Stress Fractures: Diagnosis and Management in the Primary Care Setting

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Epidemiology

Snyder and colleagues43 extensively reviewed epidemiologic studies on stress fractures in athletes. It is difficult to generalize data from different studies because of methodological differences among them. Factors that influence the acquisition, results, and interpretation of data include differences in definition of injury exposure, study designs, definition of injury, and accuracy and method of diagnosis (clinical, radiological). Given these limitations, several conclusions are drawn.43

Diagnosis

Activity-related, insidious onset of pain that is localized to the affected area is the cardinal presenting symptom of stress fracture.1 Initially, the pain is reduced or transiently relieved with rest, allowing the athlete to continue the activity; however, progression of stress injury results in increased intensity of pain and functional deterioration or limitation of activity, which prompts the athlete to seek medical attention.6, 53, 54, 55 Pain from stress fracture is usually described as

Management

Management of stress fractures is guided by consideration of several factors. It is important to first recognize whether the fracture is at a high-risk (Box 1) or low-risk site (Table 5).2, 3 In general, when a high-risk stress fracture is suspected or identified, orthopedic or sports medicine consultation is recommended, although this decision may be tempered by personal experience of the primary care physician and the site and severity of the fracture. While awaiting further definitive

Summary

Stress fractures in adolescent athletes are common injuries seen in practice. Stress fractures most frequently affect lower extremities and are most common in long-distance runners and track and field athletes. Diagnosis is based mainly on clinical evaluation. MRI is the study of choice for further delineating the stress injury of the bone. Most stress fractures that involve low-risk sites can be managed conservatively in the primary care setting and heal in 6 to 10 weeks.

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References (66)

  • M.C. Koester et al.

    Pharmacologic agents in fracture healing

    Clin Sports Med

    (2006)
  • G.O. Matheson et al.

    Stress fracture in athletes

    Am J Sports Med

    (1987)
  • B.P. Boden et al.

    Low-risk stress fractures

    Am J Sports Med

    (2001)
  • B.P. Boden et al.

    High-risk stress fractures: evaluation and treatment

    Am Acad Orthop Surg

    (2000)
  • K. Harmon

    Lower extremity stress fractures

    Clin J Sport Med

    (2003)
  • D. Bolin et al.

    Current concepts in the evaluation and management of stress fractures

    Curr Rep Sport Med

    (2005)
  • L.I. Gardner et al.

    Prevention of lower extremity stress fractures: a controlled trial of a shock absorbent insole

    Am J Public Health

    (1988)
  • A. Finestone et al.

    Prevention of stress fractures using custom biomechanical shoe orthosis

    Clin Orthop

    (1999)
  • W.J. Gillespie et al.

    Interventions for preventing and treating stress fractures and stress reactions of bone of the lower limbs in young adults

    Cochrane Database Syst Rev

    (2000)
  • I. Ekenman et al.

    The role of biomechanical shoe orthosis in tibial stress fracture prevention

    Am J Sports Med

    (2002)
  • C. Milgrom et al.

    Are overground or treadmill runners more likely to sustain tibial stress fracture?

    Br J Sports Med

    (2003)
  • K.L. Bennell et al.

    The incidence and distribution of stress fractures in competitive track and field athletes: a twelve-month prospective study

    Am J Sports Med

    (1996)
  • G.J. Hickey et al.

    Injuries to elite rowers over a 10-yr period

    Med Sci Sports Exerc

    (1997)
  • T.J. Brudvig et al.

    Stress fractures in 295 trainees: a one-year study of incidence as related to age, sex, and race

    Mil Med

    (1983)
  • C. Milgrom et al.

    Youth is a risk factor for stress fracture: a study of 783 infantry recruits

    J Bone Joint Surg Br

    (1994)
  • A.C. Winfield et al.

    Risk factors associated with stress reactions in female Marines

    Mil Med

    (1997)
  • H. Vaitkevicius et al.

    Ethnic differences in titratable acid excretion and bone mineralization

    Med Sci Sports Exerc

    (2002)
  • A. Swissa et al.

    The effect of pretraining sports activity on the incidence of stress fractures among military recruits: a prospective study

    Clin Orthop

    (1989)
  • K.L. Bennell et al.

    Risk factors for stress fractures in track and field athletes: a twelve-month prospective study

    Am J Sports Med

    (1996)
  • M. Giladi et al.

    External rotation of the hip: a predictor of risk for stress fractures

    Clin Orthop

    (1987)
  • K.H. Myburg et al.

    Low bone density is an etiologic factor for stress fractures in athletes

    Ann Intern Med

    (1990)
  • R.G. Marx et al.

    Stress fracture sites related to underlying bone health in athletic females

    Clin J Sport Med

    (2001)
  • K.L. Cobb et al.

    Disordered eating, menstrual irregularity, and bone mineral density in female runners

    Med Sci Sports Exerc

    (2003)
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