Stress and Insufficiency Fractures

Stress fractures are most common in athletes and military recruits but also occur in patients with underlying metabolic bone disease (insufficiency fractures). Stress fractures are most frequent in the lower extremities and more common in women. The female athlete triad is an important risk factor. At the cellular level, the osteocyte may be important in the detection of stress fractures. Further, osteocytes are probably important in the healing of stress fractures. In patients with recurrent stress fractures, a biochemical evaluation for underlying metabolic bone disease should be undertaken. Prevention includes avoidance of sudden increases in the exercise, the use of proper footwear, avoidance of rough and hilly surfaces, and adequate nutrition. In premenopausal women with persistent amenorrhea and hypoestrogenism, estrogen replacement should be considered. Altering the mechanics of running might decrease the risk in some patients. In the patient with a stress fracture, the offending activity must be stopped for the fracture to heal. In some high-risk stress fractures, orthopedic surgery is advised. There is no specific drug therapy. Stress fractures are also associated with several metabolic bone diseases which are highlighted in this review with clinical vignettes. Diagnosis and management of these conditions is critical in the treatment of these patients.