Stress Fractures

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12 Lessons

Stress fractures represent the failure of the bony skeleton to absorb repetitive loads. This results in structural fatigue of the bone, causing pain, performance impairment and potentially a complete fracture. Loading can be intrinsic through transmission of impact forces within the bone and/or extrinsic via the application of tension across bone from the muscles and connective tissue. As a result, a footballer with a stress fracture may suffer prolonged periods out of the game and require further medical interventions including surgery.

Bone strain can be described in a continuum from bone strain (mild) to stress reaction to stress fracture (severe) and, ultimately, fracture.

The management of stress fractures generally involves a reduction of the inciting load to restore the normal bone physiology. In some cases, however, stress fractures may require special consideration and treatment. Prevention and early recognition of stress fractures is required to reduce the impact on the player.

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Learning outcomes

By the end of this topic, you should:

  • be aware of the basic science relating to stress fractures, including the epidemiology of these injuries in football,
  • be able to diagnose bone stress injuries by taking an appropriate history, examination and order appropriate investigation (where needed),
  • understand and be able to implement an appropriate conservative treatment and rehabilitation programme to treat common stress fractures in football players,
  • understand the indications for surgical treatment and be able to initiate an appropriate referral,
  • understand the potential sequelae following cervical injuries and their treatment,
  • have an understanding regarding the effectiveness and implementation of injury prevention programmes.


  • Review the provided text and media content
  • Read the provided articles
  • Complete the case-based assessment task

Suggested reading

Brukner and Khan’s
Clinical Sports Medicine – 4th edition
Chapter 5, pages 25-38


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  22. Batt M.E., Kemp S., Kerslake R. Delayed union stress fractures of the anterior tibia: Conservative management. Br J Sports Med. 2001;35(1):74-77.
  23. Cruz A.S., de Hollanda J.P., Duarte A. Jr, Hungria Neto J.S. Anterior tibial stress fractures treated with anterior tension band plating in high-performance athletes. Knee Surg Sports Traumatol Arthrosc. 2013;21(6):1447-1450.
  24. Boden B.P., Speer K.P. Femoral stress fractures. Clin Sports Med. 1997;16(2):307-317.
  25. Johnson A.W., Weiss C.B. Jr, Wheeler D.L. 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.
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  28. Shelbourne K.D., Fisher D.A., Rettig A.C., McCarroll J.R. Stress fractures of the medial malleolus. Am J Sports Med. 1988;16(1):60-63.
  29. Orava S., Karpakka J., Taimela S., Hulkko A., Permi J., Kujala U. Stress fracture of the medial malleolus. J Bone Joint Surg Am. 1995;77(3):362-365.