Educational draft · awaiting clinical reviewUse Rapid for revision, not patient-care decisions. Check current national and local guidance and the BNF or BNFC before acting.
2 min synopsisUK scopeSources checked 27 Aug 2026Clinical review pending
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High-risk stress injury must be unloaded immediately
Tension-side femoral-neck, anterior tibial cortex, navicular, talar and proximal fifth-metatarsal injuries can propagate, displace, lose blood supply or fail to unite when activity continues despite deceptively modest early symptoms.
Action: Stop impact loading, provide protected or non-weight bearing according to site, obtain urgent specialist assessment and appropriate radiographs plus MRI, and treat inability to bear weight, acute worsening, deformity, hip effusion or neurovascular change as possible completed fracture requiring same-day emergency care.
Synopsis
Recognise bone stress injury before displacement, distinguish fatigue from insufficiency mechanisms, identify high-risk anatomical sites, use MRI when early radiographs are normal, and correct loading, energy and skeletal-health drivers.
Stress injury is a continuum from bone stress response to visible crack; load-related focal pain and tenderness can precede radiographic change by weeks.
Classify mechanism as fatigue injury in normal bone or insufficiency injury in weakened bone, then search for training, nutrition, endocrine, medicine and bone-density contributors.
Deep groin pain, pain on hip rotation or an antalgic gait in a runner, military recruit, pregnant or recently postpartum person, or someone with osteoporosis may represent femoral-neck stress injury and requires immediate unloading and urgent MRI-based assessment.
Investigation priorities
01
First-line targeted radiographsFirst stepFirst line
Find completed fracture, cortical reaction, alignment change or alternative pathology.
02
Preferred MRIPreferred
Confirm and grade bone stress response before a cortical fracture becomes radiographically visible.
Management branches
UrgentUnload a high-risk site
Pain and examination suggest femoral-neck, anterior tibial, navicular, talar, proximal fifth-metatarsal or another high-risk stress injury.
Stop impact immediately, provide crutches and site-appropriate non-weight bearing or protected loading and avoid provocative hop testing.
Obtain targeted radiographs and urgent MRI despite normal films, escalating acute inability to bear weight or deformity as completed fracture.
Low riskRestore capacity under controlled load
Imaging and specialist assessment define a stable low-risk bone stress injury.
Key medicines
Paracetamol for short-term painIf analgesia is needed, give 1 g orally up to four times daily with at least 4 hours between doses and no more than 4 g in 24 hours; reduce the maximum for body weight under 50 kg, frailty, malnutrition or hepatic risk.
National guidance is shown before implementation-dependent detail. Typical adult dose examples remain subject to patient factors, contraindications and the live BNF or specialist protocol. Source check completed 27 Aug 2026; clinical approval remains outstanding.