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Stress fracture

Other Names
March fracture, Spontaneous Fracture, Fatigue Fractures

Signs and Symptoms
Symptoms usually have a gradual onset, with complaints that include isolated pain along the shaft of the bone. In cases of fibular stress fractures, pain occurs proximal to the lateral malleolus, that increases with activity and subsides with rest.

During activity, in some cases the affected may report decreased muscular strength and cramping

Palpation, in the affected, area may reveal crepitus in well-developed stress fractures and point tenderness isolated to a single spot along the bone

Causes
A narrow tibial shaft, high degree of hip external rotation, osteopenia, osteoporosis, and pes cavus are common predisposing factors for stress fractures

Potential causes include overload caused by muscle contraction, amenorrhea, an altered stress distribution in the bone accompanying muscle fatigue, a change in ground reaction force  (concrete to grass)  or the performance of a rhythmically repetitive stress that leads up to a vibratory summation point.

A bone may become vulnerable to fractures during the first few weeks of intense physical activity or training due to the weight-bearing bones undergo bone resorption and become weaker before becoming stronger

-Over training

-Going back to competition too soon after an injury or illness

-Going from one event to another without proper training for the second event

-Starting initial training too quickly

-Changing habits or the environment like training surface or shoes

Diagnosis
Tuning forks have been advocated as an inexpensive alternative to identifying the presence of stress fractures. The clinician places a vibrating tuning fork along the shaft of the suspected bone. If a stress fracture is present, the vibration would cause pain. It should be noted that this test has a low positive likelihood ratio and a high negative likelihood ratio meaning it should not be used as the only diagnostic method.

Epidemiology
This type of injury is mostly seen in lower extremities, due to them being under constant weight-bearing (WB). From most common bones that are frequently affected by stress fractures to least are the tibia, tarsals, metatarsals (MT), fibula, femur, pelvis and spine. Upper extremity stress fractures do occur, but they are uncommon. The main reason why this type of injury happens in upper torso is due to muscle forces.

The populations that are at the highest risk for stress fractures are athletes and military recruits who are participating in repetitive, high intensity training. Sports and activities that have excessive, repetitive ground reaction forces have the highest incidence of stress fractures. The site at which the stress fracture occurs depends on the activity/sports that the individual participates in.

Women are more at risk for stress fractures than men due to factors such as lower aerobic capacity, reduced muscle mass, lower bone mineral density, among other anatomical and hormone-related elements. Women also have a two- to four-times increased risk of stress fractures when suffering from amenorrhea when compared to women who are eumenorrheic. Reduced bone health increases the risk of stress fractures and studies have shown an inverse relationship between bone mineral density and stress fracture occurrences. This condition is most notable and commonly seen on the femoral neck