One of the most common diagnoses, if not the most common diagnosis, I
make at New Jersey Sports Medicine, is a stress fracture.
"It's a stress fracture until proven otherwise" I tell my athletes. And one of
the most common responses I am given if they have already seen another
physician, is "I had an x-ray and was told I don't have a stress fracture".
While x-ray can rule in a stress fracture; meaning if you see it on an x-ray
you have one, they can not rule out a stress fracture; meaning if you do not
see one on an x-ray, it does not mean you do not have one.
Taking bilateral x-rays with comparison views involves no extra radiation for
almost all body parts and can provide invaluable information in early
diagnosis of a stress fracture, yet most athletes coming from other
institutions rarely have had comparison views of the contra-lateral limb.
An MRI is the diagnostic tool of choice to rule in and rule out a stress
While x-ray can pick up already healing stress fractures, with appearance of
callous, cortical thickening, or periosteal elevation or the rarer completed
stress fracture with ominous fracture line, MRI is the test of choice for early
diagnosis when not seen on x-ray and has the additional benefit of grading
the stress fracture, from a Grade 1 to a Grade 4, or better graded here as
low grade versus high grade.
The stress fracture bone is further classified as either a high risk bone or a
low risk bone, with high risk bones sometimes requiring prolong rest, many
times non-weight bearing with cast, a bone stimulating healing device, or
even surgery as the treatment, though Dr. Silberman has never had to have
one of his athletes who presented here first require surgery.
Prior to MRI, triple phase bone scan was the test of choice to diagnose a
stress fracture, but bone scans involve radiation, so if your college
recommends a bone scan over an MRI, likely due to cost, decline and
request an MRI.
It is not uncommon to have an athlete in continued pain come in for
consultation having already had an MRI and told they did not have a stress
fracture, to actually have a stress fracture diagnosed by Dr. Silberman.
Often the athlete was told over the phone by a physician assistant, usually
based on the radiology report which might have been written with the words
"bone contusion" or "stress reaction" or "medial tibial stress syndrome" or
At New Jersey Sports Medicine, every MRI is personally read by Dr.
Silberman along side the patient.
At New Jersey Sports Medicine, Dr. Silberman will teach you how to read
and grade stress fractures on MRI better than other physicians. And it is not
uncommon for the unfortunate athlete or parent who has been seen here
previously, now with pain again to then read films immediately while Dr.
Silberman loads the images, learning the bad news before Dr. Silberman
even points out the findings, having been taught how to read MRIs
previously here at New Jersey Sports Medicine. "I see it" they say with a
The cause of stress fractures are multifactorial. Our bones build up and
break down every day, and there is period of time when after your bones
are exposed to more stress they break down more than they build up, and it
appears here where they may be most vulnerable. You can not blame one
thing as the cause, though certainly training load and intensity play a role
(sometimes it's the distance, sometimes it's the speed - short repeats).
Calorie intake plays a huge role in bone health metabolism and calorie
deficits will weaken the bones through alteration in your pulsatile hormonal
secretion. Lack of sleep is another huge risk for stress fractures, one the
biggest risks found in an Israeli military study on stress fractures. Stress
fractures can occur in strong bones and stress fractures can occur in weak
bones. If your muscles are fatigued, they may fail to provide shock
absorption and greater bone stress can occur when hitting the ground. And
in a recent 2019 study, your foot hitting the ground was said not to be the
main problem but strong muscles pulling on your bones were implicated as
the cause of your stress fracture (Vanderbilt University. "Stress fracture?
Your foot hitting pavement wasn't the main problem: Engineer, NFL Players
Association adviser find issue with running sensors." ScienceDaily.
ScienceDaily, 17 January 2019) Stress fractures can occur acutely, and
usually do, meaning the athlete can report the exact moment in the race or
training when it occurred. It is at that point in time when the bone finally
says I have had enough. Although the name implies repetitive stress, that is
not how they seem to occur. And once they occur, you are done, often for
8 to 12 weeks.
Dr. Silberman may check labs and order a Dexa Scan as part of your stress
fracture care. And Dr. Silberman will certainly work with you to ensure
long time missed from sport does not occur again as a result of a stress
fracture, often with specific weekly instructions for your coach.
The Original New Jersey Sports Medicine. Since 2004. Web design by Marc Silberman MD.
Copyright 2004 - 2019, New Jersey Sports Medicine and Performance Center LLC.