Prevention of Lower Extremity Stress Fractures in Athletes and Soldiers: A Systematic Review

Stress fractures represent one of the most common and potentially serious overuse injuries (1–5). The first cited reports on stress fracture were case studies of soldiers incurring such fractures in the 19th and early 20th centuries (2, 4, 6–9). By the mid-1900s, the condition was being reported in nonmilitary populations with increasing frequency (10–15). Although almost any athlete or exerciser who engages in frequent, repetitive activity may develop a stress fracture (3, 16), repetitive weight-bearing activities such as running and marching are the most frequently reported causes of stress fracture (2, 3, 6, 16, 17). Stress fractures have been reported in most bones of the extremities, as well as the ribs and the spine (3), but the most common location is the lower extremities (2, 3, 16). Among runners, the tibia is the bone most commonly injured (1, 3, 18–20). Early military reports of stress fractures among recruits described march fractures of the foot (7, 21–24). However, during World War II, increasing numbers of military studies described march fractures in other bones of the lower extremities, primarily the tibia (25, 26) and femur (26–28). Recent military papers have shown increasing numbers occurring in the tibia (29–31).