Stress Fracture = Osteoporosis

October 5, 2012 4 Comments

A fragility fracture is a fracture which happens from minor trauma.  A stress fracture happens from repeated normal daily activities, like walking or going up or down stairs.  This is a fracture from no trauma.

Bone must be at very high risk of fracture to develope a stress fracture.  Clinical Osteoporosis was defined by NIH in 2001 as increased risk of fracture.  Therefore, a Stress Fracture is defined as Clinical Osteoporosis.

Stress fracture does not necessarily mean low Bone Mineral Density (BMD).  A person can have “normal” BMD on DXA testing and still have Clinical Osteoporosis.  Fracture risk does not depend solely on BMD.  Remember FRAX.  Stress fractures can occur when bone is too thick, has a lot of mineral (high BMD), and is too rigid, too stiff, and too brittle.

The key to healing a stress fracture is to decrease weight bearing.  That means crutches or a walker.  “Canadian” crutches are far easier to manage and avoid sore armpits.  Immobilization is usually not necessary as long as weight bearing is decreased.

A Stress Fracture makes the diagnosis Clinical Osteoporosis.  Therefore a full Bone Health work-up is needed, including VFA and lab tests.  Common findings include: low 25-hydroxy Vitamin D, Secondary HyperParathyroidism, inadequate Calcium intake, Smoking, Alcohol intake more than 2 drinks daily, body weight below BMI of 19, and poor diet / low protein nutrition.

Treatment with an Antiresorptive can make the situation worse.  Therefore, I use the Anabolic, Forteo (Teriparatide), as do most who treat stress fractures, including atypical femur fractures.

Jay Ginther, MD

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  • Olga Karin Wer-Ramirez

    I had a three heel fractures 6 months ago on August 28, 2014. Then i developed a stress fracture in front Of My foot…. I had To push myself With My two feet while i Was in a wheel chair for 4 months since i had no body To push me. I live alone and i am a senior Citizen. I kept mailing my doctor that I Was so much in pain but he así red me that it Was the healing process while could take up To a year. Could You tell me Please If the stress fracture as due To the above And relates To the first fracture? God bless You.

    • Multiple stress fractures in your feet strongly suggest a problem with your bone quality and the ability of your bone to heal. You probably have “Clinical Osteoporosis” regardless of your DXA score. You should have a Complete Bone Health Evaluation. Click that topic in the left column.
      The Anabolic, Forteo, may help stimulate bone healing, if you are an approrpriate patient for this medication. All other osteoporosis medications may slow the healing of stress fractures at times.
      Many issues may be involved in your problem. Get a Complete Bone Health Evaluation and discuss the results fully with your doctor.

      • Ryan Ladd

        I have recently commenced treatment with Denosumab (brand name: Prolia). Will this assist with stress fracture healing or slow bone development? I have a stress fracture in my sacrum.

        • I do not know your full story, but I can give some general information
          We do not have definite evidence that Prolia will slow healing
          But there is NO eviidence that Prolia will facilitate healing and its mechanism of action suggests that it cannot assist healing, especially in a stress fracture
          Stress fracture healing requires osteoclasts
          The only medication which specifically stimulates osteoclasts is Forteo – although its main action is to stimulate osteoblasts
          Forteo is the default medication for healing stress fractures
          Tymlos might also work in a treatment naive patient, but it has much less osteoclast stimulation and should be less effective on a stress fracture
          Discuss this with your doctor

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