Intended for healthcare professionals

Clinical Review

Diagnosis and management of bone stress injuries of the lower limb in athletes

BMJ 2012; 344 doi: (Published 24 April 2012) Cite this as: BMJ 2012;344:e2511
  1. James Pegrum, orthopaedic and trauma registrar, honorary research associate13,
  2. Tom Crisp, consultant sports physician2,
  3. Nat Padhiar, consultant podiatric surgeon and honorary reader3
  1. 1Centre for Sport and Exercise Medicine, Queen Mary’s University, London E1 4NS
  2. 2BUPA Health and Wellbeing, London, UK
  3. 3Milton Keynes Hospital, Milton Keynes MK6 5LD, UK
  1. Correspondence to: J Pegrum jpegrum{at}

Summary points

  • Stress fractures occur mostly in track and distance runners, athletes who take part in field sports, gymnasts, dancers, and military recruits

  • Consider the diagnosis in sports people with risk factors for bone injury and progressively worsening localised bone pain

  • Women with the “female athlete triad” are especially at risk of bony stress injury

  • Magnetic resonance imaging is the most sensitive and specific imaging modality for diagnosing stress fractures

  • Stress fractures with low risk of non-union can be managed in primary care by modifying sports activity and reducing risk factors

  • Involvement of a specialist is necessary for fractures at high risk of non-union and operative fixation may be considered

The annual incidence of overuse injuries in track and field athletes is estimated to be 3.9 per 1000 training hours, with a prevalence of 76%,w1 and 10-20% of consultations in sports medicine practice are for stress fractures.1 Stress fractures are also common among army recruits.

With the advent of magnetic resonance imaging, stress fractures are diagnosed earlier and more readily than they were in the past, and early surgical treatment is increasingly considered as a management option for patients who are at high risk of fracture non-union. Rapid and accurate diagnosis of stress fractures is important to prevent propagation of the fracture, and early effective treatment may reduce time away from training and participation in sport. Experts think that overtreatment of low risk stress injuries and undertreatment of high risk injuries both occur and lead to unnecessary time away from training.2 In addition, increasing participation of non-athletes in endurance sports such as marathon running has led to an increase in stress injuries among non-professional sportspeople.

We review the diagnosis and management of stress injuries of the lower limb, drawing on evidence from randomised trials, non-randomised intervention studies, observational studies, …

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