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Not all bone overuse injuries are stress fractures: it is time for updated terminology
  1. Stuart J Warden1,2,
  2. Tim Hoenig3,
  3. Austin M Sventeckis1,
  4. Kathryn E Ackerman4,
  5. Adam S Tenforde5
  1. 1 Department of Physical Therapy, Indiana University, Indianapolis, Indiana, USA
  2. 2 Indiana Center for Musculoskeletal Health, Indiana University, Indianapolis, IN, USA
  3. 3 Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
  4. 4 Sports Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
  5. 5 Spaulding Rehabilitation Hospital, Physical Medicine and Rehabilitation, Harvard Medical School, Charlestown, MA, USA
  1. Correspondence to Dr Stuart J Warden, Department of Physical Therapy, Indiana University, Indianapolis, IN 46202, USA; stwarden{at}

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Mention ‘stress fracture’ to an athlete or coach and there is instant concern. Frequently occurring at the beginning of an athletic season or in the lead up to a major competition, there is awareness that diagnosis invariably disrupts participation. The term ‘stress fracture’ has deep roots in our vernacular. Its use in the literature has risen steadily since the 1970s/1980s and shows no sign of waning. But are we all talking about the same thing, and does it matter?

Most bone stress injuries are not stress fractures

Stress fractures are a type of ‘bone stress injury’ (BSI).1 A BSI represents the inability of a generally normal bone to withstand repetitive loading leading to localised bone weakness and pain. A history of repetitive loading distinguishes BSIs from insufficiency-type injuries occurring with ageing and disease, although some athletes share a similar phenotype of compromised general bone health.

Stress fractures are characterised by a discernible fracture line on imaging. Only one-in-five athletes presenting with a BSI have a stress fracture.2 The other 80% have stress …

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  • Twitter @StuartJWarden, @drkateackerman, @AdamTenfordeMD

  • Contributors SJW developed the initial draft. All authors revised and approved the final version.

  • Funding This contribution was made possible by support from the National Institutes of Health (NIH/NIAMS P30 AR072581) and the Indiana Clinical Translational Science Award/Institute (NCATS UL1TR002529-01).

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.