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Stress Reaction and Fractures

John Kiel1; Kimberly Kaiser2.
1
University of Kentucky
2
University of Kentucky

Last Update: June 11, 2018.

Introduction
Stress injuries represent a spectrum of injuries ranging from periostitis, caused by inflammation of the periosteum, to
a complete stress fracture that includes a full cortical break. They are relatively common overuse injuries in athletes
that are caused by repetitive submaximal loading on a bone over time. Stress injuries are often seen in running and
jumping athletes and are associated with increased volume or intensity of training workload. Most commonly, they
are found in the lower extremities and are specific to the sport in which the athlete participates. Upper extremity stress
injuries are much less common than lower extremity stress injuries, but when they do occur, they are most commonly
seen in the ulna. Similar to the lower extremity injuries, upper extremity stress injuries are the result of overuse and
fatigue.

Rib stress fractures are an uncommon site of stress injuries. First rib fractures are the most common, and these are
seen in pitchers, basketball players, weightlifters, and ballet dancers. Stress fractures in ribs 4 through 9 are seen in
competitive rowers, and posteromedial rib stress fractures can be seen in golfers.

Stress fractures of the pelvis can be vague clinically and mimic other causes of groin and hip pain, for example,
adductor strain, osteitis pubis, or sacroiliitis. The most common location is the ischiopubic ramus and sacrum. These
injuries are seen most commonly in runners.

Femoral neck stress fractures make up approximately 11% of stress injuries in athletes. The patient complains of hip
or groin pain which is worse with weight bearing and range of motion especially internal rotation. There are 2 types of
femoral neck stress fractures: tension-type (or distraction) fractures and compression-type fractures. Tension-type
femoral neck stress fractures involve the superior-lateral aspect of the neck and are at highest risk for complete
fracture; thus, these should be detected early. Compression-type fractures are seen in younger athletes and involve the
inferior-medial femoral neck. A trial of non-surgical management can be attempted for patients without a visible
fracture line on radiographs in compression type injuries. This injury is common in runners.

Stress fractures of the femoral shaft are well documented in the literature, and in one study among military recruits,
they represented 22.5% of all stress fractures. Patients typically complain of poorly localized, insidious leg pain often
mistaken for muscle injury. An exam is often nonfocal, although the “fulcrum test” test can be used by providers to
localize the affected pain and suggest the diagnosis. If there is no evidence of a cortical break on imaging, a non-
surgical approach can be attempted.

The patella is a rare location for a stress fracture and can be oriented either transverse or vertical. Transverse fractures
are at higher risk for displacement and immobilization is recommended.

Tibial stress injuries are the most common location of stress reactions and fractures. Medial tibial stress syndrome
(MTSS), also known as shin splints or tibial periostitis, can be difficult to distinguish from medial tibial stress
fractures. Typically, the patient will be tender over the medial posterior edge of the tibia often made worse with a
motor exam. Stress injuries will present with pain during activities of daily living, while MTSS is generally limited to
exertional activity. Anterior cortex tibial stress fractures are less common than the posteromedial ones and are found
in jumping and leaping athletes. These patients may have the “dreaded black line” on x-ray. They are at a greater risk
of nonunion and full cortical break and require aggressive conservative therapy. If that fails, surgical management
such as an intramedullary rod or flexible plate is indicated. Stress fractures of the medial tibial plateau are uncommon
but can be confused for meniscus injury or pes anserine bursitis, and thus, a high index of suspicion is needed.

Fibular stress fractures are common and most commonly located in the lower third of the fibula, proximal to the
tibiofibular ligament. Patients will have reproducible pain on palpation of the affected bone.

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Medial malleolus stress fractures are uncommon. Running and jumping athletes can develop vertical stress fractures
at the junction of the medial malleolus and tibial plafond. If full cortical disruption is identified, surgical fixation is
typically indicated.

Calcaneal stress fractures present as localized tenderness over the heel of the calcaneus posterior to the talus. Patients
will have a positive squeeze test.

Stress fractures can develop in the navicular, medial cuneiform, and lateral process of the talus. Navicular stress
fractures are difficult to diagnose early on and are at high risk of nonunion due to poor vascular flow, primarily in the
middle third. These are common in basketball players and runners. They are usually tender on the navicular bone.

Metatarsal stress fractures account for 9% of all stress fractures in athletes. The second and third metatarsals are most
commonly affected and are usually in the neck or distal shaft. They will be point tender with localized swelling over
the affected bone. Dancers fracture is a stress fracture at the base of the second metatarsal. Stress fractures distal to the
tuberosity of the fifth metatarsal are termed Jones fractures but must be distinguished from an acute Jones fracture.

Sesamoid stress injuries of the great toe present as gradual unilateral plantar pain with the medial (tibial) sesamoid
most frequently affected. Direct tenderness or pain with passive extension of the toe aid in diagnosis.

Etiology
Stress fractures are the partial or complete fracture of a bone as a result of sub-maximal loading. This injury is often
compared analogously to fatigue fractures found in engineering materials such as bridges and buildings although
some would argue that the mechanisms are different. Normally, submaximal forces do not result in the fracture;
however, with repetitive loading and inadequate time for healing and recovery, stress fractures can potentially occur.
The debate continues whether the cause is contractile muscle forces acting on a bone or increased fatigue of
supporting structures; it is likely that both contribute.

Stress fractures can be stratified as high or low risk, a categorization that alludes to the likelihood of propagation to
displacement or non-union thus requiring surgical fixation. High-risk areas include the calcaneus, fifth metatarsal,
sesamoid, talar neck, tarsal navicular, anterior tibial cortex, medial malleolus, femoral neck, femoral head, patella, and
pars interarticularis of the lumbar spine. Low-risk stress injuries include pubic ramus, sacrum, ribs, proximal
humerus/humeral shaft, posteromedial tibial shaft, fibula, and second through fourth metatarsal shafts.

Risk factors for stress injuries include energy deficiency through diet (i.e., low caloric intake based on the amount of
exercise performed) and hypovitaminosis D. The female athlete triad consisting of disordered eating, amenorrhea or
oligomenorrhea, and decreased bone mineral density also increase the risk for stress injuries. Late onset of menarche,
metabolic bone disorders including osteomalacia and Paget disease of the bone, and high serum cortisol levels may
also be associated with an increased risk. Rapid changes in training programs including increased distance, pace,
volume, or cross training without adequate time for adaptation can contribute. Failure to follow intense training days
with easy ones for recovery can also contribute to injury.

Because stress injuries frequently occur with a change in training routine, they are common in runners and military
recruits. For runners, this may mean an increase in training intensity or a change in footwear or training surface.
Increasing distance beyond 32 km (20 miles) per week was found to be associated with an increased rate of stress
fractures in one study. In military recruits, these injuries are often associated with the initiation of basic training or
changes in training with increased running and marching.

Anatomic and biomechanical risk factors are more difficult to study. Among military recruits, only a narrow width of
the tibia and increased external rotation were found to be risk factors for stress fracture. Female runners with stress
fractures were found to have smaller calf girth and less lean muscle mass in the lower limb. Previously, ground
reaction forces were thought to contribute to the development of lower-limb stress fractures. However, a 2011
systematic review found that the evidence did not support this assumption. On the other hand, the vertical loading
rate, or the rate at which the heel strike occurs, was positively associated. On diagnostic imaging, running athletes
with stress fractures were found to have smaller tibial cross sectional area than runners without stress fractures. This
finding supports the notion that bone geometry plays a role in the development of stress fractures.

Epidemiology

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Up to 20% of all sports medicine clinic injuries may be related to stress injuries. They are so common among military
recruits that stress injuries are the number one cause of missed training days. Among high school athletes, 0.8% of all
injuries sustained were stress fractures. The rate was 1.54 per 100,000 athlete exposures with the incidence highest in
cross-country athletes. The lower leg (40.3%) and foot (34.9%) represent the majority of stress injuries. Among elite
soccer players, the incidence was 0.04 injuries/1000 hours, and all involved the lower extremity with 78% involving
the fifth metatarsal. Among US Army recruits, the rate of stress fractures in men and women was 19.3 with 79.9
cases/1000 recruits.

Stress fractures are more common in weight-bearing than non-weight bearing limbs. Stress fractures of the tibia,
metatarsals, and fibula are the most frequently reported sites. Medial tibial stress syndrome, also known as shin
splints, is the most common form of early stress injury. This diagnosis reflects a spectrum of medial tibial pain in
early manifestations before developing into a stress fracture.

The location of stress injuries varies by sport. Among track athletes, fractures to the navicular, tibia, and metatarsals
are most common, and among distance runners, the tibia and fibula are most common. Among dancers, the
metatarsals are most afflicted, and in military recruits, the calcaneus and metatarsals are the most commonly fractured
site. The ulna is the upper extremity bone most frequently affected.

Pathophysiology
Stress injuries reflect a mismatch between the native bone strength and the chronic mechanical load placed upon the
bone. This mismatch can be due to fatigue, i.e., abnormal stress on normal bony architecture, or insufficiency,
meaning normal stress on the abnormal bone. Insufficiency stress fracture may be termed pathologic in some
literature although the classic definition of pathological fracture refers to a focal bony abnormality.

In healthy bone, osteoblastic activity repairs areas of trauma or injury including that from physical activity. However,
if the recovery period is not sufficient for osteoblasts to generate new bone, the rate of resorption by osteoclasts
exceeds new bone formation, and thus, the bone weakens. Accumulated repetitively over time, this leads to stress
reactions, and if training is not modified, these become completed stress fractures. Advanced imaging studies
demonstrate this trabecular bone with linear microfractures from repetitive loading.

Histopathology
The histology of stress fractures show that repetitive stress response leads to increased osteoclastic activity surpassing
the rate of osteoblastic activity and new bone formation. Subsequently, there is a weakening of the bone.

History and Physical

Patients will report a history of insidious onset of pain without any specific trauma. They will often describe a history
of a significant volume of a specific exercise such as running, an increase in training intensity or volume, or a change
in training surface. Initially, symptoms are made worse when training only but may progress to pain with activities of
daily living. The symptoms often improve with cessation of activity.

On exam, the clinician will appreciate focal tenderness on the area of a suspected stress injury. There may be soft
tissue swelling. Soft tissue tenderness will tend to suggest muscle injury, early stress reaction, or another etiology of
the pain whereas bony tenderness is more likely to suggest stress fracture. Some areas of stress injuries may be more
clinically subtle or difficult to examine such as the pelvis and sacrum thus requiring the clinician to have a higher
index of suspicion from the history alone.

A “one leg hop test” can be used to distinguish between medial tibial stress syndrome and tibial stress fractures.
Patients with stress injuries can tolerate repeated jumping whereas stress fractures cannot hop without pain. Of note,
the landing is typically when the patient notices the pain.

A 3-point “fulcrum test” can be used to aid in the diagnosis of a femoral shaft stress fracture. The examiner's arm is
used as a fulcrum under the thigh while pressure is applied to the knee. A positive test is pain or apprehension at the
point of the fulcrum.

Evaluation

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Workup of a suspected stress injury initially involves radiographic evaluation of the affected area. X-ray of the
affected area will typically appear normal, especially during the first few weeks after onset of symptoms and thus has
low sensitivity. Abnormal findings include periosteal elevation, sclerosis, cortical thickening, and potentially a
fracture line. Loss of cortical density may also suggest an early-stage stress injury. One may see the so-called
“dreaded black line” seen on a tibial or femoral stress fracture or other high-risk stress fractures. Since stress reactions
and fractures may not be evident on initial plain radiographs, repeat x-rays, CT, MRI or bone scintigraphy may be
indicated.

Computerized tomography (CT) findings are similar to plain radiographs with sclerosis, new bone formation,
periosteal reaction and fracture lines in long bones. It is helpful to rule out other etiologies if the diagnosis is uncertain
based on other imaging.

Bone scintigraphy is moderately sensitive at 74%. Positive findings on scintigraphy will identify high radioisotope
activity, or uptake is found in the affected area within a few days of symptom onset. Increased uptake can also be due
to other pathology (avascular necrosis, osteomyelitis, neoplasm, among others) which makes specificity low.

MRI is the most sensitive imaging modality (approximately 88%) and is replacing bone scintigraphy as standard
practice for workup of suspected stress injuries. The fracture line usually extends through the cortex into the
medullary canal with surrounding bone edema. MRI can also be used to evaluate other possible soft tissue injuries
including muscle, ligament, and cartilage injuries.

Treatment / Management
Treatment of stress injuries varies depending on whether it is a stress reaction or stress fracture, by the site of injury,
and by its suitability for rehabilitation. Clinicians should recognize which fractures are at risk for delayed union,
nonunion, displacement, or intra-articular involvement. It is important to recognize the injury early as early
intervention is associated with more rapid healing and recovery. High-risk stress fractures may be managed
conservatively or surgically depending on the occupation and sport of choice of the individual.

Stress injuries that are low-risk sites are typically managed conservatively with a 2-phase protocol. Phase one includes
analgesia, modified weight bearing, and activity modification including discontinuing the offending activities. If the
patient cannot ambulate without pain, temporary immobilization is indicated. Examples of activity modification
include water fitness, cycling, and elliptical to maintain strength and fitness. Phase 2 begins after a period of pain-free
rest and involves a gradual return to activity over the subsequent weeks including continued physical therapy. For
example, a runner may initially start running at half pace and distance every other day. Over the subsequent weeks,
one can gradually increase their distance, frequency, and intensity with the goal of returning to their baseline. The
length of each phase can vary. A good rule of thumb is however long an injury takes to become pain-free, the same
amount of additional time is needed to perform a graduated return to activity. When adding in the time required for
rehabilitation training to achieve prior physical fitness levels, loss of training time can be as great as 19 weeks.

Athletes with overly pronated or supinated feet may benefit from orthotics. Inadequate shock absorption may also be
ameliorated by changing or addressing footwear. Running shoes should be changed every 300 to 350 miles of use
depending on the type of shoe, surface, and athlete. Characteristics of a proper running shoe include heel width and
support, firm midsole, and a straight last. Clinicians with expertise in running may be able to perform gait analyses
and recommend form changes that will reduce their risk of re-injury.

Females runners with late menarche, fewer menses, and lower bone mineral density are at an increased risk of stress
fracture. If history reveals these risk factors, a bone mineral density test and endocrine workup should be considered.
Routine supplementation of vitamin D and calcium is not typically indicated unless dietary inadequacy exists. In
athletes with repeated stress fractures, testing vitamin D and calcium levels and subsequent supplementation in
deficient individuals is recommended. Athletes with eating disorders should be evaluated, and psychiatric testing and
nutritional counseling recommended when indicated. Bisphosphonates, which work by inhibiting osteoclastic activity
and increasing bone mineral density, have shown early promise in individuals with stress fractures, although more
research is required.

Regarding specific types of stress fractures, management varies:

Rib: Rib stress injuries are managed nonoperatively with rest, analgesia, and cessation of the offending activity.
Correction in training errors and faulty mechanics may be helpful as well.

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Pelvis: Pelvic stress injuries are managed conservatively with rest, crutches (if required), and a gradual return to
sport.

Femoral neck: Compression side femoral neck stress injuries can be managed conservatively with non-weight
bearing using crutches and activity restriction if the fatigue line is less than 50% of the femoral width. Tension
side stress injuries or a compression fracture with fatigue line more than 50% of the femoral neck width
typically require open reduction and internal fixation (ORIF) with percutaneous screw fixation.

Femoral shaft: Most femoral shaft stress injuries can be managed conservatively including rest, activity
modification, and protected weight bearing. If the patient has low bone mineral density, is older than 60 years
old, or has fracture completion or displacement, ORIF with an intramedullary nail is indicated.

Patella: Patellar stress injuries can be managed conservatively with immobilization and gradual return to
activity.

Tibia: Most tibial shaft stress injuries can be managed conservatively. This includes activity restriction and
protected weight-bearing. If the “dreaded black line” is present and violates the anterior cortex, then ORIF with
intramedullary tibial nailing or plating may be indicated. This depends on the duration of conservative
treatment and the patient’s occupation and the sport in which the patient participates. Medial tibial plateau stress
fractures can be managed conservatively. Medial malleolus stress fractures can typically be managed
conservatively but should be discussed with one’s orthopedic surgeon.

Fibula: Fibular stress injuries can be managed conservatively with rest, immobilization, activity modification,
and a gradual return to play.

Tarsals: Calcaneal stress injuries respond well to conservative management with rapid healing and return to
activity. Navicular stress injuries are at high risk of nonunion. They can be managed conservatively including
non-weight-bearing for up to 12 weeks with close follow up before beginning return to play, or if there’s a
completed fracture line, ORIF with screw fixation is typically performed. Medial cuneiform and some talus
stress injuries can also be managed conservatively.

Metatarsals: Most metatarsal fractures can be managed conservatively including adding metatarsal padding as
needed. Dancers fractures at the base of the second metatarsal should be made non-weight bearing. Fifth
metatarsal stress fractures are at high risk for nonunion and should be non-weight bearing with immobilization
and close follow up as they may require surgical intervention. Sesamoid stress fractures require rest from
offending activity and immobilization and offloading of the sesamoids.

Differential Diagnosis
The differential diagnosis for stress reaction and a stress fracture is broad and generally specific to the affected area of
the patient.

For most patient complaints, the provider must consider other musculoskeletal causes including bursitis, tendonitis,
muscle or tendon strain, ligament strain, degenerative changes, arthropathy, radiculopathy, bone contusion, avascular
necrosis, neoplasm (osteosarcoma), and infection (osteomyelitis). Where anatomically appropriate, non-
musculoskeletal causes could include dermatologic, vascular, neurologic, genitourinary, reproductive, or
gastrointestinal etiologies. For example, a stress injury of the pelvis and proximal femur could present as the pelvis,
hip, thigh, or groin pain, and the differential should be focused on this region. Stress fractures of the fibula will
present as leg pain, and the provider will need to consider the appropriate anatomy.

The differential diagnosis of tibial stress injuries includes periostitis or completed stress fracture, chronic exertional
compartment syndrome (CECS), and popliteal artery entrapment syndrome.

Staging
Staging of stress injuries is based on MRI findings which are the most sensitive diagnostic modality. The MRI
findings use the Fredericson classification system:

Grade 1: Periosteal edema only

Grade 2: Bone marrow edema (only on T2 weighted sequences)

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Grade 3: Bone marrow edema (on T1 and T2 weighted sequences)

Grade 4: (4a) Multiple discrete areas of intracortical signal changes; (4b) Linear areas of intracortical signal
change correlating with a frank stress fracture

One may also visualize a periosteal reaction on x-ray which typically correlates with a grade 3 stress injury on MRI or
completed fracture line that correlates with a grade 4 stress injury.

Prognosis
Most athletes will return to play with minimal pain and normal function if provided appropriate relative rest and
rehabilitation. If athletes return to play too soon or are inadequately rehabilitated, their pain may lead to chronic
injury. Adequate rest, immobilization and non-weight bearing when appropriate, and a gradual return to activity
typically result in a return to pre-injury level of play. The primary issue with stress injuries is missed playing time.

Complications
Acute complications from stress injuries include pain, swelling, and missed playing time. Individuals with full cortical
break may require surgery and all the risks associated with surgical intervention. Chronic complications include
chronic pain, inability to return to the initial level of play, and repeat or recurrent stress fractures.

Questions
To access free multiple choice questions on this topic, click here.

References
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fractures. J Orthop. 2018 Mar;15(1):122-127. [PMC free article: PMC5895937] [PubMed: 29657454]
2. Fukushima Y, Ray J, Kraus E, Syrop IP, Fredericson M. A Review and Proposed Rationale for the use of
Ultrasonography as a Diagnostic Modality in the Identification of Bone Stress Injuries. J Ultrasound Med. 2018
Apr 14; [PubMed: 29655254]
3. Kwon JY, Cronin P, Velasco B, Chiodo C. Evaluation and Significance of Mortise Instability in Supination
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29652191]
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6. Chaudhry ZS, Raikin SM, Harwood MI, Bishop ME, Ciccotti MG, Hammoud S. Outcomes of Surgical Treatment
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01;:363546517741137. [PubMed: 29528694]
7. Słowiński JJ, Kudłacik K. Analysis of the Impact of Configuration of the Stabilisation System for Femoral
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