Diagnosis and treatment of stress fractures

Stress fracture diagnosis and treatment are clinical techniques that cannot be separated. The clinician has to make staged decisions in fields of uncertainty. Frequently, diagnosis is based on the patients' response to treatment (partial rest). Underdiagnosis can lead to devastating results in certain stress fractures, whereas overdiagnosis may prevent training for significant periods of time, crucial to trainees, whether athletes or military personnel. The recognition that bone scintigraphy is associated with significant doses of ionizing radiation has led to more conservative use of this tool for suspected tibia stress fractures. The management of suspected metatarsal stress fractures is clinical, assisted by X-rays. Subjects with complaints and signs indicative of a femoral stress fracture cannot be permitted to continue training. Femoral stress fractures are usually best ruled out scintigraphically, due to the risk of displacement without significant warning pain, but as MRI is becoming more accessible, some cases may be managed with MRI, and in cases of patients who have had several tests with ionizing radiation, this may be the recommended management. The protocols presented are those recommended by the Israel Defense Forces Medical Corps, following many years of trial and improvement. They now include the option of MRI where it is justified.