Risk factors for subchondral insufficiency fracture of the femoral head in renal transplant patients.

INTRODUCTION: Risk factors associated with subchondral insufficiency fracture (SIF) of the femoral head have not been established. The aim of the present study was to determine the incidence and risk factors for SIF of the femoral head following renal transplantation (RT). MATERIALS AND METHODS: We analyzed the cases of 681 RT patients (mean age at surgery: 49.5 ± 13.6 years, 249 women, 432 men) to determine the incidence of SIF. Hip magnetic resonance imaging (MRI) was performed 6 months post-RT. The following potential predictors of SIF were evaluated: (1) patient's condition at RT: bone mineral density (BMD), pre-RT laboratory values including calcium (Ca), phosphorus (P), calcium-phosphorus product (Ca × P), and intact parathyroid hormone; the patient and donor's blood relationship; and mismatching number of human leukocyte antigens (HLAs), and (2) post-RT dosage(s) of steroid(s), the immunosuppressive regimen, and the incidence of acute rejection. RESULTS: SIF was observed in 15 hips (13 patients, 1.9%). We successfully matched 39 patients without SIF. A multivariate logistic regression analysis adjusted for cumulative dosages of steroids, revealed the following were risk factors for SIF: osteoporosis (OR: 11.4, p = 0.046), lumbar BMD (OR: 0.003, p = 0.038), pre-RT serum P (OR 2.68, p = 0.004), and pre-RT serum Ca × P (OR: 1.11, p = 0.005). CONCLUSION: Since osteoporosis, the lumbar BMD, serum P, and serum Ca × P were identified as risk factors for a post-RT SIF, these factors should be evaluated before RT for the prediction of the SIF risk.

Vitamin D and Stress Fractures in Sport: Preventive and Therapeutic Measures-A Narrative Review.

There are numerous risk factors for stress fractures that have been identified in literature. Among different risk factors, a prolonged lack of vitamin D (25(OH)D) can lead to stress fractures in athletes since 25(OH)D insufficiency is associated with an increased incidence of a fracture. A 25(OH)D value of <75.8 nmol/L is a risk factor for a stress fracture. 25(OH)D deficiency is, however, only one of several potential risk factors. Well-documented risk factors for a stress fracture include female sex, white ethnicity, older age, taller stature, lower aerobic fitness, prior physical inactivity, greater amounts of current physical training, thinner bones, 25(OH)D deficiency, iron deficiency, menstrual disturbances, and inadequate intake of 25(OH)D and/or calcium. Stress fractures are not uncommon in athletes and affect around 20% of all competitors. Most athletes with a stress fracture are under 25 years of age. Stress fractures can affect every sporty person, from weekend athletes to top athletes. Stress fractures are common in certain sports disciplines such as basketball, baseball, athletics, rowing, soccer, aerobics, and classical ballet. The lower extremity is increasingly affected for stress fractures with the locations of the tibia, metatarsalia and pelvis. Regarding prevention and therapy, 25(OH)D seems to play an important role. Athletes should have an evaluation of 25(OH)D -dependent calcium homeostasis based on laboratory tests of 25-OH-D3, calcium, creatinine, and parathyroid hormone. In case of a deficiency of 25(OH)D, normal blood levels of ≥30 ng/mL may be restored by optimizing the athlete's lifestyle and, if appropriate, an oral substitution of 25(OH)D. Very recent studies suggested that the prevalence of stress fractures decreased when athletes are supplemented daily with 800 IU 25(OH)D and 2000 mg calcium. Recommendations of daily 25(OH)D intake may go up to 2000 IU of 25(OH)D per day.

Medial tibial stress fracture diagnosis and treatment guidelines.

OBJECTIVES: To validate and make evidence based changes to the Israel Defense Forces medial tibial stress fracture diagnosis and treatment protocol. DESIGN: Prospective cohort study. METHODS: 429 Elite infantry recruits were reviewed for signs and symptoms of medial tibial stress fracture during 14 weeks of basic training. Suspicion of medial tibial stress fracture was based on the presence of pain, tenderness <1/3 the length of the tibia and a positive fulcrum and/or hop test. Recruits with suspected medial tibial stress fractures were initially treated with 10-14 days of rest. Bone scan was performed only when recruits failed to respond to the rest regimen or required immediate diagnosis. RESULTS: 31 Out of 49 recruits with a suspicion of medial tibial stress fracture underwent bone scan, including 8/26 recruits whose symptoms did not resolve after being treated clinically as stress fractures. There was a significantly greater incidence of medial tibial stress fractures when a positive hop test was present in addition to tibial pain and tenderness (p=0.0001), odds ratio 52.04 (95% CL, 2.80-967.74). Medial tibial stress fracture was found to occur when the band of tibial tenderness was ≤10cm in length. Tibial pain scores were not predictive of stress fracture. CONCLUSIONS: This validation study provides the clinician with evidence based guidelines for the clinical diagnosis and treatment of medial stress fractures and their differentiation from shin splints. An initial treatment protocol without the use of imaging was found to be effective in more than two-thirds of the cases.

Prevalence of Vitamin D Insufficiency and Deficiency in Young, Female Patients With Lower Extremity Musculoskeletal Complaints.

BACKGROUND: Low levels of vitamin D have well-known impacts on bone health, but vitamin D also has a more global role throughout many tissues, including skeletal muscle. The high prevalence of hypovitaminosis D and the vast physiological features of vitamin D have led researchers to examine the influence of vitamin D on physical performance and injury. Because of the critical role of vitamin D in maintaining musculoskeletal health and function, a high rate of hypovitaminosis D among female patients with a variety of musculoskeletal issues could be of high clinical relevance. HYPOTHESIS: There is a high prevalence of low vitamin D in female patients with both acute and overuse sports-related issues of both soft tissue and bone. STUDY DESIGN: Prospective cohort study. LEVEL OF EVIDENCE: Level 3. METHODS: Female patients, aged 16 to 40 years, presenting with lower extremity injury diagnosed within the past 4 weeks, no use of multivitamin or vitamin D supplement, and no history of malabsorption syndrome met the inclusion criteria. Vitamin D levels were assessed and categorized as normal (≥32 ng/mL) and low, which includes insufficient (20.01-31.9 ng/mL) and deficient (≤20 ng/mL). RESULTS: Of the 105 patients enrolled, 65.7% had low vitamin D. Within the low vitamin D cohort, 40.6% were deficient and 59.4% were insufficient. Injuries were grouped into overuse or acute with 74 overuse injuries and 31 acute injuries, exhibiting low vitamin D prevalence of 60.8% and 77.4%, respectively. Patients with ligamentous/cartilaginous injuries exhibited the highest percentage of low vitamin D (76.5%), followed by those with patellofemoral-related complaints (71.0%), muscle/tendon injuries (54.6%), and bone stress injuries (45.5%). In univariable analysis, older age, non-White race, less physical activity, less high-intensity interval training days, less endurance training days, and more rest days showed an association with low vitamin D, but none showed an independent association in multivariable analysis. CONCLUSION: The prevalence of low vitamin D in female patients with various musculoskeletal complaints was high. Clinicians should evaluate for low vitamin D in both acute and overuse injuries. CLINICAL RELEVANCE: In addition to screening, this study suggests that clinicians should evaluate for low vitamin D levels beyond bone stress injuries in the setting of acute and overuse injuries.

Stress Fractures: Etiology, Epidemiology, Diagnosis, Treatment, and Prevention.

Stress fractures are part of a continuum of changes in healthy bones in response to repeated mechanical deformation from physical activity. If the activity produces excessive repetitive stress, osteoclastic processes in the bone may proceed at a faster pace than osteoblastic processes, thus weakening the bone and augmenting susceptibility to stress fractures. Overall stress fracture incidence is about three cases per 1,000 in active duty Servicemembers, but it is much higher among Army basic trainees: 19 per 1,000 for men and 80 per 1,000 for women. Well-documented risk factors include female sex, white ethnicity, older age, taller stature, lower aerobic fitness, prior physical inactivity, greater amounts of current physical training, thinner bones, cigarette smoking, and inadequate intake of vitamin D and/or calcium. Individuals with stress fractures present with focal tenderness and local pain that is aggravated by physical activity and reduced by rest. A sudden increase in the volume of physical activity along with other risk factors is often reported. Simple clinical tests can assist in diagnosis, but more definitive imaging tests will eventually need to be conducted if a stress fracture is suspected. Plain radiographs are recommended as the initial imaging test, but magnetic resonance imaging has higher sensitivity and is more likely to detect the injury sooner. Treatment involves first determining if the stress fracture is of higher or lower risk; these are distinguished by anatomical location and whether the bone is loaded in tension (high risk) or compression (lower risk). Lowerrisk stress fractures can be initially treated by reducing loading on the injured bone through a reduction in activity or by substituting other activities. Higher-risk stress fractures should be referred to an orthopedist. Investigated prevention strategies include modifications to physical training programs, use of shock absorbing insoles, vitamin D and calcium supplementation, modifications of military equipment, and leadership education with injury surveillance.

Stress Fractures: Concepts and Therapeutics.

Context: Stress fractures are repetitive use injuries in which recurrent strains lead to material fatigue and microarchitectural discontinuities. They account for up to 20% of athletic injuries, more often in women and in the setting of track-and-field events. In women, menstrual disturbances, low body mass index, low energy intake, and sometimes low bone mass, may be contributing factors. There are no standard protocols for evaluation or management of stress fractures. Evidence Acquisition: Available literature published in English was retrieved using the following terms: stress fractures; fractures; osteoporosis, athletes, premenopausal women, and athletic triad; through PubMed. Reviews, original reports, and case reports were all included. Evidence Synthesis: Despite lack of consistency among the publications, a phenotype emerges, namely of individuals whose bone mineral density is reduced along with low intake of dietary calcium and low circulating levels of 25-hydroxy vitamin D. Limited experience suggests that calcium and vitamin D supplementation might be helpful. Bisphosphonates or teriparatide may accelerate fracture healing in special circumstances. Conclusions: Most individuals who experience a stress fracture are young and healthy and do not appear to have an underlying metabolic bone disease. On the other hand, the presence of low bone mass and hormonal disturbances in some afflicted individuals might identify a cohort who needs endocrinological attention. Prospective, well-designed studies of stress fractures are needed to elucidate further underlying pathophysiological elements that predispose such individuals. Guidelines for prevention and treatment may follow from such well-controlled studies.

Consumption of a calcium and vitamin D-fortified food product does not affect iron status during initial military training: a randomised, double-blind, placebo-controlled trial.

Ca/vitamin D supplementation maintains bone health and decreases stress fracture risk during initial military training (IMT); however, there is evidence that Ca may negatively affect the absorption of other critical micronutrients, particularly Fe. The objective of this randomised, double-blind, placebo-controlled trial was to determine whether providing 2000 mg/d Ca and 25 µg/d vitamin D in a fortified food product during 9 weeks of military training affects Fe status in young adults. Male (n 98) and female (n 54) volunteers enrolled in US Army basic combat training (BCT) were randomised to receive a snack bar with Ca/vitamin D (n 75) or placebo (snack bar without Ca/vitamin D; n 77) and were instructed to consume 2 snack bars/d between meals throughout the training course. Circulating ionised Ca was higher (P0·05) in markers of Fe status between placebo and Ca/vitamin D groups. Collectively, these data indicate that Ca/vitamin D supplementation through the use of a fortified food product consumed between meals does not affect Fe status during IMT.

The effects of prenatal vitamin supplementation on operationally significant health outcomes in female air force trainees.

OBJECTIVES: A prenatal vitamin supplementation program for female basic military trainees at Joint Base San Antonio-Lackland was initiated in June 2012 with the goals of decreasing attrition and improving performance. This project examined whether supplementation influences attrition rates, incidence of stress fractures and iron deficiency anemia, and physical performance. METHODS: This was a cohort-based pilot study with an historical control group. Primary outcome measures included all-cause attrition, medical attrition, stress fractures, and iron deficiency anemia. RESULTS: Incidence rates of all-cause attrition, medical attrition, stress fractures, and anemia were similar in both groups, although the lower medical attrition in the supplementation group approached statistical significance (risk ratio, 0.74; 95% confidence interval, 0.54-1.01). CONCLUSION: Although this study found no statistical benefit, the operationally significant reduction in medical attrition of 26% suggests that providing prenatal vitamin supplementation to female basic trainees in the Air Force may be worthwhile.

Dietary Intake, Anthropometric Characteristics, and Iron and Vitamin D Status of Female Adolescent Ballet Dancers Living in New Zealand.

Ballet dancing is a multifaceted activity requiring muscular power, strength, endurance, flexibility, and agility; necessitating demanding training schedules. Furthermore dancers may be under aesthetic pressure to maintain a lean physique, and adolescent dancers require extra nutrients for growth and development. This cross-sectional study investigated the nutritional status of 47 female adolescent ballet dancers (13-18 years) living in Auckland, New Zealand. Participants who danced at least 1 hr per day 5 days per week completed a 4-day estimated food record, anthropometric measurements (Dual-energy X-ray Absorptiometry) and hematological analysis (iron and vitamin D). Mean BMI was 19.7 ± 2.4 kg/m2 and percentage body fat, 23.5 ± 4.1%. The majority (89.4%) of dancers had a healthy weight (5th-85th percentile) using BMI-for-age growth charts. Food records showed a mean energy intake of 8097.3 ± 2155.6 kJ/day (48.9% carbohydrate, 16.9% protein, 33.8% fat, 14.0% saturated fat). Mean carbohydrate and protein intakes were 4.8 ± 1.4 and 1.6 ± 0.5 g/kg/day respectively. Over half (54.8%) of dancers consumed less than 5 g carbohydrate/kg/day, and 10 (23.8%) less than 1.2 g protein/kg/day. Over 60% consumed less than the estimated average requirement for calcium, folate, magnesium and selenium. Thirteen (28.3%) dancers had suboptimal iron status (serum ferritin (SF) < 20 µg/L). Of these, four had iron deficiency (SF < 12 µg/L, hemoglobin (Hb) ≥ 120 g/L) and one iron deficiency anemia (SF < 12 µg/L, Hb < 120 g/L). Mean serum 25-hydroxy vitamin D was 75.1 ± 18.6 nmol/L, 41 (91.1%) had concentrations above 50 nmol/L. Female adolescent ballet dancers are at risk for iron deficiency, and possibly inadequate nutrient intakes.

Prevalence of vitamin D deficiency in patients with foot and ankle injuries.

BACKGROUND: Vitamin D deficiency has been identified as one of the most common causes of fragility fractures and poor fracture healing. Although rates of vitamin D deficiency have been delineated in various orthopaedic populations, little is known about the prevalence of vitamin D deficiency in patients with foot and ankle disorders. The goal of this study was to identify the prevalence of vitamin D deficiency in patients with a low energy fracture of the foot or ankle. METHODS: Over a 6-month period, a serum 25-OH vitamin D level was obtained from consecutive patients with a low energy ankle fracture, fifth metatarsal base fracture, or stress fracture of the foot or ankle. For comparative purposes, vitamin D levels in patients with an ankle sprain and no fracture were also examined. RESULTS: The study cohort included 75 patients, of which 21 had an ankle fracture, 23 had a fifth metatarsal base fracture, and 31 had a stress fracture. The mean age was 52 (range, 16-80) years. Thirty-five of the fracture patients (47%) had an insufficient vitamin D level (below the recommended level of 30 ng/mL), and 10 of the patients (13%) had a level that was deficient (< 20 ng/mL). Vitamin D levels were significantly lower in those with a fracture than in those with an ankle sprain (P = .02). In the fracture cohort, the factors significantly associated with vitamin D insufficiency in the multivariate analysis were smoking (P = .03), obesity (P = .003), and other medical risk factors for vitamin D deficiency (P = .03). CONCLUSION: Hypovitaminosis D was common among patients with a foot or ankle injury seen at our institution. Patients with a low energy fracture of the foot or ankle were at particular risk for low vitamin D, especially if they smoked, were obese, or had other medical risk factors. Given that supplementation with vitamin D (± calcium) has been shown to reduce the risk of fragility fractures and improve fracture healing, monitoring of 25-OH vitamin D and supplementation should be considered in patients with fractures. LEVEL OF EVIDENCE: Level III, prospective case control.

Preventive osteopathic manipulative treatment and stress fracture incidence among collegiate cross-country athletes.

CONTEXT: Stress fractures are common among athletes, particularly distance runners, with many theories regarding the etiologic process of stress fractures and various studies identifying risk factors or suggesting preventive techniques. To our knowledge, no previous studies have discussed the possible causative effects of somatic dysfunction or the preventive capabilities of osteopathic manipulative treatment (OMT). OBJECTIVE: To apply a preventive OMT protocol for cross-country athletes to reduce the incidence of stress fractures. DESIGN: Cohort study. METHODS: Examinations of cross-country athletes at an NCAA (National Collegiate Athletic Association) Division I university were performed by supervising physician-examiners and first- and second-year osteopathic medical students during several consecutive academic years. Athletes re-enrolled in the study each year they continued to be eligible. The intervention included osteopathic structural examination and OMT that focused on somatic dysfunction identified in the pelvis, sacrum, and lower extremities. RESULTS: More than 1800 participant examinations were performed on 124 male and female participants by 3 supervising physician-examiners and 141 osteopathic medical students over the course of 5 consecutive academic years (2004-2005 to 2008-2009). Data from these academic years were compared with data from the previous 8 academic years (1996-1997 to 2003-2004). An average of 20 new participants enrolled yearly. The number of annual stress fractures per team ranged from 0 to 6 for male participants and 1 to 6 for female participants. The cumulative annual incidence of stress fractures for male participants demonstrated a statistically significant decrease from 13.9% (20 of 144) before intervention to 1.0% (1 of 105) after intervention, resulting in a 98.7% relative reduction in stress-fracture diagnosis (P=.019). The cumulative annual incidence for female participants showed a minimal decrease from 12.9% (23 of 178) before intervention to 12.0% (17 of 142) after intervention, an 8.5% relative reduction in stress-fracture diagnosis (P=.671). The cumulative annual incidence of all participants decreased from 13.4% (43 of 322) before intervention to 7.3% (18 of 247) after intervention, a 45% relative reduction in stress-fracture diagnosis (P=.156). CONCLUSION: There was a statistically significant decrease in the cumulative annual incidence of stress fractures in male, but not female, cross-country athletes after receiving OMT.

Rib stress fractures among rowers: definition, epidemiology, mechanisms, risk factors and effectiveness of injury prevention strategies.

Rib stress fractures (RSFs) can have serious effects on rowing training and performance and accordingly represent an important topic for sports medicine practitioners. Therefore, the aim of this review is to outline the definition, epidemiology, mechanisms, intrinsic and extrinsic risk factors, injury management and injury prevention strategies for RSF in rowers. To this end, nine relevant books, 140 journal articles, the proceedings of five conferences and two unpublished presentations were reviewed after searches of electronic databases using the keywords 'rowing', 'rib', 'stress fracture', 'injury', 'mechanics' and 'kinetics'. The review showed that RSF is an incomplete fracture occurring from an imbalance between the rate of bone resorption and the rate of bone formation. RSF occurs in 8.1-16.4% of elite rowers, 2% of university rowers and 1% of junior elite rowers. Approximately 86% of rowing RSF cases with known locations occur in ribs four to eight, mostly along the anterolateral/lateral rib cage. Elite rowers are more likely to experience RSF than nonelite rowers. Injury occurrence is equal among sweep rowers and scullers, but the regional location of the injury differs. The mechanism of injury is multifactorial with numerous intrinsic and extrinsic risk factors contributing. Posterior-directed resultant forces arising from the forward directed force vector through the arms to the oar handle in combination with the force vector induced by the scapula retractors during mid-drive, or repetitive stress from the external obliques and rectus abdominis in the 'finish' position, may be responsible for RSF. Joint hypomobility, vertebral malalignment or low bone mineral density may be associated with RSF. Case studies have shown increased risk associated with amenorrhoea, low bone density or poor technique, in combination with increases in training volume. Training volume alone may have less effect on injury than other factors. Large differences in seat and handle velocity, sequential movement patterns, higher elbow-flexion to knee-extension strength ratios, higher seat-to-handle velocity during the initial drive, or higher shoulder angle excursion may result in RSF. Gearing may indirectly affect rib loading. Increased risk may be due to low calcium, low vitamin D, eating disorders, low testosterone or use of depot medroxyprogesterone injections. Injury management involves 1-2 weeks cessation of rowing with analgesic modalities followed by a slow return to rowing with low-impact intensity and modified pain-free training. Some evidence shows injury prevention strategies should focus on strengthening the serratus anterior, strengthening leg extensors, stretching the lumbar spine, increasing hip joint flexibility, reducing excessive protraction, training with ergometers on slides or floating-head ergometers, and calcium and vitamin D supplementation. Future research should focus on the epidemiology of RSF over 4-year Olympic cycles in elite rowers, the aetiology of the condition, and the effectiveness of RSF prevention strategies for injury incidence and performance in rowing.

High serum 25-hydroxyvitamin D is associated with a low incidence of stress fractures.

Low serum 25-hydroxyvitamin D [25(OH)D] concentrations are associated with hip fractures, but the dose-response relationship of serum 25(OH)D with risk of stress fractures in young women is unknown. This nested case-control study in a cohort of female Navy recruits was designed to determine whether those with low prediagnostic serum 25(OH)D concentrations had greater risk of stress fracture. Sera were drawn in 2002-2009 from 600 women who were diagnosed subsequently with stress fracture of the tibia or fibula and 600 matched controls who did not experience a stress fracture. The 25(OH)D concentration was measured using the DiaSorin radioimmunoassay method. Controls were individually matched to cases on race (white, black, or other), length of service (±30 days), and day blood was drawn (±2 days). There was approximately half the risk of stress fracture in the top compared with the bottom quintile of serum 25(OH)D concentration (odds ratio [OR] = 0.51, 95% CI 0.34-0.76, p ≤ 0.01). The range of serum 25(OH)D in the lowest quintile was 1.5 to 19.7 (mean 13.9) ng/mL, whereas in the highest it was 39.9 to 112 (mean 49.7) ng/mL. It is concluded that there was a monotonic inverse dose-response gradient between serum 25(OH)D and risk of stress fracture. There was double the risk of stress fractures of the tibia and fibula in women with serum 25(OH)D concentrations of less than 20 ng/mL compared to those with concentrations of 40 ng/mL or greater. A target for prevention of stress fractures would be a serum 25(OH)D concentration of 40 ng/mL or greater, achievable with 4000 IU/d of vitamin D(3) supplementation.

Evaluating the relationship of calcium and vitamin D in the prevention of stress fracture injuries in the young athlete: a review of the literature.

Calcium and vitamin D are recognized as 2 components of nutrition needed to achieve and maintain bone health. Calcium and vitamin D have been clearly shown to improve bone density and prevent fractures at all ages. However, the literature is conflicting as to the role of these nutrients in young athletes ages 18 to 35 years, both for bone development and for the prevention of bone overuse injuries. Differences in findings may relate to study design. Although retrospective and cross-sectional studies have had mixed results, the authors of prospective studies have consistently demonstrated a relationship of increased calcium intake with an improvement in bone density and a decrease in fracture risk. A randomized trial in female military recruits demonstrated that calcium/vitamin D supplementation reduced the incidence of stress fractures. A prospective study in young female runners demonstrated reduced incidence of stress fractures and increased bone mineral density with increased dietary calcium intake. Findings from both studies suggest female athletes and military recruits who consumed greater than 1500 mg of calcium daily exhibited the largest reduction in stress fracture injuries. To date, no prospective studies have been conducted in male athletes or in adolescent athletes. In most studies, males and nonwhite participants were poorly represented. Evidence regarding the relationship of vitamin D intake with the prevention of fractures in athletes is also limited. More prospective studies are needed to evaluate the role of calcium and vitamin D intake in prevention of stress fracture injuries in both male and female adolescent athletes, particularly those participating in sports with greater incidences of stress fracture injury.

[Stress fracture in athletes and prevalence of extensive rehabilitation]. / Fracture de fatigue chez le sportif et prise en charge intensive de rééducation.

OBJECTIVE: The aim of this work was to review the literature for the place of extensive rehabilitation for athletes with stress fractures. METHOD: We searched the Medline and Embase databases using the keywords stress fracture, sports, rehabilitation, management and treatment. Only French and English articles were included, and articles about bone physiology, animal models, and spine and chest localisations were excluded. From 468 scientific articles, 62 were chosen because they corresponded to literary reviews or to therapeutic evaluations. RESULTS: Treatment of stress fracture is justified according to risk factors, stress-fracture complications, the precocity of diagnosis, the therapeutic method and when the athlete needs to return to the sport. The most common treatment is discontinuing the sport, followed by rest. The progressive resumption of sport is rarely described but must take into account mechanical constraints that can be controlled by the use of shoes adapted to a supple ground. Some treatments such as immobilization by pneumatic splint surgery or use of electric fields are controversial. CONCLUSION: Extensive treatment of stress fractures is mainly dedicated to high-level athletes who need to regain previous physical capacities as soon as possible.