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Stress fractures: Pathophysiology, epidemiology, and risk factors

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Abstract

A stress fracture represents the inability of the skeleton to withstand repetitive bouts of mechanical loading, which results in structural fatigue and resultant signs and symptoms of localized pain and tenderness. To prevent stress fractures, an appreciation of their risk factors is required. These are typically grouped into extrinsic and intrinsic risk factors. Extrinsic risk factors for stress fractures are those in the environment or external to the individual, including the type of activity and factors involving training, equipment, and the environment. Intrinsic risk factors for stress fractures refer to characteristics within the individual, including skeletal, muscle, joint, and biomechanical factors, as well as physical fitness and gender. This article discusses these extrinsic and intrinsic risk factors, as well as the pathophysiology and epidemiology of stress fractures.

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References and Recommended Reading

  1. Bennell KL, Brukner PD: Epidemiology and site specificity of stress fractures. Clin Sports Med 1997, 16:179–196.

    Article  PubMed  Google Scholar 

  2. Bennell KL, Malcolm SA, Thomas SA, et al.: Risk factors for stress fractures in track and field athletes: a twelve-month prospective study. Am J Sports Med 1996, 24:810–818.

    Article  PubMed  CAS  Google Scholar 

  3. Snyder RA, Koester MC, Dunn WR: Epidemiology of stress fractures. Clin Sports Med 2006, 25:37–52.

    Article  PubMed  Google Scholar 

  4. Bennell KL, Malcolm SA, Khan KM, et al.: Bone mass and bone turnover in power athletes, endurance athletes, and controls: a 12-month longitudinal study. Bone 1997, 20:477–484.

    Article  PubMed  CAS  Google Scholar 

  5. Bennell KL, Malcolm SA, Thomas SA, 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, 24:211–217.

    Article  PubMed  CAS  Google Scholar 

  6. Warden SJ, Gutschlag FR, Wajswelner H, Crossley KM: Aetiology of rib stress fractures in rowers. Sports Med 2002, 32:819–836.

    Article  PubMed  Google Scholar 

  7. Sabick MB, Torry MR, Kim YK, Hawkins RJ: Humeral torque in professional baseball pitchers. Am J Sports Med 2004, 32:892–898.

    Article  PubMed  Google Scholar 

  8. Goldberg B, Pecora C: Stress fractures: a risk of increased training in freshmen. Phys Sportsmed 1994, 22:68–78.

    Google Scholar 

  9. Sullivan D, Warren RF, Pavlov H, Kelman G: Stress fractures in 51 runners. Clin Orthop Relat Res 1984, 187:188–192.

    PubMed  Google Scholar 

  10. Gardner LI, Dziados JE, Jones BH, et al.: Prevention of lower extremity stress fractures: a controlled trial of a shock absorbent insole. Am J Public Health 1988, 78:1563–1567.

    Article  PubMed  Google Scholar 

  11. Schwellnus MP, Jordaan G, Noakes TD: Prevention of common overuse injuries by the use of shock absorbing insoles. A prospective study. Am J Sports Med 1990, 18:636–641.

    Article  PubMed  CAS  Google Scholar 

  12. Finestone A, Giladi M, Elad H, et al.: Prevention of stress fractures using custom biomechanical shoe orthoses. Clin Orthop Relat Res 1999, 360:182–190.

    Article  PubMed  Google Scholar 

  13. Finestone A, Novack V, Farfel A, et al.: A prospective study of the effect of foot orthoses composition and fabrication on comfort and the incidence of overuse injuries. Foot Ankle Int 2004, 25:462–466.

    PubMed  Google Scholar 

  14. Milgrom C, Finestone A, Shlamkovitch N, et al.: Prevention of overuse injuries of the foot by improved shoe shock attenuation: a randomized prospective study. Clin Orthop Relat Res 1992, 281:189–192.

    PubMed  Google Scholar 

  15. Milgrom C, Finestone A, Segev S, et al.: Are overground or treadmill runners more likely to sustain tibial stress fracture? Br J Sports Med 2003, 37:160–163.

    Article  PubMed  CAS  Google Scholar 

  16. Marti B, Vader JP, Minder CE, Abelin T: On the epidemiology of running injuries. The 1984 Bern Grand-Prix study. Am J Sports Med 1988, 16:285–294.

    Article  PubMed  CAS  Google Scholar 

  17. Walter SD, Hart LE, McIntosh JM, Sutton JR: The Ontario cohort study of running-related injuries. Arch Intern Med 1989, 149:2561–2564.

    Article  PubMed  CAS  Google Scholar 

  18. Bennell K, Matheson G, Meeuwisse W, Brukner P: Risk factors for stress fractures. Sports Med 1999, 28:91–122.

    Article  PubMed  CAS  Google Scholar 

  19. Zahger D, Abramovitz A, Zelikovsky L, et al.: Stress fractures in female soldiers: an epidemiological investigation of an outbreak. Mil Med 1988, 153:448–450.

    PubMed  CAS  Google Scholar 

  20. Carter DR, Hayes WC: Fatigue life of compact bone. II. Effects of microstructure and density. J Biomech 1976, 9:211–218.

    Article  PubMed  CAS  Google Scholar 

  21. Warden SJ, Hurst JA, Sanders MS, et al.: Bone adaptation to a mechanical loading program significantly increases skeletal fatigue resistance. J Bone Miner Res 2005, 20:809–816. Animal study investigating the influence of bone mass and size on stress fracture risk. It found that a small (less than twofold) change in the structural properties of a bone increased its fatigue resistance more than 100-fold, indicating that a moderate exercise program that induces bone adaptation may be an effective strategy for preventing stress fractures.

    Article  PubMed  Google Scholar 

  22. Bennell KL, Malcolm SA, Thomas SA, et al.: Risk factors for stress fractures in female track-and-field athletes: a retrospective analysis. Clin J Sports Med 1995, 5:229–235.

    Article  CAS  Google Scholar 

  23. Armstrong DW 3rd, Rue J-PH, Wilckens JH, Frassica FJ: Stress fracture injury in young military men and women. Bone 2004, 35:806–816.

    Article  PubMed  Google Scholar 

  24. Bennell K, Crossley K, Jayarajan J, et al.: Ground reaction forces and bone parameters in females with tibial stress fracture. Med Sci Sports Exerc 2004, 36:397–404.

    Article  PubMed  Google Scholar 

  25. Crossley KM, Bennell KL, Wrigley T, Oakes B: Ground reaction forces, bone characteristics, and tibial stress fracture in male runners. Med Sci Sports Exerc 1999, 31:1088–1093.

    Article  PubMed  CAS  Google Scholar 

  26. Beck TJ, Ruff CB, Mourtada FA, et al.: Dual-energy x-ray absorptiometry derived structural geometry for stress fracture prediction in male U.S. Marine Corps recruits. J Bone Miner Res 1996, 11:645–653.

    Article  PubMed  CAS  Google Scholar 

  27. Lappe J, Davies K, Recker R, Heaney R: Quantitative ultrasound: utility in screening for susceptibility to stress fractures in female army recruits. J Bone Miner Res 2005, 20:571–578.

    Article  PubMed  Google Scholar 

  28. Arndt A, Ekenman I, Westblad P, Lundberg A: Effects of fatigue and load variation on metatarsal deformation measured in vivo during barefoot walking. J Biomech 2002, 35:621–628.

    Article  PubMed  CAS  Google Scholar 

  29. Fyhrie DP, Milgrom C, Hoshaw SJ, et al.: Effect of fatiguing exercise on longitudinal bone strain as related to stress fracture in humans. Ann Biomed Eng 1998, 26:660–665.

    Article  PubMed  CAS  Google Scholar 

  30. Sharkey NA, Ferris L, Smith TS, Matthews DK: Strain and loading of the second metatarsal during heel-lift. J Bone Joint Surg Am 1995, 77:1050–1057.

    PubMed  CAS  Google Scholar 

  31. Yoshikawa T, Mori S, Santiesteban AJ, et al.: The effects of muscle fatigue on bone strain. J Exp Biol 1994, 188:217–233.

    PubMed  CAS  Google Scholar 

  32. Beck TJ, Ruff CB, Shaffer RA, et al.: Stress fracture in military recruits: gender differences in muscle and bone susceptibility factors. Bone 2000, 27:437–444.

    Article  PubMed  CAS  Google Scholar 

  33. McNair PJ, Prapavessis H, Callender K: Decreasing landing forces: effect of instruction. Br J Sports Med 2000, 34:293–296.

    Article  PubMed  CAS  Google Scholar 

  34. Mizrahi J, Susak Z: In-vivo elastic and damping response of the human leg to impact forces. J Biomech Eng 1982, 104:63–66.

    Article  PubMed  CAS  Google Scholar 

  35. Seliktar R, Mizrahi J: Partial immobilization of the ankle and talar joints complex and its effect on the ground-foot force characteristics. Eng Med 1984, 13:5–10.

    Article  PubMed  CAS  Google Scholar 

  36. Hughes LY: Biomechanical analysis of the foot and ankle for predisposition to developing stress fractures. J Orthop Sports Phys Ther 1985, 7:96–101.

    PubMed  CAS  Google Scholar 

  37. Kaufman KR, Brodine SK, Shaffer RA, et al.: The effect of foot structure and range of motion on musculoskeletal overuse injuries. Am J Sports Med 1999, 27:585–593.

    PubMed  CAS  Google Scholar 

  38. Davis I, Milner C, Hamill J: Does increased loading during running lead to tibial stress fractures? A prospective study. Med Sci Sports Exerc 2004, 36(suppl):S58.

    Article  CAS  Google Scholar 

  39. Milner CE, Ferber R, Pollard CD, et al.: Biomechanical factors associated with tibial stress fracture in female runners. Med Sci Sports Exerc 2006, 38:323–328. Study retrospectively investigating biomechanical factors potentially associated with tibial stress fractures. It demonstrated that stress fracture risk may be related to loading rates and the magnitude of tibial shock; the latter could categorize individuals according to stress fracture history with 70% accuracy.

    Article  PubMed  Google Scholar 

  40. Finestone A, Shlamkovitch N, Eldad A, et al.: Risk factors for stress fractures among Israeli infantry recruits. Mil Med 1991, 156:528–530.

    PubMed  CAS  Google Scholar 

  41. Giladi M, Milgrom C, Stein M, et al.: The low arch, a protective factor in stress fractures: a prospective study of 295 military recruits. Orthop Rev 1985, 14:709–712.

    Google Scholar 

  42. Simkin A, Leichter I, Giladi M, et al.: Combined effect of foot arch structure and an orthotic device on stress fractures. Foot Ankle 1989, 10:25–29.

    PubMed  CAS  Google Scholar 

  43. Dixon SJ, Creaby MW, Allsopp AJ: Comparison of static and dynamic biomechanical measures in military recruits with and without a history of third metatarsal stress fracture. Clin Biomech 2006, 21:412–419.

    Article  Google Scholar 

  44. Jones BH, Thacker SB, Gilchrist J, et al.: Prevention of lower extremity stress fractures in athletes and soldiers: a systematic review. Epidemiol Rev 2002, 24:228–247.

    Article  PubMed  Google Scholar 

  45. Milgrom C, Simkin A, Eldad A, et al.: Using bone’s adaptation ability to lower the incidence of stress fractures. Am J Sports Med 2000, 28:245–251.

    PubMed  CAS  Google Scholar 

  46. Lappe JM, Stegman MR, Recker RR: The impact of lifestyle factors on stress fractures in female Army recruits. Osteoporos Int 2001, 12:35–42.

    Article  PubMed  CAS  Google Scholar 

  47. Redman LM, Loucks AB: Menstrual disorders in athletes. Sports Med 2005, 35:747–755. An excellent review of the incidence, mechanisms, and clinical consequences of menstrual disorders in female athletes. Concludes that athletic women may acquire their menstrual disorders by failing to increase dietary intake in compensation for exercise energy expenditure.

    Article  PubMed  Google Scholar 

  48. Frusztajer NT, Dhuper S, Warren MP, et al.: Nutrition and the incidence of stress fractures in ballet dancers. Am J Clin Nutr 1990, 51:779–783.

    PubMed  CAS  Google Scholar 

  49. Loucks AB, Thuma JR: Luteinizing hormone pulsatility is disrupted at a threshold of energy availability in regularly menstruating women. J Clin Endocrinol Metab 2003, 88:297–311.

    Article  PubMed  CAS  Google Scholar 

  50. Ihle R, Loucks AB: Dose-response relationships between energy availability and bone turnover in young exercising women. J Bone Miner Res 2004, 19:1231–1240. Study investigating the dose-response relationship between energy availability and selected markers of bone turnover in female military recruits. Bone formation markers decreased and bone resorption markers increased in those who had restricted energy availability, suggesting that nutritional status may contribute to the higher incidence of stress fractures in female military recruits.

    Article  PubMed  Google Scholar 

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Authors and Affiliations

  1. Department of Physical Therapy, Indiana University, 1140 W. Michigan St., CF-326, 46202, Indianapolis, IN, USA

    Stuart J. Warden PhD, PT

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  1. Stuart J. Warden PhD, PT
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  2. David B. Burr PhD
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  3. Peter D. Brukner MBBS
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Correspondence to Stuart J. Warden PhD, PT.

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Warden, S.J., Burr, D.B. & Brukner, P.D. Stress fractures: Pathophysiology, epidemiology, and risk factors. Curr Osteoporos Rep 4, 103–109 (2006). https://doi.org/10.1007/s11914-996-0029-y

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