Stress Fracture

18 y/o F military recruit with h/o eating disorder, smoking, and consuming > 10 alcoholic drinks per week presents with acute onset tenderness/edema in the lower extremities shortly after starting basic training. Recent physical activity has included running > 25 miles/week. Pain reproducible with ambulation; no tenderness along length of posteromedial tibial shaft.

• Imaging

  • Obtain plain film x-ray; if negative and pain persists, repeat in 2 weeks

  • Need for immediate diagnosis or suspected 5th metatarsal stress fracture: Obtain MRI

• Treatment

  • Acetaminophen 500 mg QID; consider naproxen 500 mg BID if additional pain control needed

  • Non-weight bearing crutches for 4 days before transitioning to a walking boot for 4 weeks, and then a rigid sole shoe for an additional 4 weeks

  • Suspected tibial stress fracture: Recommend pneumatic compression device to reduce time to resumption of full activity

  • Proximal 5th metatarsal stress (Jones) fracture: Refer to orthopedics

• Counseling

  • Pt counseled that she may resume physical activity upon pain resolution, but that this may require up to 12 weeks

  • Pt encouraged to adopt balanced diet and engage in cross-training to prevent future stress fractures

• Schedule follow-up in 4 weeks

Notes

• Epidemiology

  • Risk factors include female sex/female athlete triad, sudden increase in activity (e.g. military recruit), smoking, and > 10 drinks per week

  • Approximately 75% of stress fractures occur in the tibia/fibula, tarsal navicular bone, or metatarsals

• Differential diagnosis

  • Includes tendinopathy, nerve/artery entrapment syndrome and compartment syndrome

  • Medial tibial stress syndrome (shin splints) presents with tenderness along posteromedial tibial shaft and no edema

• Treatment

  • NSAIDs may slow healing time

  • Fifth metatarsal stress fractures may require surgery if located proximally and should be evaluated with MRI