Pain will tend to be localised, in contrast to medial tibial periostitis, where pain is more diffuse. On examination, findings of oedema, redness, muscle contracture, tenderness, and painful range of movement may be found. Pain at the offending site is typically reported during and following activity, and relieved by rest. There is unlikely to be a history of trauma. The previously mentioned risk factors should be explored, with a focus on establishing the patients’ current exercise load and if this has changed or increased in intensity recently. Thorough history taking can identify characteristic features suggestive of a stress fracture. Usually a combination of these factors is responsible. 8 Extrinsic factors include high volume or intense exercise, a sudden increase in volume or intensity of exercise, individual biomechanical factors, changes to foot–ground interface, that is, shoe modification, and environmental factors, such as running on hard surfaces. Intrinsic factors include female sex, steroid use, and nutritional deficits of calcium and vitamin D. Risk factors for stress fracture or reactions can be classified as intrinsic and extrinsic. 7 Although upper limb and axial stress fractures are less frequent, they do exist in particular sports such as golf, cricket, and tennis. 6 In athletes, the tibia, metatarsals, pelvis, and femur, are the most commonly affected bones, and fractures are bilateral in about 16% of cases. 5 In the paediatric population, one study showed an incidence of 4% over 7 years in females aged 9–15 years. 1, 2 In the athletic population, incidence ranges from 5–10% 3, 4 and stress injuries compromised 2% of all injuries seen at the 2016 Rio Olympic Games. ![]() The career incidence of stress fractures in military personnel has been described as ranging between 5–20% and is two to five times more common in females. ![]() The incidence of stress fractures in the general population is not clear and most research has studied their incidence in the athletic and military populations.
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