1212. Snyder RA, Koester MC, Dunn WR. Epidemiology of stress fractures. Clin Sports Med. 2006;25(1):37-52.,3838. Ishibashi Y, Okamura Y, Otsuka H, Nishizawa K, Sasaki T, Toh S. Comparison of scintigraphy and magnetic resonance imaging for stress injuries of bone. Clin J Sport Med. 2002;12(2):79-84.,4141. Fredericson M, Bergman AG, Hoffman KL, Dillingham MS. Tibial stress reaction in runners. Correlation of clinical symptoms and scintigraphy with a new magnetic resonance imaging grading system. Am J Sports Med. 1995;23(4): 472-81.,4343. Shin AY, Morin WD, Gorman JD, Jones SB, Lapinski AS. The superiority of magnetic resonance imaging in differentiating the cause of hip pain in endurance athletes. Am J Sports Med. 1996;24(2):168-76.,4646. Sofka CM. Imaging of stress fractures. Clin Sports Med. 2006;25(1):53-62.and4848. Fredericson M, Jennings F, Beaulieu C, Matheson GO. Stress fractures in athletes. Top Magn Reson Imaging. 2006;17(5):309-25.with early detection of edema in the bone tissue and adjacent areas.1010. Bennell KL, Malcolm SA, Thomas SA, Wark JD, Brukner PD. The incidence and distribution of stress fractures in competitive track and field athletes. A twelve-month prospective study. Am J Sports Med. 1996;24(2):211-7.,4141. Fredericson M, Bergman AG, Hoffman KL, Dillingham MS. Tibial stress reaction in runners. Correlation of clinical symptoms and scintigraphy with a new magnetic resonance imaging grading system. Am J Sports Med. 1995;23(4): 472-81.and4646. Sofka CM. Imaging of stress fractures. Clin Sports Med. 2006;25(1):53-62.This examination makes it possible to differentiate medullary damage from cortical, endosteal and periosteal damage allows gradation of the lesions regarding their severity and prognosis.66. Carmont RC, Mei-Dan O, Bennell LK. Stress fracture management: current classification and new healing modalities. Oper Tech Sports Med. 2009;17:81-9. Intramedullary endosteal edema is one of the first signs of bone remodeling and may continue to be present for up to six months after the fracture has been diagnosed and treated, while the cortical maturation and remodeling take place.1616. Jones BH, Bovee MW, Harris JM, Cowan DN. Intrinsic risk factors for exercise- related injuries among male and female army trainees. Am J Sports Med. 1993;21(5):705-10.and4848. Fredericson M, Jennings F, Beaulieu C, Matheson GO. Stress fractures in athletes. Top Magn Reson Imaging. 2006;17(5):309-25. Medullary edema or signs of bone stress may also be present in asymptomatic physically active patients, without any correlation with increased incidence of stress fractures, especially in the tibia in marathon runners.4646. Sofka CM. Imaging of stress fractures. Clin Sports Med. 2006;25(1):53-62. The fracture line is less commonly visible.10 It presents sensitivity slightly greater than or equal to that of scintigraphy, but it is considered to be a more specific examination.66. Carmont RC, Mei-Dan O, Bennell LK. Stress fracture management: current classification and new healing modalities. Oper Tech Sports Med. 2009;17:81-9.,3838. Ishibashi Y, Okamura Y, Otsuka H, Nishizawa K, Sasaki T, Toh S. Comparison of scintigraphy and magnetic resonance imaging for stress injuries of bone. Clin J Sport Med. 2002;12(2):79-84.and4141. Fredericson M, Bergman AG, Hoffman KL, Dillingham MS. Tibial stress reaction in runners. Correlation of clinical symptoms and scintigraphy with a new magnetic resonance imaging grading system. Am J Sports Med. 1995;23(4): 472-81.

Classification

Fractures can and should be classified so that the prognosis and treatment can be measured and thus give rise to a better result for the patient.

Arendt and Griffiths apud Royer et al.1111. Royer M, Thomas T, Cesini J, Legrand E. Stress fractures in 2011: practical approach. Joint Bone Spine. 2012;79 Suppl. 2:S86-90. used imaging parameters obtained through MRI to divide stress fractures into four stages. The aim of this classification is to define the length of resting time that is needed for a return to sport, according to the patient's current stage. These stages can also be used for reevaluation during follow-up of the lesion.77. Patel DS, Roth M, Kapil N. Stress fractures: diagnosis, treatment, and prevention. Am Fam Physician. 2011;83(1):39-46. Lesions treated at stage 1 require an average of 3.3 weeks of resting, while those at stage 4 require 14.3 weeks77. Patel DS, Roth M, Kapil N. Stress fractures: diagnosis, treatment, and prevention. Am Fam Physician. 2011;83(1):39-46. (Table 1).

Table 1
Classification of Arendt and Griffiths.

Stress fractures can also be classified as high and low-risk fractures. The bone location, the prognosis for consolidation and traits ascertained through imaging examinations are some of the characteristics that define whether there is higher risk that a stress fracture might not evolve satisfactorily during the treatment66. Carmont RC, Mei-Dan O, Bennell LK. Stress fracture management: current classification and new healing modalities. Oper Tech Sports Med. 2009;17:81-9.and1111. Royer M, Thomas T, Cesini J, Legrand E. Stress fractures in 2011: practical approach. Joint Bone Spine. 2012;79 Suppl. 2:S86-90. (Table 2 and Table 3).

Table 2
Classification of low-risk stress fractures.

Table 3
Classification of high-risk stress fractures.

Fredericson proposed a stress fracture classification through using the alterations seen on MRI. The progressive stages of lesion severity are assessed according to periosteal involvement, followed by medullary involvement and going as far as the point at which the cortical bone also becomes compromised1010. Bennell KL, Malcolm SA, Thomas SA, Wark JD, Brukner PD. The incidence and distribution of stress fractures in competitive track and field athletes. A twelve-month prospective study. Am J Sports Med. 1996;24(2):211-7.and4141. Fredericson M, Bergman AG, Hoffman KL, Dillingham MS. Tibial stress reaction in runners. Correlation of clinical symptoms and scintigraphy with a new magnetic resonance imaging grading system. Am J Sports Med. 1995;23(4): 472-81. (Table 4).

Table 4
Fredericson classification.

Treatment

In order to adequately treat stress fractures, it is essential to identify risk factors that lead to disease. Treatments for stress fractures are based on prevention of new episodes and on recovery of the injured area.66. Carmont RC, Mei-Dan O, Bennell LK. Stress fracture management: current classification and new healing modalities. Oper Tech Sports Med. 2009;17:81-9.,1010. Bennell KL, Malcolm SA, Thomas SA, Wark JD, Brukner PD. The incidence and distribution of stress fractures in competitive track and field athletes. A twelve-month prospective study. Am J Sports Med. 1996;24(2):211-7.and2020. Raasch WG, Hergan DJ. Treatment of stress fractures: the fundamentals. Clin Sports Med. 2006;25(1):29-36.

Prevention of new episodes is achieved through modifying activities, correcting sports movements, changing sports equipment, changing training locations that might be favoring bone overloading, changing nutritional habits, recognizing hormonal, anatomical and muscle strength alterations and recognizing low cardiomuscular conditioning.2020. Raasch WG, Hergan DJ. Treatment of stress fractures: the fundamentals. Clin Sports Med. 2006;25(1):29-36. The ideal type of footwear for each type of sports practice is the external factor that has been studied most with regard to the genesis of stress fractures.2020. Raasch WG, Hergan DJ. Treatment of stress fractures: the fundamentals. Clin Sports Med. 2006;25(1):29-36. Some studies have shown that there is lower incidence of injuries when running on asphalt is replaced by running on softer surfaces, such as athletics tracks. Nonetheless, other authors have reported in their studies that there was no relationship between these factors.2020. Raasch WG, Hergan DJ. Treatment of stress fractures: the fundamentals. Clin Sports Med. 2006;25(1):29-36. Voloshin4949. Voloshin KW. Dynamic loading during running on various surfaces. Human Mov Sci. 1992;11:675-89. believed that there was interference between the different shock-absorbing surfaces: the stress on the bone tissue is not due solely to the reaction forces from the ground. The combined forces generated by muscle action through the athlete's movement and his adaptation to the training surface may also be considered to be risk factors for a given type of injury.2020. Raasch WG, Hergan DJ. Treatment of stress fractures: the fundamentals. Clin Sports Med. 2006;25(1):29-36.and4949. Voloshin KW. Dynamic loading during running on various surfaces. Human Mov Sci. 1992;11:675-89.

The treatments for these injuries comprise diminution of the overloading on the site affected, medication for pain control and physiotherapeutic rehabilitation.66. Carmont RC, Mei-Dan O, Bennell LK. Stress fracture management: current classification and new healing modalities. Oper Tech Sports Med. 2009;17:81-9.,1010. Bennell KL, Malcolm SA, Thomas SA, Wark JD, Brukner PD. The incidence and distribution of stress fractures in competitive track and field athletes. A twelve-month prospective study. Am J Sports Med. 1996;24(2):211-7.and2020. Raasch WG, Hergan DJ. Treatment of stress fractures: the fundamentals. Clin Sports Med. 2006;25(1):29-36.

Analgesics are used for pain relief.66. Carmont RC, Mei-Dan O, Bennell LK. Stress fracture management: current classification and new healing modalities. Oper Tech Sports Med. 2009;17:81-9. Anti-inflammatory drugs, if used, should be prescribed cautiously and only for short periods. Studies on animals have demonstrated that there may be negative interference in the bone healing process.66. Carmont RC, Mei-Dan O, Bennell LK. Stress fracture management: current classification and new healing modalities. Oper Tech Sports Med. 2009;17:81-9. However, reviews of the literature conducted more recently have reported that there is no conclusive evidence regarding this negative action.5050. Mehallo CJ, Drezner JA, Bytomski JR. Practical management: non steroidal anti- inflammatory drug (NSAID) use in athletic injuries. Clin J Sport Med. 2006;16:170-4.,5151. Wheeler P, Batt ME. Do non- steroidal anti- inflammatory drugs adversely affect stress fracture healing? A short review. Br J Sports Med. 2005;39(2):65-9.and5252. Burns AS, Lauder TD. Deep water running: an effective non weight bearing exercise for the maintenance of land based running performance. Mil Med. 2001;166(3):253-8.

The time taken for fracture consolidation is generally between four and 12 weeks when the fractures are low-risk.66. Carmont RC, Mei-Dan O, Bennell LK. Stress fracture management: current classification and new healing modalities. Oper Tech Sports Med. 2009;17:81-9. For the metatarsals, a time of three to six weeks is expected, while for the posteromedial region of the tibial diaphysis, the femur and the pelvis, six to 12 weeks is expected.1010. Bennell KL, Malcolm SA, Thomas SA, Wark JD, Brukner PD. The incidence and distribution of stress fractures in competitive track and field athletes. A twelve-month prospective study. Am J Sports Med. 1996;24(2):211-7.and1111. Royer M, Thomas T, Cesini J, Legrand E. Stress fractures in 2011: practical approach. Joint Bone Spine. 2012;79 Suppl. 2:S86-90. The patient should be reexamined every two to three weeks, to monitor the changes to the symptoms and pain during resting and rehabilitation periods.66. Carmont RC, Mei-Dan O, Bennell LK. Stress fracture management: current classification and new healing modalities. Oper Tech Sports Med. 2009;17:81-9.,5353. Johansson C, Ekenman I, Tornkvist H, Eriksson E. Stress fractures of the femoral neck in athletes: the consequence of a delay in diagnosis. Am J Sports Med. 1990;18(5):524-8.,5454. Bennet MH, Stanford R, Turner R. Hyperbaric oxygen therapy for promoting fracture healing and treating fracture non union. Cochrane Database Syst Rev. 2005;25(1): CD004712.,5555. Shima Y, Engebretsen L, Iwasa J, Kitaoka K, Tomita K. Use ofbisphosphonates for the treatment of stress fractures inathletes. Knee Surg Sports Traumatol Arthrosc.2009;17(5):542-50.and5656. Ekenman I. Do not use bisphosphonates without scientificevidence, neither in the treatment nor prophylactic, in thetreatment of stress fractures. Knee Surg Sports TraumatolArthrosc. 2009;17(5):433-4. IN order to maintain flexibility, strength and cardiovascular physical conditioning during the resting period, the patient needs to be engaged in a physiotherapy program66. Carmont RC, Mei-Dan O, Bennell LK. Stress fracture management: current classification and new healing modalities. Oper Tech Sports Med. 2009;17:81-9.,5353. Johansson C, Ekenman I, Tornkvist H, Eriksson E. Stress fractures of the femoral neck in athletes: the consequence of a delay in diagnosis. Am J Sports Med. 1990;18(5):524-8.and5454. Bennet MH, Stanford R, Turner R. Hyperbaric oxygen therapy for promoting fracture healing and treating fracture non union. Cochrane Database Syst Rev. 2005;25(1): CD004712. and a controlled exercise program.5757. Hammond JW, Hinton RY, Curl LA, Muriel JM, Lovering RM.Use of autologous plateletrich plasma to treat muscle straininjuries. Am J Sports Med. 2009;37(6):1135-42.

Immobilization is only rarely used for treating stress fractures because of its deleterious effects on muscles, tendons, ligaments and joints.55. Niva MH, Mattila VM, Kiuru MJ, Pihlajamäki HK. Bone stress injuries are common in female military trainees: a preliminary study. Clin Orthop Relat Res. 2009;467(11):2962-9. However, there are some specific types of fracture for which immobilization is fundamental for obtaining appropriate conditions for a cure: this is the case for the navicular bone, sesamoids, patella and posteromedial region of the tibia.55. Niva MH, Mattila VM, Kiuru MJ, Pihlajamäki HK. Bone stress injuries are common in female military trainees: a preliminary study. Clin Orthop Relat Res. 2009;467(11):2962-9.

High-risk fractures commonly evolve to non-consolidation of the bone and surgical intervention by an orthopedist becomes necessary.66. Carmont RC, Mei-Dan O, Bennell LK. Stress fracture management: current classification and new healing modalities. Oper Tech Sports Med. 2009;17:81-9. Stress fractures of the lateral cortical bone (due to tension) at the femoral neck is associated with catastrophic results, such as complete displacement of the femoral head and osteonecrosis, when this is not treated surgically.2020. Raasch WG, Hergan DJ. Treatment of stress fractures: the fundamentals. Clin Sports Med. 2006;25(1):29-36.and5353. Johansson C, Ekenman I, Tornkvist H, Eriksson E. Stress fractures of the femoral neck in athletes: the consequence of a delay in diagnosis. Am J Sports Med. 1990;18(5):524-8. Fractures of the anterior cortical bone of the middle third of the tibial diaphysis are another type that, if not treated surgically, mostly presents an extremely poor prognosis.2020. Raasch WG, Hergan DJ. Treatment of stress fractures: the fundamentals. Clin Sports Med. 2006;25(1):29-36. Fractures of the base of the fifth metatarsal and of the navicular bone can also be cited as types that commonly require surgical intervention in order to achieve a satisfactory result from their treatment.2020. Raasch WG, Hergan DJ. Treatment of stress fractures: the fundamentals. Clin Sports Med. 2006;25(1):29-36.

New types of therapy

Some new types of therapy for stress fractures are being studied with the aim of achieving faster consolidation and an earlier return to physical activities. These can be divided into biological and physical methods.5050. Mehallo CJ, Drezner JA, Bytomski JR. Practical management: non steroidal anti- inflammatory drug (NSAID) use in athletic injuries. Clin J Sport Med. 2006;16:170-4.

Oxygen supplementation therapy (hyperbaric oxygen therapy)

In vitro studies have demonstrated that administration of 100% oxygen is capable of stimulating osteoblasts and consequently bone formation.5050. Mehallo CJ, Drezner JA, Bytomski JR. Practical management: non steroidal anti- inflammatory drug (NSAID) use in athletic injuries. Clin J Sport Med. 2006;16:170-4. However, there is still no consensus in the literature regarding its benefits for treating stress fractures. 5050. Mehallo CJ, Drezner JA, Bytomski JR. Practical management: non steroidal anti- inflammatory drug (NSAID) use in athletic injuries. Clin J Sport Med. 2006;16:170-4.and5454. Bennet MH, Stanford R, Turner R. Hyperbaric oxygen therapy for promoting fracture healing and treating fracture non union. Cochrane Database Syst Rev. 2005;25(1): CD004712.

Bisphosphonates

Bisphosphonates suppress bone reabsorption and inactivate osteoclasts through their bonding with calcium phosphate crystals.2020. Raasch WG, Hergan DJ. Treatment of stress fractures: the fundamentals. Clin Sports Med. 2006;25(1):29-36.and5050. Mehallo CJ, Drezner JA, Bytomski JR. Practical management: non steroidal anti- inflammatory drug (NSAID) use in athletic injuries. Clin J Sport Med. 2006;16:170-4. Their high cost and various side effects may be the deciding factor with regard to choosing and attempting to use this therapeutic method.5050. Mehallo CJ, Drezner JA, Bytomski JR. Practical management: non steroidal anti- inflammatory drug (NSAID) use in athletic injuries. Clin J Sport Med. 2006;16:170-4.and5555. Shima Y, Engebretsen L, Iwasa J, Kitaoka K, Tomita K. Use ofbisphosphonates for the treatment of stress fractures inathletes. Knee Surg Sports Traumatol Arthrosc.2009;17(5):542-50. There is not yet any scientific basis for their prophylactic use.5050. Mehallo CJ, Drezner JA, Bytomski JR. Practical management: non steroidal anti- inflammatory drug (NSAID) use in athletic injuries. Clin J Sport Med. 2006;16:170-4.and5656. Ekenman I. Do not use bisphosphonates without scientificevidence, neither in the treatment nor prophylactic, in thetreatment of stress fractures. Knee Surg Sports TraumatolArthrosc. 2009;17(5):433-4.

Growth factors and growth factor-rich preparations

Growth factors are applied directly to diseased tissues with the aim of accelerating and promoting their repair. The preliminary results from muscles, tendons and ligaments have been encouraging.5050. Mehallo CJ, Drezner JA, Bytomski JR. Practical management: non steroidal anti- inflammatory drug (NSAID) use in athletic injuries. Clin J Sport Med. 2006;16:170-4.and5757. Hammond JW, Hinton RY, Curl LA, Muriel JM, Lovering RM.Use of autologous plateletrich plasma to treat muscle straininjuries. Am J Sports Med. 2009;37(6):1135-42. There are only a few studies on treating stress fractures. Some of them have reported that when these factors are used during surgical treatment of high-risk fractures, they may accelerate and improve the recovery.5050. Mehallo CJ, Drezner JA, Bytomski JR. Practical management: non steroidal anti- inflammatory drug (NSAID) use in athletic injuries. Clin J Sport Med. 2006;16:170-4.

Bone morphogenic proteins

Bone morphogenic proteins contain bioactive factors that are responsible for inducing bone matrix activity with an osteoinductive function.5050. Mehallo CJ, Drezner JA, Bytomski JR. Practical management: non steroidal anti- inflammatory drug (NSAID) use in athletic injuries. Clin J Sport Med. 2006;16:170-4.Their primary activity is in relation to differentiation of mesenchymal cells into bone and cartilage tissue-forming cells, through direct and osteochondral ossification. They have an important function in repairing bone lesions. Studies on animals have demonstrated acceleration of the injury cure process in cases of traumatic fractures, but little can be concluded regarding their use in stress fractures.5050. Mehallo CJ, Drezner JA, Bytomski JR. Practical management: non steroidal anti- inflammatory drug (NSAID) use in athletic injuries. Clin J Sport Med. 2006;16:170-4.

Recombinant parathyroid hormone

Parathormone acts toward regulating serum calcium levels through gastrointestinal absorption, calcium and phosphorus reabsorption in the kidney, and calcium release from the skeletal tissue.5050. Mehallo CJ, Drezner JA, Bytomski JR. Practical management: non steroidal anti- inflammatory drug (NSAID) use in athletic injuries. Clin J Sport Med. 2006;16:170-4. Although this initially promotes stimulation of osteoclasts through regular administration, when it is done intermittently in a controlled manner, it gives rise to anabolic stimulation of osteoblasts and results in formation of bone with increased strength and density, followed by remodeling.5050. Mehallo CJ, Drezner JA, Bytomski JR. Practical management: non steroidal anti- inflammatory drug (NSAID) use in athletic injuries. Clin J Sport Med. 2006;16:170-4. Studies have demonstrated that this hormone stimulates bone repair through both endochondral and membranous mechanisms.5050. Mehallo CJ, Drezner JA, Bytomski JR. Practical management: non steroidal anti- inflammatory drug (NSAID) use in athletic injuries. Clin J Sport Med. 2006;16:170-4.

Low-intensity pulsatile ultrasonography

High-frequency sound waves that are above the audible limit of human beings interact with bone tissue and the adjacent soft tissues and generate microstress and tension that are capable of stimulating consolidation.66. Carmont RC, Mei-Dan O, Bennell LK. Stress fracture management: current classification and new healing modalities. Oper Tech Sports Med. 2009;17:81-9.,1313. Iwamoto J, Takeda T. Stress fractures in athletes: review of 196 cases. J Orthop Sci. 2003;8(3):273-8.and5050. Mehallo CJ, Drezner JA, Bytomski JR. Practical management: non steroidal anti- inflammatory drug (NSAID) use in athletic injuries. Clin J Sport Med. 2006;16:170-4. However, their exact mechanism of action remains unknown.1919. Mori S, Burr DB. Increasing intracortical remodelling following fatigue damage. Bone. 1993;14(2):103-9. Some studies have demonstrated its efficacy in treating stress fractures.5050. Mehallo CJ, Drezner JA, Bytomski JR. Practical management: non steroidal anti- inflammatory drug (NSAID) use in athletic injuries. Clin J Sport Med. 2006;16:170-4.and5858. Heckman JD, Ryaby JP, McCabe J, Frey JJ, Kilcoyne RF.Acceleration of tibial fracture healing by noninvasivelow-intensity pulsed ultrasound. J Bone Joint Surg Am.1994;76(1):26-34. Other studies have completely supported its use for treating these fractures.66. Carmont RC, Mei-Dan O, Bennell LK. Stress fracture management: current classification and new healing modalities. Oper Tech Sports Med. 2009;17:81-9.

Application of magnetic fields

Magnetic fields can be applied by means of a direct current at the focus of the fracture through surgical placement of electrodes, use of an electrical capacitation field device or use of electromagnetic field pulses.5050. Mehallo CJ, Drezner JA, Bytomski JR. Practical management: non steroidal anti- inflammatory drug (NSAID) use in athletic injuries. Clin J Sport Med. 2006;16:170-4. There is still no concrete evidence regarding its use in stress fractures.2020. Raasch WG, Hergan DJ. Treatment of stress fractures: the fundamentals. Clin Sports Med. 2006;25(1):29-36.and5050. Mehallo CJ, Drezner JA, Bytomski JR. Practical management: non steroidal anti- inflammatory drug (NSAID) use in athletic injuries. Clin J Sport Med. 2006;16:170-4.

Criteria for return to sport

The time taken from diagnosis to cure and until the return to sport depends on multiple factors such as the injury site, sports activity, severity of the injury and possibility of correcting risk factors that are intrinsic to the patient.2020. Raasch WG, Hergan DJ. Treatment of stress fractures: the fundamentals. Clin Sports Med. 2006;25(1):29-36. Low-risk stress fractures and non-surgical treatment usually make it possible for the patient to return to his activities four to 17 weeks after the injury.66. Carmont RC, Mei-Dan O, Bennell LK. Stress fracture management: current classification and new healing modalities. Oper Tech Sports Med. 2009;17:81-9.

The criteria that can be used for allowing an athlete to return to his practice may include: total absence of pain at the site affected, especially during sports movements; absence of symptoms during pain provocation tests at the injury site; absence of abnormalities in imaging examinations; and, above all, comprehension by the patient, trainers and technical team of the sport regarding the risk factors and conditions that led to the injury, so that corrections can be made so as to prevent recurrence and reappearance of injuries.1010. Bennell KL, Malcolm SA, Thomas SA, Wark JD, Brukner PD. The incidence and distribution of stress fractures in competitive track and field athletes. A twelve-month prospective study. Am J Sports Med. 1996;24(2):211-7.

The gradual definitive return to sports activity should be started after the patient has been free from pain for 10-14 days, with 10% increases in training intensity per week.2020. Raasch WG, Hergan DJ. Treatment of stress fractures: the fundamentals. Clin Sports Med. 2006;25(1):29-36.and5050. Mehallo CJ, Drezner JA, Bytomski JR. Practical management: non steroidal anti- inflammatory drug (NSAID) use in athletic injuries. Clin J Sport Med. 2006;16:170-4. Formation of a bone callus and obliteration of the fracture line on simple radiographs and, especially, on computed tomography scans are the factors that determine whether the cure process for the stress fracture has been adequate.5050. Mehallo CJ, Drezner JA, Bytomski JR. Practical management: non steroidal anti- inflammatory drug (NSAID) use in athletic injuries. Clin J Sport Med. 2006;16:170-4.

Prevention

Although several methods for preventing stress fractures have been proposed, only some of them present proven validity that can justify their recommendations.66. Carmont RC, Mei-Dan O, Bennell LK. Stress fracture management: current classification and new healing modalities. Oper Tech Sports Med. 2009;17:81-9. The possible risk factors that contribute to appearance of these fractures need to be carefully studied, modified and followed up.66. Carmont RC, Mei-Dan O, Bennell LK. Stress fracture management: current classification and new healing modalities. Oper Tech Sports Med. 2009;17:81-9.and1010. Bennell KL, Malcolm SA, Thomas SA, Wark JD, Brukner PD. The incidence and distribution of stress fractures in competitive track and field athletes. A twelve-month prospective study. Am J Sports Med. 1996;24(2):211-7. Constant control and modification of physical activity, with adequate recovery time, are extremely important.66. Carmont RC, Mei-Dan O, Bennell LK. Stress fracture management: current classification and new healing modalities. Oper Tech Sports Med. 2009;17:81-9.and1010. Bennell KL, Malcolm SA, Thomas SA, Wark JD, Brukner PD. The incidence and distribution of stress fractures in competitive track and field athletes. A twelve-month prospective study. Am J Sports Med. 1996;24(2):211-7. It is considered that daily intake of 2000 mg of calcium and 800 IU of vitamin D may be protection factors.66. Carmont RC, Mei-Dan O, Bennell LK. Stress fracture management: current classification and new healing modalities. Oper Tech Sports Med. 2009;17:81-9.and99. Cosman F, Ruffing J, Zion M, Uhorchak J, Ralston S, Tendy S, et al. Determinants of stress fractures risk in United States Military Academy cadets. Bone. 2013;55(2):359-66. The kinematics and biomechanical factors predisposing toward such fractures need to be monitored and corrected, through correct understanding of the sports movements, equipment, orthoses, training surface and all the other factors that may be involved in sports practice.66. Carmont RC, Mei-Dan O, Bennell LK. Stress fracture management: current classification and new healing modalities. Oper Tech Sports Med. 2009;17:81-9.,1010. Bennell KL, Malcolm SA, Thomas SA, Wark JD, Brukner PD. The incidence and distribution of stress fractures in competitive track and field athletes. A twelve-month prospective study. Am J Sports Med. 1996;24(2):211-7.and5050. Mehallo CJ, Drezner JA, Bytomski JR. Practical management: non steroidal anti- inflammatory drug (NSAID) use in athletic injuries. Clin J Sport Med. 2006;16:170-4. Some studies have investigated prophylactic use of bisphosphonates for preventing stress fractures, but there is still no evidence regarding its benefits in prevention of this type of injury.66. Carmont RC, Mei-Dan O, Bennell LK. Stress fracture management: current classification and new healing modalities. Oper Tech Sports Med. 2009;17:81-9.

Complications

The main complications occur in cases of high-risk stress fractures. Inappropriate management may cause progression of the fracture to a complete and displaced fracture line and thus give rise to delayed consolidation, avascular necrosis and pseudarthrosis.66. Carmont RC, Mei-Dan O, Bennell LK. Stress fracture management: current classification and new healing modalities. Oper Tech Sports Med. 2009;17:81-9.and2020. Raasch WG, Hergan DJ. Treatment of stress fractures: the fundamentals. Clin Sports Med. 2006;25(1):29-36.Furthermore, bisphosphonates used in treating stress fractures may weaken some bone regions when used over the long term and may predispose toward appearance of fractures due to insufficiency and a potential teratogenic effect among pregnant patients.66. Carmont RC, Mei-Dan O, Bennell LK. Stress fracture management: current classification and new healing modalities. Oper Tech Sports Med. 2009;17:81-9.

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  • Work performed at the Sports Traumatology Center, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, SP, Brazil.

Publication Dates

  • Publication in this collection
    jan-feb 2016

History

  • Received
    05 Jan 2015
  • Accepted
    05 Feb 2015
Sociedade Brasileira de Ortopedia e Traumatologia Al. Lorena, 427 14º andar, 01424-000 São Paulo - SP - Brasil, Tel.: 55 11 2137-5400 - São Paulo - SP - Brazil
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