Emergency Radiology

, Volume 23, Issue 4, pp 365–375 | Cite as

Stress fractures: pathophysiology, clinical presentation, imaging features, and treatment options

  • George R. MatcukJrEmail author
  • Scott R. Mahanty
  • Matthew R. Skalski
  • Dakshesh B. Patel
  • Eric A. White
  • Christopher J. Gottsegen
Review Article


Stress fracture, in its most inclusive description, includes both fatigue and insufficiency fracture. Fatigue fractures, sometimes equated with the term “stress fractures,” are most common in runners and other athletes and typically occur in the lower extremities. These fractures are the result of abnormal, cyclical loading on normal bone leading to local cortical resorption and fracture. Insufficiency fractures are common in elderly populations, secondary to osteoporosis, and are typically located in and around the pelvis. They are a result of normal or traumatic loading on abnormal bone. Subchondral insufficiency fractures of the hip or knee may cause acute pain that may present in the emergency setting. Medial tibial stress syndrome is a type of stress injury of the tibia related to activity and is a clinical syndrome encompassing a range of injuries from stress edema to frank-displaced fracture. Atypical subtrochanteric femoral fracture associated with long-term bisphosphonate therapy is also a recently discovered entity that needs early recognition to prevent progression to a complete fracture. Imaging recommendations for evaluation of stress fractures include initial plain radiographs followed, if necessary, by magnetic resonance imaging (MRI), which is preferred over computed tomography (CT) and bone scintigraphy. Radiographs are the first-line modality and may reveal linear sclerosis and periosteal reaction prior to the development of a frank fracture. MRI is highly sensitive with findings ranging from periosteal edema to bone marrow and intracortical signal abnormality. Additionally, a brief description of relevant clinical management of stress fractures is included.


Stress fracture Fatigue fracture Insufficiency fracture Subchondral insufficiency fracture Medial tibial stress syndrome Bisphosphonate-related atypical subtrochanteric femoral fracture 



We would like to thank Robert W. Henderson, MD for contributing the case of a sacral insufficiency fracture on PET-CT (Fig. 7c). We would also like to honor the memory of Deborah M. Forrester, MD, who was a co-author on the educational exhibit from which this paper derives and served as such an inspirational teacher and mentor to us during her long and brilliant career.

Compliance with Ethical Standards

Conflict of interest

The authors declare that they have no conflict of interest.


The authors did not receive any grants.


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Copyright information

© American Society of Emergency Radiology 2016

Authors and Affiliations

  1. 1.Department of Radiology, Keck School of MedicineUniversity of Southern CaliforniaLos AngelesUSA
  2. 2.Department of RadiologyUniversity of California San FranciscoSan FranciscoUSA
  3. 3.Department of RadiologySouthern California University of Health SciencesWhittierUSA
  4. 4.Department of RadiologyNew York University, Langone Medical CenterNew YorkUSA

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