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A Brief Review of Stress Fractures

By Kristine Banks, M.D.

“The dreaded black line” refers to an anterior tibia shaft stress fracture which is the most commonly known of all stress fractures. Such injuries can plague athletes of all ages and levels of competition. Running and dancing are common mechanisms, as these fractures are due to overuse and repetitive stresses. While there is a recorded history of fractures in the military, the actual incidence in the general population is unknown.

Bone remodeling is an ongoing process. Normally, the cycle of bone catabolism and anabolism is balanced. The pathophysiology behind stress fractures follows from an imbalance in this cycle. The bone does not have time to repair the damage from repetitive stresses, thus resulting in the fracture.

The majority of stress fractures involve the lower extremity. Examples include: femoral neck, tibia, metatarsals (2nd and 5th), and tarsal navicular.

Symptoms can include a localized area of pain and tenderness, and inability to bear weight on the extremity. For an accurate diagnosis the physician needs to obtain a detailed history and physical exam. Further identification can be made via a combination of X-rays, cat scans (CTs), MRIs, or bone scans.

The best form of treatment is prevention, which includes cross-training, appropriate equipment, and a healthy diet. However when a fracture is present, treatment is generally conservative, with a few exceptions (fracture location, duration, special circumstances of elite athletes). Initial management involves rest, avoidance of aggravating activities, and protected weight bearing. Occasionally, bracing or casting is needed. Rehabilitation is used to strengthen the surrounding muscles and joints for future protection of the bone.