Preventing and managing stress fractures in athletes

Stress fractures are common overuse injuries of bone resulting from the repeated application of submaximal load. Factors that reduce bone strength or increase the load applied to bone can place an athlete at risk of developing a stress fracture. These factors include low bone density, menstrual disturbances, inadequate dietary intake and eating disorders, training errors, inadequate muscle function and biomechanical features. Identification of the at-risk athlete can allow prevention strategies to be implemented. Diagnosis of a stress fracture is generally made clinically but investigations such as bone scan, CT or MRI can be performed to confirm the diagnosis, grade the stage of the bone response and localize the site. Most stress fractures will heal with modified rest and permit return to sport around 8 weeks. However, there is a group of stress fractures that requires additional treatment and special consideration. Treatment of the typical stress fracture requires pain management, modification (or cessation) of the aggravating activity, muscle strengthening and maintenance of aerobic fitness, identification and subsequent modification of risk factors and gradual resumption of bone loading activities. The use of braces has been shown to reduce the time to return to full activity in some lower limb stress fractures. Similarly the use of electrical stimulation and ultrasound may be helpful. Recovery should be monitored clinically