Practice Essentials

The stress fracture, first described by Breithaupt in 1855, is a common overuse injury seen in athletes and military recruits.^{[1, 2]}The injury is usually seen in the lower extremities, but it has also been reported in the upper extremities and the ribs. The most common locations for stress fractures include the tibia, metatarsals, fibula, and navicular bones; less common locations include the femur, pelvis, and sacrum.

A stress fracture is caused by repetitive and submaximal loading of the bone, which eventually becomes fatigued and leads to a true fracture. The typical presentation is a complaint of increasing pain in the lower extremity during exercise or activity. The patient's history usually reveals a recent increase in either training volume or intensity.

The treatment of most stress fractures is relatively straightforward and includes decreased activity and immobilization; however, patients with some stress fractures, such as displaced femoral neck stress fractures^[3]and fifth metatarsal base stress fractures,^[4]are more likely to have complications such as nonunion. These complications should be monitored closely because surgical intervention may be necessary.

Next: Pathophysiology

Pathophysiology

Stress fractures result from recurrent and repetitive loading of bone. The stress fracture differs from other types of fractures in that in most cases, no acute traumatic event precedes the symptoms.

Beck TJ, Ruff CB, Shaffer RA, Betsinger K, Trone DW, Brodine SK. Stress fracture in military recruits: gender differences in muscle and bone susceptibility factors. Bone. 2000 Sep. 27 (3):437-44. [QxMD MEDLINE Link].
Hod N, Ashkenazi I, Levi Y, Fire G, Drori M, Cohen I, et al. Characteristics of skeletal stress fractures in female military recruits of the Israel defense forces on bone scintigraphy. Clin Nucl Med. 2006 Dec. 31 (12):742-9. [QxMD MEDLINE Link].
Bernstein EM, Kelsey TJ, Cochran GK, Deafenbaugh BK, Kuhn KM. Femoral Neck Stress Fractures: An Updated Review. J Am Acad Orthop Surg. 2022 Apr 1. 30 (7):302-311. [QxMD MEDLINE Link].
DeLee JC, Evans JP, Julian J. Stress fracture of the fifth metatarsal. Am J Sports Med. 1983 Sep-Oct. 11 (5):349-53. [QxMD MEDLINE Link].
Bennell KL, Malcolm SA, Thomas SA, Ebeling PR, McCrory PR, Wark JD, et al. Risk factors for stress fractures in female track-and-field athletes: a retrospective analysis. Clin J Sport Med. 1995 Oct. 5 (4):229-35. [QxMD MEDLINE Link].
Uthgenannt BA, Kramer MH, Hwu JA, Wopenka B, Silva MJ. Skeletal self-repair: stress fracture healing by rapid formation and densification of woven bone. J Bone Miner Res. 2007 Oct. 22 (10):1548-56. [QxMD MEDLINE Link].
Reeder MT, Dick BH, Atkins JK, Pribis AB, Martinez JM. Stress fractures. Current concepts of diagnosis and treatment. Sports Med. 1996 Sep. 22 (3):198-212. [QxMD MEDLINE Link].
Oh Y, Yamamoto K, Yoshii T, Kitagawa M, Okawa A. Current concept of stress fractures with an additional category of atypical fractures: a perspective review with representative images. Ther Adv Endocrinol Metab. 2021. 12:20420188211049619. [QxMD MEDLINE Link]. [Full Text].
Bennell K, Matheson G, Meeuwisse W, Brukner P. Risk factors for stress fractures. Sports Med. 1999 Aug. 28 (2):91-122. [QxMD MEDLINE Link].
Loud KJ, Micheli LJ, Bristol S, Austin SB, Gordon CM. Family history predicts stress fracture in active female adolescents. Pediatrics. 2007 Aug. 120 (2):e364-72. [QxMD MEDLINE Link].
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 Dec. 41 (12):2145-50. [QxMD MEDLINE Link].
Myburgh KH, Hutchins J, Fataar AB, Hough SF, Noakes TD. Low bone density is an etiologic factor for stress fractures in athletes. Ann Intern Med. 1990 Nov 15. 113 (10):754-9. [QxMD MEDLINE Link].
Nattiv A, Armsey TD Jr. Stress injury to bone in the female athlete. Clin Sports Med. 1997 Apr. 16 (2):197-224. [QxMD MEDLINE Link].
Montain SJ, McGraw SM, Ely MR, Grier TL, Knapik JJ. A retrospective cohort study on the influence of UV index and race/ethnicity on risk of stress and lower limb fractures. BMC Musculoskelet Disord. 2013 Apr 12. 14:135. [QxMD MEDLINE Link]. [Full Text].
Tenforde AS, Sayres LC, McCurdy ML, Sainani KL, Fredericson M. Identifying sex-specific risk factors for stress fractures in adolescent runners. Med Sci Sports Exerc. 2013 Oct. 45 (10):1843-51. [QxMD MEDLINE Link].
Chen YT, Tenforde AS, Fredericson M. Update on stress fractures in female athletes: epidemiology, treatment, and prevention. Curr Rev Musculoskelet Med. 2013 Jun. 6 (2):173-81. [QxMD MEDLINE Link].
Moreira CA, Bilezikian JP. Stress Fractures: Concepts and Therapeutics. J Clin Endocrinol Metab. 2017 Feb 1. 102 (2):525-534. [QxMD MEDLINE Link]. [Full Text].
Schnackenburg KE, Macdonald HM, Ferber R, Wiley JP, Boyd SK. Bone quality and muscle strength in female athletes with lower limb stress fractures. Med Sci Sports Exerc. 2011 Nov. 43 (11):2110-9. [QxMD MEDLINE Link].
Giladi M, Milgrom C, Simkin A, Danon Y. Stress fractures. Identifiable risk factors. Am J Sports Med. 1991 Nov-Dec. 19 (6):647-52. [QxMD MEDLINE Link].
Kale NN, Wang CX, Wu VJ, Miskimin C, Mulcahey MK. Age and Female Sex Are Important Risk Factors for Stress Fractures: A Nationwide Database Analysis. Sports Health. 2022 Nov-Dec. 14 (6):805-811. [QxMD MEDLINE Link].
Ruffer N, Krusche M, Beil FT, Amling M, Kötter I, Rolvien T. Clinical features of methotrexate osteopathy in rheumatic musculoskeletal disease: A systematic review. Semin Arthritis Rheum. 2022 Feb. 52:151952. [QxMD MEDLINE Link].
Kurklu M, Ozboluk S, Kilic E, Tatar O, Ozkan H, Basbozkurt M. Stress fracture of bilateral tibial metaphysis due to ceremonial march training: a case report. Cases J. 2010 Jan 4. 3:3. [QxMD MEDLINE Link].
Balius R, Pedret C, Estruch A, Hernández G, Ruiz-Cotorro A, Mota J. Stress fractures of the metacarpal bones in adolescent tennis players: a case series. Am J Sports Med. 2010 Jun. 38 (6):1215-20. [QxMD MEDLINE Link].
Hetsroni I, Nyska M, Ben-Sira D, Mann G, Segal O, Maoz G, et al. Analysis of foot structure in athletes sustaining proximal fifth metatarsal stress fracture. Foot Ankle Int. 2010 Mar. 31 (3):203-11. [QxMD MEDLINE Link].
Welck MJ, Hayes T, Pastides P, Khan W, Rudge B. Stress fractures of the foot and ankle. Injury. 2017 Aug. 48 (8):1722-1726. [QxMD MEDLINE Link]. [Full Text].
Joshi A, Kc BR, Shah BC, Chand P, Thapa BB, Kayastha N. Femoral neck stress fractures in military personnel. JNMA J Nepal Med Assoc. 2009 Apr-Jun. 48 (174):99-102. [QxMD MEDLINE Link].
Taimela S, Kujala UM, Orava S. Two consecutive rib stress fractures in a female competitive swimmer. Clin J Sport Med. 1995 Oct. 5 (4):254-6; discussion 257. [QxMD MEDLINE Link].
Lee AD. Golf-related stress fractures: a structured review of the literature. J Can Chiropr Assoc. 2009 Dec. 53 (4):290-9. [QxMD MEDLINE Link].
Karlson KA. Rib stress fractures in elite rowers. A case series and proposed mechanism. Am J Sports Med. 1998 Jul-Aug. 26 (4):516-9. [QxMD MEDLINE Link].
Funakoshi T, Furushima K, Kusano H, Itoh Y, Miyamoto A, Horiuchi Y, et al. First-Rib Stress Fracture in Overhead Throwing Athletes. J Bone Joint Surg Am. 2019 May 15. 101 (10):896-903. [QxMD MEDLINE Link].
Bijur PE, Horodyski M, Egerton W, Kurzon M, Lifrak S, Friedman S. Comparison of injury during cadet basic training by gender. Arch Pediatr Adolesc Med. 1997 May. 151 (5):456-61. [QxMD MEDLINE Link].
Rauh MJ, Macera CA, Trone DW, Shaffer RA, Brodine SK. Epidemiology of stress fracture and lower-extremity overuse injury in female recruits. Med Sci Sports Exerc. 2006 Sep. 38 (9):1571-7. [QxMD MEDLINE Link].
Frusztajer NT, Dhuper S, Warren MP, Brooks-Gunn J, Fox RP. Nutrition and the incidence of stress fractures in ballet dancers. Am J Clin Nutr. 1990 May. 51 (5):779-83. [QxMD MEDLINE Link].
Nattiv A, Agostini R, Drinkwater B, Yeager KK. The female athlete triad. The inter-relatedness of disordered eating, amenorrhea, and osteoporosis. Clin Sports Med. 1994 Apr. 13 (2):405-18. [QxMD MEDLINE Link].
Rauh MJ, Barrack M, Nichols JF. Associations between the female athlete triad and injury among high school runners. Int J Sports Phys Ther. 2014 Dec. 9 (7):948-58. [QxMD MEDLINE Link]. [Full Text].
Markey KL. Stress fractures. Clin Sports Med. 1987 Apr. 6 (2):405-25. [QxMD MEDLINE Link].
Deutsch AL, Coel MN, Mink JH. Imaging of stress injuries to bone. Radiography, scintigraphy, and MR imaging. Clin Sports Med. 1997 Apr. 16 (2):275-90. [QxMD MEDLINE Link].
Arendt EA, Griffiths HJ. The use of MR imaging in the assessment and clinical management of stress reactions of bone in high-performance athletes. Clin Sports Med. 1997 Apr. 16 (2):291-306. [QxMD MEDLINE Link].
Moran DS, Evans RK, Hadad E. Imaging of lower extremity stress fracture injuries. Sports Med. 2008. 38 (4):345-56. [QxMD MEDLINE Link].
Wright AA, Hegedus EJ, Lenchik L, Kuhn KJ, Santiago L, Smoliga JM. Diagnostic Accuracy of Various Imaging Modalities for Suspected Lower Extremity Stress Fractures: A Systematic Review With Evidence-Based Recommendations for Clinical Practice. Am J Sports Med. 2016 Jan. 44 (1):255-63. [QxMD MEDLINE Link].
Brukner P, Bennell K. Stress fractures in female athletes. Diagnosis, management and rehabilitation. Sports Med. 1997 Dec. 24 (6):419-29. [QxMD MEDLINE Link].
Hulkko A, Orava S. Stress fractures in athletes. Int J Sports Med. 1987 Jun. 8 (3):221-6. [QxMD MEDLINE Link].
Rome K, Handoll HH, Ashford R. Interventions for preventing and treating stress fractures and stress reactions of bone of the lower limbs in young adults. Cochrane Database Syst Rev. 2005 Apr 18. (2):CD000450. [QxMD MEDLINE Link]. [Full Text].
Murakami R, Sanada T, Fukai A, Yoshitomi H, Honda E, Goto H, et al. Less Invasive Surgery With Autologous Bone Grafting for Proximal Fifth Metatarsal Diaphyseal Stress Fractures. J Foot Ankle Surg. 2022 Jul-Aug. 61 (4):807-811. [QxMD MEDLINE Link].
Boden BP, Osbahr DC, Jimenez C. Low-risk stress fractures. Am J Sports Med. 2001 Jan-Feb. 29 (1):100-11. [QxMD MEDLINE Link].
Schwellnus MP, Jordaan G. Does calcium supplementation prevent bone stress injuries? A clinical trial. Int J Sport Nutr. 1992 Jun. 2 (2):165-74. [QxMD MEDLINE Link].
Finestone A, Giladi M, Elad H, Salmon A, Mendelson S, Eldad A, et al. Prevention of stress fractures using custom biomechanical shoe orthoses. Clin Orthop Relat Res. 1999 Mar. (360):182-90. [QxMD MEDLINE Link].
Milgrom C, Giladi M, Kashtan H, Simkin A, Chisin R, Margulies J, et al. A prospective study of the effect of a shock-absorbing orthotic device on the incidence of stress fractures in military recruits. Foot Ankle. 1985 Oct. 6 (2):101-4. [QxMD MEDLINE Link].

Media Gallery

Fifth metatarsal stress fracture.

of 1

Table 1. Epidemiologic Features of Stress Fractures According to Location and Activity

Location of Fracture	Activity Involved
Metatarsals, general	Football, basketball, gymnastics, ballet, military training^[22]
Metatarsal, base of second	Ballet
Metatarsal, fifth	Tennis,^{[23, 24]} ballet
Sesamoids of foot	Running, ballet, basketball, skating
Navicular	Sprinting,^[25] jumping, basketball, football
Talus	Pole vaulting
Calcaneus	Military drills, running, aerobics
Fibula	Running, jumping, ballet, repeated heavy lifting^[25]
Tibia	Running sports, dancing, ballet
Patella	Running, hurdling
Femoral neck	Distance running, military training^[26]
Pubic rami	Military drills, distance running
Pars articularis	Gymnastics, ballet, cricket, volleyball, diving, football
Chest, ribs	Swimming,^[27] golf,^[28] rowing,^[29] overhead throwing sports^[30]
Sternum	Wrestling
Ulna	Racquet sports, volleyball
Olecranon	Baseball, throwing sports

Table 2. Grading of Stress Fractures According to Radiologic Findings^[38]

Grade	Radiographic Finding	Bone Scan Finding	MRI Finding
1	Normal	Poorly defined area	Increased activity on STIR image
2	Normal	More intense	Poor definition on STIR and T2-weighted images
3	Discrete line	Sharp area of uptake	No focal or fusiform cortical break on T1- and T2-weighted images
4	Fracture or periosteal reaction	More intense localized transcortical uptake	Fracture line on T1- and T2-weighted images

Table 3. Healing Times for Various Stress Fractures*^[41]

Site of Stress Fracture	Percentage Healed at 2-4 wk, %	Percentage Healed at 1-2 mo, %	Percentage Healed at > 2 mo, %
Tibia, proximal third	0	43	57
Tibia, middle third	0	48	52
Tibia, distal third	0	53	47
Fibula	7	75	18
Metatarsals	20	57	23
Sesamoids	0	0	100
Femur, shaft	7	7	86
Femur, neck	0	0	100
Pelvis	0	29	75
Olecranon	0	0	100
*Adapted from Hulkko et al.^[42] Findings were from a case series of 368 stress fractures in athletes, in which the healing times of stress fractures in different locations were assessed.

Back to List

#author-disclosures{display:block}#author-disclosures.modal-layer{position:relative}#author-disclosures .modal-content{max-height:none}#author-disclosures .close-modal{display:none}

Author

Stefanos F Haddad, MD Fellow in Hand and Upper Extremity Surgery, Rothman Institute

Stefanos F Haddad, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Society for Surgery of the Hand, New York State Society of Orthopaedic Surgeons

Disclosure: Nothing to disclose.

Coauthor(s)

Cory M Czajka, MD Orthopedic Surgeon, Capital Region Orthopedic Group

Cory M Czajka, MD is a member of the following medical societies: Orthopaedic Trauma Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Samuel Agnew, MD, FACS Associate Professor, Departments of Orthopedic Surgery and Surgery, Chief of Orthopedic Trauma, University of Florida at Jacksonville College of Medicine; Consulting Surgeon, Department of Orthopedic Surgery, McLeod Regional Medical Center

Samuel Agnew, MD, FACS is a member of the following medical societies: American Association for the Surgery of Trauma, American College of Surgeons, Orthopaedic Trauma Association, Southern Orthopaedic Association

Disclosure: Nothing to disclose.

Chief Editor

Murali Poduval, MBBS, MS, DNB Orthopaedic Surgeon, Senior Consultant, and Subject Matter Expert, Tata Consultancy Services, Mumbai, India

Murali Poduval, MBBS, MS, DNB is a member of the following medical societies: Association of Medical Consultants of Mumbai, Bombay Orthopedic Society, Indian Orthopedic Association, Indian Society of Hip and Knee Surgeons

Disclosure: Nothing to disclose.

Additional Contributors

John S Early, MD Foot/Ankle Specialist, Texas Orthopaedic Associates, LLP; Co-Director, North Texas Foot and Ankle Fellowship, Baylor University Medical Center

John S Early, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Medical Association, American Orthopaedic Foot and Ankle Society, Orthopaedic Trauma Association, Texas Medical Association

Disclosure: Received honoraria from AO North America for speaking and teaching; Received consulting fee from Stryker for consulting; Received consulting fee from Biomet for consulting; Received grant/research funds from AO North America for fellowship funding; Received honoraria from MMI inc for speaking and teaching; Received consulting fee from Osteomed for consulting; Received ownership interest from MedHab Inc for management position.

John M Martinez, MD Staff Physician, Kaiser Permanente

John M Martinez, MD is a member of the following medical societies: American Academy of Family Physicians, American College of Sports Medicine, American Medical Society for Sports Medicine

Disclosure: Nothing to disclose.

TOP PICKS FOR YOU

Stress Fractures

Practice Essentials

Pathophysiology

References

Tables

Contributor Information and Disclosures

What would you like to print?