Stress fractures — Rapid | Doctor’s Passport

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.
Immediately unload suspected high-risk sites: femoral-neck tension side, anterior tibial cortex, navicular, talus, proximal fifth metatarsal and patella need urgent specialist assessment.
Obtain targeted radiographs initially because they identify a completed fracture and alternative pathology, but do not use normal early films to exclude a clinically important stress injury.
MRI is the preferred definitive test when suspicion persists because it detects marrow and periosteal stress response, fracture line and surrounding tissue without ionising radiation.
Use CT selectively to define a cortical line, navicular or fifth-metatarsal anatomy, delayed union and surgical planning; bone scintigraphy is sensitive but less specific and uses radiation.
Treatment starts with site-specific load reduction, pain-free cross-training when safe and correction of energy availability, calcium and vitamin D deficiency, menstrual or gonadal disturbance and biomechanics.
Return to impact only after daily activity and focal examination are pain free, high-risk healing is confirmed when required, strength and mechanics recover, and load increases gradually without recurrent symptoms.

Key red flags

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.

Sudden increase in previously gradual pain, a crack, new inability to bear weight, deformity or swelling suggests propagation to a complete or displaced fracture and requires emergency imaging and orthopaedic review.

Anterior tibial focal pain, navicular dorsal tenderness, proximal fifth-metatarsal pain or talar pain is a high-risk pattern because tension, limited blood supply or joint consequences raise delayed-union and displacement risk.

Weight loss, restrictive eating, menstrual disturbance, low libido, recurrent injury, fatigue or reduced performance signals low energy availability or an endocrine disorder requiring confidential multidisciplinary assessment, not exercise advice alone.

Investigation priorities

First-line targeted radiographsFirst stepFirst line

Find completed fracture, cortical reaction, alignment change or alternative pathology.

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.
Arrange early orthopaedic or specialist sports review to decide immobilisation, fixation and imaging surveillance from site and grade.
Screen simultaneously for low energy availability, pregnancy or lactation, medicines and metabolic bone disease without delaying fracture protection.

Low riskRestore capacity under controlled load

Imaging and specialist assessment define a stable low-risk bone stress injury.

Remove painful impact and use a boot or crutches only as needed to make daily activity pain free while preserving safe conditioning.
Address training progression, surface, footwear, strength, biomechanics, sleep and adequate energy, protein, calcium and vitamin D status.
Progress from pain-free daily walking to strengthening, then short impact intervals separated by recovery days under a written plan.

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.Count combination products and liver and alcohol risk; regular analgesia that masks focal pain can defeat load monitoring, and escalating rest pain requires diagnostic review rather than stronger routine medication.

Open full textbook →Answer 2 questions