Focus on Overuse Injuries in Kids: Stress Fractures

Stress fractures can be a scary diagnosis, because it is often a season ending injury, which is difficult for a young athlete to handle.  It is rare for stress fractures to occur before the teenage years, but it can happen if a young child is over-training. 

Most commonly stress fractures in kids occur in the lower extremities.  There is not a threshold for how many hours a week a child must train for a stress fracture to occur, but typically they occur in young athletes doing weight-bearing activity for more than about 10-15 hours a week.  Sometimes there is an underlying metabolic or nutritional problem that makes an athlete more prone to a stress fracture (such as low calcium intake).  Also, young females who are underweight and have irregular menses because of over-training are at especially high risk of stress fractures. 

A stress fracture can also progress to a complete fracture or break if not treated appropriately.  Often times they are misdiagnosed as muscle strains, but should be suspected if a child has pain with regular walking or is limping. 

Treating stress fractures usually does not require an operation, but does generally require a long period of rest.  For example, a stress fracture in the femur can take months to heal, while a stress fracture in the inside part of the shin may only take a few weeks.  Some stress fractures don't heal well on their own and require surgery (for instance, the front part of the shin and the hip).  After a stress fracture heals it is important to gradually return to playing sports, and physical therapy may be required in the meantime to help with flexibility and muscle strengthening. 

If your child trains many hours a week at his or her sport, it is crucial that they have days of rest during the peak training and also weeks of rest during the off season.  Also, make sure that your child has an adequate intake of calcium in his or her diet.  It is especially important that adolescent females maintain an appropriate body weight and regular periods to prevent stress fractures from occurring. 

Ask your pediatrician if you are concerned that your child may have a stress fracture - further studies are necessary to make an accurate diagnosis and consultation with a sports medicine doctor is helpful.  A stress fracture is usually not visible on an x-ray and often another study is needed.  MRI is shown to be the best study for detecting stress fractures even if they have only just developed (with the exception of low back stress fractures where bone scan is used).  Regardless, it is important to know that stress fractures do occur in kids, especially in teenagers. 

Rachel Brewer, MD

Originally Posted on Pediatricians for Parents