My daughter and granddaughter have suffered stress fractures. The following Government Printing Office monograph helped them understand the issues.
120 page monograph including footnotes for further research if interested. Full pdf below; Basic Combat training (BCT) and Advanced Individual Training (ACT).

Sonja M. Thompson, MD, Colonel, MC, US Army, Chief of Surgery Carl R. Darnall Army Medical Center Fort Hood

 “This monograph is an excellent reference for lower extremity and back injuries, and contributes significantly to understanding the differences between women and men in the rate and distribution of musculoskeletal overuse and traumatic injuries sustained by our military members. This publication sheds light on the nature of the biomechanics differences between women and men, and how these differences result in notable changes in injury patterns that impact the length of healing time and ultimately impact the readiness of the unit. Drs Springer and Ross have provided us with an excellent tool for addressing the unique challenges healthcare providers face in providing the best possible care—both therapeutic and preventive—to our women military members.”

Pathophysiology. A progressive decline in the muscular support of the bone, secondary to muscle fatigue, may lead to the transmission of excessive forces to the underlying bone. Muscles that are not adapted to repetitive work, and therefore lack endurance and muscle mass, may be unable to support the long bones of the lower extremity. Muscles may also contribute to stress injuries by concentrating forces across a localized area of bone, thus causing mechanical insults that exceed the stress-bearing capacity of the bone. The aforementioned pathophysiology of stress fractures is a simplified model; however, other physiological and anatomical factors, such as those mentioned previously and others that are beyond the scope of this text, ultimately contribute to the occurrence of a stress fracture. The
endocrine system plays a vital role in bone health. Male and female competitive endurance athletes with abnormally low sex hormone levels are predisposed to stress fractures. The “female athlete triad”—which refers to the combination of amenorrhea, osteoporosis, and disordered eating— may predispose a female to stress fractures. In attempts to minimize body fat to further increase athletic performance, a female may find herself in an estrogen-deficient state leading eventually to decreased bone mineral density and increased risk of stress fractures. Although not specific to military women, amenorrhea and oligomenorrhea are common findings in competitive female distance runners.
Diagnosis. The history of a patient with a stress fracture is typically one of insidious onset of activity-related pain. The pain is generally well localized and described as a mild ache occurring after exercise. As time and activity participation continue, the patient may report more severe pain or pain that occurs at an earlier stage in exercise. The most obvious finding on physical examination is localized bony tenderness, which may also be accompanied by periosteal thickening, redness, and swelling if the stress fracture occurs in a superficial area of the body. The physical examination should include evaluation of limb biomechanics to identify potential predisposing factors e.g., leg-length discrepancy or malalignment, muscle imbalance, weakness, excessive subtalar pronation, or lack of flexibility. The differential diagnosis of stress fracture may include nonbony pathology, such as exertional compartment syndrome, nerve entrapment, muscle strain, bursitis, traction periostitis, or medial tibial stress syndrome. Bony pathologies that can mimic stress fracture include infection and neoplasm. Although a classic history of exercise-associated bone pain and typical examination findings of localized bony tenderness have a high correlation with the diagnosis of stress fracture, various imaging techniques are also available to the clinician for further evaluation. Additional diagnostic imaging studies include radiography (plain X-ray), bone scintigraphy (bone scan), computerized tomography, and magnetic resonance imaging (MRI). Radiographs are typically normal for the first 2 to 3 weeks after the onset of symptoms and may not reveal positive findings, such as periosteal reaction, cortical lucency, or a fracture line for several months. Therefore, radionuclide imaging (bone scan), which is highly sensitive for detecting stress injuries, may be used to confirm a clinically suspected stress fracture. Changes may be seen as early as 48 to 72 hours after the beginning of symptoms.Fractures that have a propensity for progressing to complete fracture, delayed union, or nonunion are considered high-risk fractures and should be treated more aggressively. Fractures that have been identified as high risk in the general population include fractures of the femoral neck (tension side), the patella, the anterior cortex of the tibia, the medial malleolus, the talus, the tarsal navicular, the fifth metatarsal, and the great toe sesmoids. Tibial stress fractures are common in both men and women; however, women appear to have more femoral, metatarsal, and pelvic stress fractures than men. Researchers studying 2,962 women undergoing basic training at the Marine Corps Recruit Depot found the most common sites of stress fracture (in descending order of occurrence) to be the tibia, metatarsals, pelvis, and femur. Each will be considered independently.

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