Diagnosis
H&P
DDx and Etiologies:
Risk Factors: Repetitive high-intensity training; a patient who increases running distance rapidly.
Common presentation:
Provocative testing: E.g. Have the patient jump on the affected leg to reproduce the pain.
Diagnostic studies: XR (the initial imaging modality of choice for a suspected stress fracture). If XR is negative, repeat in 2-3 weeks. Get MRI if there is an urgent need to know the diagnosis. MRI can show fractures not seen on XR. Triple-phase bone scintigraphy is another alternative to an MRI with similar sensitivity.
Treatment
-Depends on location of the stress fracture.
-Decrease activity.
-Non-weight bearing with immobilization if there is a risk of complete fracture (e.g. when the anterior tibial cortex is involved).
-Walker boot for tibial stress fractures (reduces the time to resumption of full activity).
-Vit D and Calcium supplementation for prevention of stress fractures.
*Avoid NSAIDs b/c a few studies indicate they may delay healing of traumatic fractures.
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KTA: It may take time for symptoms to show on XR.
-“Plain radiography should be the initial imaging modality to diagnose stress fractures. One algorithm advocates radiography 2 weeks after the onset of symptoms (if symptoms persist), with repeat radiography the following week before performing more advanced imaging. An expert panel of the American College of Radiology recommends that MRI be considered next if plain radiography is negative.”
“A diagnosis of stress fracture should be considered in patients with a history of overuse and weight-bearing exercise. These patients have pain that is worse with activity, and pain on active leg raising. MRI can detect fractures not seen on plain films.
Stress fractures in the foot cause localized tenderness and swelling in superficial bones, and the pain can be reproduced by having the patient jump on the affected leg.”ABFM
Reference
Patel DS, Roth M, Kapil N: Stress fractures: Diagnosis, treatment, and prevention. Am Fam Physician 2011;83(1):39-46.
Davis BJ, Estes AR. An Adolescent With Right Shin Pain. JAMA. 2015;313(15):1566–1567. http://jamanetwork.com/journals/jama/article-abstract/2275423