Clinical Review

Bone Stress Injuries in the Military: Diagnosis, Management, and Prevention

Am J Orthop. 2017 July;46(4):176-183

Bone stress injuries occur when forces applied to a bone for an extended period exceed the ability of the bone to adequately remodel. These injuries, which range from stress reactions to nondisplaced and even displaced fractures, most often affect people who experience high levels of repetitive stress and loading in the lower extremity or changes in physical activity level. For example, stress fractures are common in endurance athletes, in athletes engaged in preseason and early-season conditioning, and in military recruits. In the military, these injuries are most often encountered during basic training, when new recruits undergo the rigors of intense physical activity to which they may not be accustomed. Female athletes and athletes with poor nutritional status are at elevated risk for injury. Bone stress injuries are difficult to diagnose with radiographs alone. Making the correct diagnosis may require a combination of physical examination, advanced imaging, and an index of suspicion. Differences in injury location account for variations in risk for nonunion, displacement, and other complications. For low-risk injuries, treatment typically consists of reduced weight-bearing for several weeks with gradual return to activity. Higher-risk injuries need to be closely monitored for progression and may require operative intervention. Even after surgery, some types of stress fractures may take several months to achieve radiographic union. In addition, underlying nutritional or metabolic deficiencies may need to be treated to prevent future injuries. In this article, we review the diagnosis, management, and prevention of bone stress injuries with a focus on more serious manifestations, such as stress fracture.

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References

1. Briethaupt MD. Zur Pathologie des menschlichen Fusses [To the pathology of the human foot]. Med Zeitung. 1855;24:169-177.

2. Berger FH, de Jonge MC, Maas M. Stress fractures in the lower extremity. Eur J Radiol. 2007;62(1):16-26.

3. Almeida SA, Williams KM, Shaffer RA, Brodine SK. Epidemiological patterns of musculoskeletal injuries and physical training. Med Sci Sports Exerc. 1999;31(8):1176-1182.

4. Jones BH, Thacker SB, Gilchrist J, Kimsey CD, Sosin DM. Prevention of lower extremity stress fractures in athletes and soldiers: a systematic review. Epidemiol Rev. 2002;24(2):228-247.

5. Jacobs JM, Cameron KL, Bojescul JA. Lower extremity stress fractures in the military. Clin Sports Med. 2014;33(4):591-613.

6. Waterman BR, Gun B, Bader JO, Orr JD, Belmont PJ. Epidemiology of lower extremity stress fractures in the United States military. Mil Med. 2016;181(10):1308-1313.

7. Hsu LL, Nevin RL, Tobler SK, Rubertone MV. Trends in overweight and obesity among 18-year-old applicants to the United States military, 1993–2006. J Adolesc Health. 2007;41(6):610-612.

8. Stanitski CL, McMaster JH, Scranton PE. On the nature of stress fractures. Am J Sports Med. 1978;6(6):391-396.

9. Johnson LC. Histogenesis of stress fractures [annual lecture]. Washington, DC: Armed Forces Institute of Pathology; 1963.

10. Friedenberg ZB. Fatigue fractures of the tibia. Clin Orthop Relat Res. 1971;(76):111-115.

11. Cameron KL, Peck KY, Owens BD, et al. Biomechanical risk factors for lower extremity stress fracture. Orthop J Sports Med. 2013;1(4 suppl).

12. Knapik J, Montain S, McGraw S, Grier T, Ely M, Jones B. Stress fracture risk factors in basic combat training. Int J Sports Med. 2012;33(11):940-946.

13. Behrens SB, Deren ME, Matson A, Fadale PD, Monchik KO. Stress fractures of the pelvis and legs in athletes. Sports Health. 2013;5(2):165-174.

14. Mountjoy M, Sundgot-Borgen J, Burke L, et al. The IOC consensus statement: beyond the female athlete triad—relative energy deficiency in sport (RED-S). Br J Sports Med. 2014;48(7):491-497.

15. Maitra RS, Johnson DL. Stress fractures. Clinical history and physical examination. Clin Sports Med. 1997;16(2):259-274.

16. Nieves JW, Melsop K, Curtis M, et al. Nutritional factors that influence change in bone density and stress fracture risk among young female cross-country runners. PM R. 2010;2(8):740-750.

17. Beck BR, Matheson GO, Bergman G, et al. Do capacitively coupled electric fields accelerate tibial stress fracture healing? Am J Sports Med. 2008;36(3):545-553.

18. Simkin A, Leichter I, Giladi M, Stein M, Milgrom C. Combined effect of foot arch structure and an orthotic device on stress fractures. Foot Ankle. 1989;10(1):25-29.

19. Johnson AW, Weiss CB, Wheeler DL. Stress fractures of the femoral shaft in athletes—more common than expected: a new clinical test. Am J Sports Med. 1994;22(2):248-256.

20. Clement D, Ammann W, Taunton J, et al. Exercise-induced stress injuries to the femur. Int J Sports Med. 1993;14(6):347-352.

21. Wood PJ, Barth JH, Freedman DB, Perry L, Sheridan B. Evidence for the low dose dexamethasone suppression test to screen for Cushing’s syndrome—recommendations for a protocol for biochemistry laboratories. Ann Clin Biochem. 1997;34(pt 3):222-229.

22. Bennell K, Matheson G, Meeuwisse W, Brukner P. Risk factors for stress fractures. Sports Med. 1999;28(2):91-122.

23. Prather JL, Nusynowitz ML, Snowdy HA, Hughes AD, McCartney WH, Bagg RJ. Scintigraphic findings in stress fractures. J Bone Joint Surg Am. 1977;59(7):869-874.

24. Arendt EA, Griffiths HJ. The use of MR imaging in the assessment and clinical management of stress reactions of bone in high-performance athletes. Clin Sports Med. 1997;16(2):291-306.

25. Boden BP, Osbahr DC. High-risk stress fractures: evaluation and treatment. J Am Acad Orthop Surg. 2000;8(6):344-353.

26. Gaeta M, Minutoli F, Scribano E, et al. CT and MR imaging findings in athletes with early tibial stress injuries: comparison with bone scintigraphy findings and emphasis on cortical abnormalities. Radiology. 2005;235(2):553-561.

27. Matheson GO, Clement DB, Mckenzie DC, Taunton JE, Lloyd-Smith DR, Macintyre JG. Stress fractures in athletes. Am J Sports Med. 1987;15(1):46-58.

28. Iwamoto J, Takeda T. Stress fractures in athletes: review of 196 cases. J Orthop Sci. 2003;8(3):273-278.

29. Noakes TD, Smith JA, Lindenberg G, Wills CE. Pelvic stress fractures in long distance runners. Am J Sports Med. 1985;13(2):120-123.

30. Neubauer T, Brand J, Lidder S, Krawany M. Stress fractures of the femoral neck in runners: a review. Res Sports Med. 2016;24(3):283-297.

31. Evans JT, Guyver PM, Kassam AM, Hubble MJW. Displaced femoral neck stress fractures in Royal Marine recruits—management and results of operative treatment. J R Nav Med Serv. 2012;98(2):3-5.

32. Orava S. Stress fractures. Br J Sports Med. 1980;14(1):40-44.

33. Niva MH, Kiuru MJ, Haataja R, Pihlajamäki HK. Fatigue injuries of the femur. J Bone Joint Surg Br. 2005;87(10):1385-1390.

34. Weishaar MD, McMillian DJ, Moore JH. Identification and management of 2 femoral shaft stress injuries. J Orthop Sports Phys Ther. 2005;35(10):665-673.

35. Salminen ST, Pihlajamäki HK, Visuri TI, Böstman OM. Displaced fatigue fractures of the femoral shaft. Clin Orthop Relat Res. 2003;(409):250-259.

36. Giladi M, Ahronson Z, Stein M, Danon YL, Milgrom C. Unusual distribution and onset of stress fractures in soldiers. Clin Orthop Relat Res. 1985;(192):142-146.

37. Matheson GO, Clement DB, Mckenzie DC, Taunton JE, Lloyd-Smith DR, Macintyre JG. Stress fractures in athletes. Am J Sports Med. 1987;15(1):46-58.

38. Green NE, Rogers RA, Lipscomb AB. Nonunions of stress fractures of the tibia. Am J Sports Med. 1985;13(3):171-176.

39. Orava S, Hulkko A. Stress fracture of the mid-tibial shaft. Acta Orthop Scand. 1984;55(1):35-37.

40. Swenson EJ Jr, DeHaven KE, Sebastianelli WJ, Hanks G, Kalenak A, Lynch JM. The effect of a pneumatic leg brace on return to play in athletes with tibial stress fractures. Am J Sports Med. 1997;25(3):322-328.

41. Rettig AC, Shelbourne KD, McCarroll JR, Bisesi M, Watts J. The natural history and treatment of delayed union stress fractures of the anterior cortex of the tibia. Am J Sports Med. 1988;16(3):250-255.

42. Varner KE, Younas SA, Lintner DM, Marymont JV. Chronic anterior midtibial stress fractures in athletes treated with reamed intramedullary nailing. Am J Sports Med. 2005;33(7):1071-1076.

43. Donahue SW, Sharkey NA. Strains in the metatarsals during the stance phase of gait: implications for stress fractures. J Bone Joint Surg Am. 1999;81(9):1236-1244.

44. Giuliani J, Masini B, Alitz C, Owens BD. Barefoot-simulating footwear associated with metatarsal stress injury in 2 runners. Orthopedics. 2011;34(7):e320-e323.

45. DeLee JC, Evans JP, Julian J. Stress fracture of the fifth metatarsal. Am J Sports Med. 1983;11(5):349-353.

46. Lappe JM, Stegman MR, Recker RR. The impact of lifestyle factors on stress fractures in female army recruits. Osteoporos Int. 2001;12(1):35-42.

47. Friedl KE, Evans RK, Moran DS. Stress fracture and military medical readiness: bridging basic and applied research. Med Sci Sports Exerc. 2008;40(11 suppl):S609-S622.

48. Lappe J, Cullen D, Haynatzki G, Recker R, Ahlf R, Thompson K. Calcium and vitamin D supplementation decreases incidence of stress fractures in female navy recruits. J Bone Miner Res. 2008;23(5):741-749.

49. DIPART (Vitamin D Individual Patient Analysis of Randomized Trials) Group. Patient level pooled analysis of 68 500 patients from seven major vitamin D fracture trials in US and Europe. BMJ. 2010;340:b5463.

50. Duckham RL, Peirce N, Meyer C, Summers GD, Cameron N, Brooke-Wavell K. Risk factors for stress fracture in female endurance athletes: a cross-sectional study. BMJ Open. 2012;2(6).

51. Milgrom C, Finestone A, Novack V, et al. The effect of prophylactic treatment with risedronate on stress fracture incidence among infantry recruits. Bone. 2004;35(2):418-424.

52. Crowell HP, Davis IS. Gait retraining to reduce lower extremity loading in runners. Clin Biomech. 2011;26(1):78-83.

53. Ekenman I, Milgrom C, Finestone A, et al. The role of biomechanical shoe orthoses in tibial stress fracture prevention. Am J Sports Med. 2002;30(6):866-870.

54. Warden SJ, Hurst JA, Sanders MS, Turner CH, Burr DB, Li J. Bone adaptation to a mechanical loading program significantly increases skeletal fatigue resistance. J Bone Miner Res. 2005;20(5):809-816.

Take-Home Points

Stress injuries, specifically of the lower extremity, are very common in new military trainees.
Stress injury can range from benign periosteal reaction to displaced fracture.
Stress injury should be treated on a case-by-case basis, depending on the severity of injury, the location of the injury, and the likelihood of healing with nonoperative management.
Modifiable risk factors such as nutritional status, training regiment, and even footwear should be investigated to determine potential causes of injury.
Prevention is a crucial part of the treatment of these injuries, and early intervention such as careful pre-enrollment physicals and vitamin supplementation can be essential in lowering injury rates.

Bone stress injuries, which are common in military recruits, present in weight-bearing (WB) areas as indolent pain caused by repetitive stress and microtrauma. They were first reported in the metatarsals of Prussian soldiers in 1855.¹ Today, stress injuries are increasingly common. One study estimated they account for 10% of patients seen by sports medicine practitioners.² This injury most commonly affects military members, endurance athletes, and dancers.^3-5 Specifically, the incidence of stress fractures in military members has been reported to range from 0.8% to 6.9% for men and from 3.4% to 21.0% for women.⁴ Because of repetitive vigorous lower extremity loading, stress fractures typically occur in the pelvis, femoral neck, tibial shaft, and metatarsals. Delayed diagnosis and the subsequent duration of treatment required for adequate healing can result in significant morbidity. In a 2009 to 2012 study of US military members, Waterman and colleagues⁶ found an incidence rate of 5.69 stress fractures per 1000 person-years. Fractures most frequently involved the tibia/fibula (2.26/1000), followed by the metatarsals (0.92/1000) and the femoral neck (0.49/1000).⁶ In addition, these injuries were most commonly encountered in new recruits, who were less accustomed to the high-volume, high-intensity training required during basic training.^4,7 Enlisted junior service members have been reported to account for 77.5% of all stress fractures.⁶ Age under 20 years or over 40 years and white race have also been found to be risk factors for stress injury.⁶

The pathogenesis of stress injury is controversial. Stanitski and colleagues⁸ theorized that multiple submaximal mechanical insults create cumulative stress greater than bone capacity, eventually leading to fracture. Johnson⁹ conducted a biopsy study and postulated that an accelerated remodeling phase was responsible, whereas Friedenberg¹⁰ argued that stress injuries are a form of reduced healing, not an attempt to increase healing, caused by the absence of callous formation in the disease process.

Various other nonmodifiable and modifiable risk factors predispose military service members to stress injury. Nonmodifiable risk factors include sex, bone geometry, limb alignment, race, age, and anatomy. Lower extremity movement biomechanics resulting from dynamic limb alignment during activity may be important. Cameron and colleagues¹¹ examined 1843 patients and found that those with knees in >5° of valgus or >5° of external rotation had higher injury rates. Although variables such as sex and limb alignment cannot be changed, proper identification of modifiable risk factors can assist with injury prevention, and nonmodifiable risk factors can help clinicians and researchers target injury prevention interventions to patients at highest risk.

Metabolic, hormonal, and nutritional status is crucial to overall bone health. Multiple studies have found that low body mass index (BMI) is a significant risk factor for stress fracture.^7,12,13Although low BMI is a concern, patients with abnormally high BMI may also be at increased risk for bone stress injury. In a recently released consensus statement on relative energy deficiency in sport (RED-S), the International Olympic Committee addressed the complex interplay of impairments in physiologic function—including metabolic rate, menstrual function, bone health, immunity, protein synthesis, and cardiovascular health—caused by relative energy deficiency.¹⁴The committee stated that the cause of this syndrome is energy deficiency relative to the balance between dietary energy intake and energy expenditure required for health and activities of daily living, growth, and sporting activities. This finding reveals that conditions such as stress injury often may represent a much broader systemic deficit that may be influenced by a patient’s overall physiologic imbalance.

Diagnosis

History and Physical Examination

The onset of stress reaction typically is insidious, with the classic presentation being a new military recruit who is experiencing a sudden increase in pain during physical activity.¹⁵ Pain typically is initially present only during activity, and is relieved with rest, but with disease progression this evolves to pain at rest. It is crucial that the physician elicit the patient’s history of training and physical activity. Hsu and colleagues⁷ reported increased prevalence of overweight civilian recruits, indicating an increase in the number of new recruits having limited experience with the repetitive physical activity encountered in basic training. Stress injury should be suspected in the setting of worsening, indolent lower extremity pain that has been present for several days, especially in the higher-risk patient populations mentioned. Diet should be assessed, with specific attention given to the intake of fruits, vegetables, and foods high in vitamin D and calcium and, most important, the energy balance between intake and output.¹⁶ Special attention should also be given to female patients, who may experience the female athlete triad, a spectrum of low energy availability, menstrual dysfunction, and impaired bone turnover (high amount of resorption relative to formation). A key part of the RED-S consensus statement¹⁴ alerted healthcare providers that metabolic derangements do not solely affect female patients. These types of patients sustain a major insult to the homeostatic balance of the hormones that sustain adequate bone health. Beck and colleagues¹⁷ found that women with disrupted menstrual cycles are 2 to 4 times more likely to sustain a stress fracture than women without disrupted menstrual cycles, making this abnormality an important part of the history.

Examination should begin with careful evaluation of limb alignment and specific attention given to varus or valgus alignment of the knees.¹¹ The feet should also be inspected, as pes planus or cavus foot may increase the risk of stress fracture.¹⁸ Identification of the area of maximal tenderness is important. The area in question may also be erythematous or warm secondary to the inflammatory response associated with attempted fracture healing. In chronic fractures in superficial areas such as the metatarsals, callus may be palpable. Although there are few specific tests for stress injury, pain may be reproducible with deep palpation and WB.

If a femoral fracture is suspected, the fulcrum test can be performed by applying downward pressure on the patient’s knee while levering the thigh over the examiner’s opposite arm or thigh (Figure 1).¹⁹ Patients with sacral stress fractures may have pain when standing or hopping on the affected side (positive flamingo test).²⁰

Laboratory Testing

When a pathology is thought to have a nutritional or metabolic cause, particularly in a low-weight or underweight patient, a laboratory workup should be obtained. Specific laboratory tests that all patients should undergo are 25-hydroxyvitamin D3, complete blood cell count, and basic chemistry panel, including calcium and thyroid-stimulating hormone levels. Although not necessary for diagnosis, phosphate, parathyroid hormone, albumin, and prealbumin should also be considered. Females should undergo testing of follicle stimulating hormone, luteinizing hormone, estradiol, and testosterone and have a urine pregnancy test. In patients with signs of excessive cortisone, a dexamethasone suppression test can be administered.²¹ In males, low testosterone is a documented risk factor for stress injury.²²

Imaging

Given their low cost and availability, plain radiographs typically are used for initial examination of a suspected stress injury. However, they often lack sensitivity, particularly in the early stages of stress fracture development (Figure 2).

Although a fracture line or callus formation is present occasionally, findings may be subtler. Images should be inspected for blunting of cortical bone and periosteal reaction, which should be correlated with the site of maximal tenderness.¹¹ When there is high clinical suspicion based on history and physical examination, but radiographs are negative, magnetic resonance imaging (MRI) or bone scan can be useful.²³ MRI is the most accurate imaging modality, with sensitivity ranging from 86% to 100% and specificity as high as 100%.^2,24,25 On MRI, stress fractures typically are seen as bright areas of increased edema. Arendt and Griffiths²⁴ proposed an MRI-based grading system for stress fractures, with grades 1 and 2 representing low-grade injuries, and 3 and 4 representing high grade. Computed tomography (CT) also has a role in diagnosis and may be better than MRI in imaging stress fractures in the pelvis and sacrum.² In a study involving tibial stress fractures, Gaeta and colleagues²⁶ found MRI was 88% sensitive and 100% specific and had a positive predictive value of 100%, and CT was 42% sensitive and 100% specific and had a positive predictive value of 100%. They concluded MRI was superior to CT in the diagnosis of tibial stress fractures.

Management

Management of bone stress injury depends on many factors, including symptom duration, fracture location and severity, and risk of progression or nonunion (Table).¹³

Patients thought to have an underlying metabolic or nutritional derangement should be treated accordingly. Injuries with a low risk of nonunion or further displacement typically can be managed with a period of modified physical activity or reduced or non-WB (NWB) ambulation; higher risk injuries may require operative intervention.⁵

References

1. Briethaupt MD. Zur Pathologie des menschlichen Fusses [To the pathology of the human foot]. Med Zeitung. 1855;24:169-177.

2. Berger FH, de Jonge MC, Maas M. Stress fractures in the lower extremity. Eur J Radiol. 2007;62(1):16-26.

3. Almeida SA, Williams KM, Shaffer RA, Brodine SK. Epidemiological patterns of musculoskeletal injuries and physical training. Med Sci Sports Exerc. 1999;31(8):1176-1182.

4. Jones BH, Thacker SB, Gilchrist J, Kimsey CD, Sosin DM. Prevention of lower extremity stress fractures in athletes and soldiers: a systematic review. Epidemiol Rev. 2002;24(2):228-247.

5. Jacobs JM, Cameron KL, Bojescul JA. Lower extremity stress fractures in the military. Clin Sports Med. 2014;33(4):591-613.

6. Waterman BR, Gun B, Bader JO, Orr JD, Belmont PJ. Epidemiology of lower extremity stress fractures in the United States military. Mil Med. 2016;181(10):1308-1313.

7. Hsu LL, Nevin RL, Tobler SK, Rubertone MV. Trends in overweight and obesity among 18-year-old applicants to the United States military, 1993–2006. J Adolesc Health. 2007;41(6):610-612.

8. Stanitski CL, McMaster JH, Scranton PE. On the nature of stress fractures. Am J Sports Med. 1978;6(6):391-396.

9. Johnson LC. Histogenesis of stress fractures [annual lecture]. Washington, DC: Armed Forces Institute of Pathology; 1963.

10. Friedenberg ZB. Fatigue fractures of the tibia. Clin Orthop Relat Res. 1971;(76):111-115.

11. Cameron KL, Peck KY, Owens BD, et al. Biomechanical risk factors for lower extremity stress fracture. Orthop J Sports Med. 2013;1(4 suppl).

12. Knapik J, Montain S, McGraw S, Grier T, Ely M, Jones B. Stress fracture risk factors in basic combat training. Int J Sports Med. 2012;33(11):940-946.

13. Behrens SB, Deren ME, Matson A, Fadale PD, Monchik KO. Stress fractures of the pelvis and legs in athletes. Sports Health. 2013;5(2):165-174.

14. Mountjoy M, Sundgot-Borgen J, Burke L, et al. The IOC consensus statement: beyond the female athlete triad—relative energy deficiency in sport (RED-S). Br J Sports Med. 2014;48(7):491-497.

15. Maitra RS, Johnson DL. Stress fractures. Clinical history and physical examination. Clin Sports Med. 1997;16(2):259-274.

16. Nieves JW, Melsop K, Curtis M, et al. Nutritional factors that influence change in bone density and stress fracture risk among young female cross-country runners. PM R. 2010;2(8):740-750.

17. Beck BR, Matheson GO, Bergman G, et al. Do capacitively coupled electric fields accelerate tibial stress fracture healing? Am J Sports Med. 2008;36(3):545-553.

18. Simkin A, Leichter I, Giladi M, Stein M, Milgrom C. Combined effect of foot arch structure and an orthotic device on stress fractures. Foot Ankle. 1989;10(1):25-29.

19. Johnson AW, Weiss CB, Wheeler DL. Stress fractures of the femoral shaft in athletes—more common than expected: a new clinical test. Am J Sports Med. 1994;22(2):248-256.

20. Clement D, Ammann W, Taunton J, et al. Exercise-induced stress injuries to the femur. Int J Sports Med. 1993;14(6):347-352.

21. Wood PJ, Barth JH, Freedman DB, Perry L, Sheridan B. Evidence for the low dose dexamethasone suppression test to screen for Cushing’s syndrome—recommendations for a protocol for biochemistry laboratories. Ann Clin Biochem. 1997;34(pt 3):222-229.

22. Bennell K, Matheson G, Meeuwisse W, Brukner P. Risk factors for stress fractures. Sports Med. 1999;28(2):91-122.

23. Prather JL, Nusynowitz ML, Snowdy HA, Hughes AD, McCartney WH, Bagg RJ. Scintigraphic findings in stress fractures. J Bone Joint Surg Am. 1977;59(7):869-874.

24. Arendt EA, Griffiths HJ. The use of MR imaging in the assessment and clinical management of stress reactions of bone in high-performance athletes. Clin Sports Med. 1997;16(2):291-306.

25. Boden BP, Osbahr DC. High-risk stress fractures: evaluation and treatment. J Am Acad Orthop Surg. 2000;8(6):344-353.

26. Gaeta M, Minutoli F, Scribano E, et al. CT and MR imaging findings in athletes with early tibial stress injuries: comparison with bone scintigraphy findings and emphasis on cortical abnormalities. Radiology. 2005;235(2):553-561.

27. Matheson GO, Clement DB, Mckenzie DC, Taunton JE, Lloyd-Smith DR, Macintyre JG. Stress fractures in athletes. Am J Sports Med. 1987;15(1):46-58.

28. Iwamoto J, Takeda T. Stress fractures in athletes: review of 196 cases. J Orthop Sci. 2003;8(3):273-278.

29. Noakes TD, Smith JA, Lindenberg G, Wills CE. Pelvic stress fractures in long distance runners. Am J Sports Med. 1985;13(2):120-123.

30. Neubauer T, Brand J, Lidder S, Krawany M. Stress fractures of the femoral neck in runners: a review. Res Sports Med. 2016;24(3):283-297.

31. Evans JT, Guyver PM, Kassam AM, Hubble MJW. Displaced femoral neck stress fractures in Royal Marine recruits—management and results of operative treatment. J R Nav Med Serv. 2012;98(2):3-5.

32. Orava S. Stress fractures. Br J Sports Med. 1980;14(1):40-44.

33. Niva MH, Kiuru MJ, Haataja R, Pihlajamäki HK. Fatigue injuries of the femur. J Bone Joint Surg Br. 2005;87(10):1385-1390.

34. Weishaar MD, McMillian DJ, Moore JH. Identification and management of 2 femoral shaft stress injuries. J Orthop Sports Phys Ther. 2005;35(10):665-673.

35. Salminen ST, Pihlajamäki HK, Visuri TI, Böstman OM. Displaced fatigue fractures of the femoral shaft. Clin Orthop Relat Res. 2003;(409):250-259.

36. Giladi M, Ahronson Z, Stein M, Danon YL, Milgrom C. Unusual distribution and onset of stress fractures in soldiers. Clin Orthop Relat Res. 1985;(192):142-146.

37. Matheson GO, Clement DB, Mckenzie DC, Taunton JE, Lloyd-Smith DR, Macintyre JG. Stress fractures in athletes. Am J Sports Med. 1987;15(1):46-58.

38. Green NE, Rogers RA, Lipscomb AB. Nonunions of stress fractures of the tibia. Am J Sports Med. 1985;13(3):171-176.

39. Orava S, Hulkko A. Stress fracture of the mid-tibial shaft. Acta Orthop Scand. 1984;55(1):35-37.

40. Swenson EJ Jr, DeHaven KE, Sebastianelli WJ, Hanks G, Kalenak A, Lynch JM. The effect of a pneumatic leg brace on return to play in athletes with tibial stress fractures. Am J Sports Med. 1997;25(3):322-328.

41. Rettig AC, Shelbourne KD, McCarroll JR, Bisesi M, Watts J. The natural history and treatment of delayed union stress fractures of the anterior cortex of the tibia. Am J Sports Med. 1988;16(3):250-255.

42. Varner KE, Younas SA, Lintner DM, Marymont JV. Chronic anterior midtibial stress fractures in athletes treated with reamed intramedullary nailing. Am J Sports Med. 2005;33(7):1071-1076.

43. Donahue SW, Sharkey NA. Strains in the metatarsals during the stance phase of gait: implications for stress fractures. J Bone Joint Surg Am. 1999;81(9):1236-1244.

44. Giuliani J, Masini B, Alitz C, Owens BD. Barefoot-simulating footwear associated with metatarsal stress injury in 2 runners. Orthopedics. 2011;34(7):e320-e323.

45. DeLee JC, Evans JP, Julian J. Stress fracture of the fifth metatarsal. Am J Sports Med. 1983;11(5):349-353.

46. Lappe JM, Stegman MR, Recker RR. The impact of lifestyle factors on stress fractures in female army recruits. Osteoporos Int. 2001;12(1):35-42.

47. Friedl KE, Evans RK, Moran DS. Stress fracture and military medical readiness: bridging basic and applied research. Med Sci Sports Exerc. 2008;40(11 suppl):S609-S622.

48. Lappe J, Cullen D, Haynatzki G, Recker R, Ahlf R, Thompson K. Calcium and vitamin D supplementation decreases incidence of stress fractures in female navy recruits. J Bone Miner Res. 2008;23(5):741-749.

49. DIPART (Vitamin D Individual Patient Analysis of Randomized Trials) Group. Patient level pooled analysis of 68 500 patients from seven major vitamin D fracture trials in US and Europe. BMJ. 2010;340:b5463.

50. Duckham RL, Peirce N, Meyer C, Summers GD, Cameron N, Brooke-Wavell K. Risk factors for stress fracture in female endurance athletes: a cross-sectional study. BMJ Open. 2012;2(6).

51. Milgrom C, Finestone A, Novack V, et al. The effect of prophylactic treatment with risedronate on stress fracture incidence among infantry recruits. Bone. 2004;35(2):418-424.

52. Crowell HP, Davis IS. Gait retraining to reduce lower extremity loading in runners. Clin Biomech. 2011;26(1):78-83.

53. Ekenman I, Milgrom C, Finestone A, et al. The role of biomechanical shoe orthoses in tibial stress fracture prevention. Am J Sports Med. 2002;30(6):866-870.

54. Warden SJ, Hurst JA, Sanders MS, Turner CH, Burr DB, Li J. Bone adaptation to a mechanical loading program significantly increases skeletal fatigue resistance. J Bone Miner Res. 2005;20(5):809-816.

Open Navicular Dislocation With Midfoot Dissociation in a 45-Year-Old Man

Bone Stress Injuries in the Military: Diagnosis, Management, and Prevention

References

Take-Home Points

Diagnosis

History and Physical Examination

Laboratory Testing

Imaging

Management

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