This results in higher peak stress and more microdamage. Due to either muscle loss or fatigue, the muscles become increasingly less able to attenuate the forces applied through the bones. One factor is a neuromuscular hypothesis. In addition to the intrinsic and extrinsic factors already noted, there are additional factors influencing stress fracture development. These injuries are also more common in women. The most common stress fractures in decreasing order of occurrence are the tibia (23.6%), tarsal navicular (17.6%), metatarsals (16.2%), femur (6.6%), and pelvis (1.6%). In runners, stress fractures account for nearly 16% of all injuries. From 2009 to 2012, US military members had 5.69 stress fractures per 1000 person-years. Due to the repetitive nature of military training, stress fractures are common among members of the military. Stress fractures account for about 20% of all sports medicine injuries, and runners who average more than 25 miles a week are considered high risk. This is a unique stress fracture related to repeated hyperextension of the spine. Gymnasts, female soccer players, some American football position players like offensive linemen and linebackers, and Olympic-style weightlifters are at increased risk of spondylolysis. Hurdlers see an increased risk of patella fractures. Runners see tibia and metatarsal with pelvic stress fractures in female runners, and in long-distance running, there is an association with femoral neck and pelvic injuries. Some stress fractures are more common in specific sports.
The clavicle, scapula, first rib and proximal humerus/shaft (thrower's shoulder), medial epicondyle (thrower's elbow), olecranon, and radial physis (gymnast's wrist) are the most common sites. In female athletes, stress fractures of the pelvis and metatarsals are most common. Upper extremity stress fractures are rare but have been reported in gymnasts, weightlifting, and throwing sports. The most common sites for stress fractures are as follows in decreasing order metatarsals, tibia, tarsals, femur, and fibula, followed by the pelvis. Military personnel includes smokers and those less fit in initial training, running is more limited, with them carrying much heavier loads and having less effective footwear in preventing these injuries. Those at the highest risk for having a stress fracture are female athletes and those with a previous stress fracture. There is a danger of extrapolating data from military studies to a general running population. In general, with male and female athletes participating in the same training regime, female athletes have a higher incidence of stress fractures. A longitudinal study of 5000 Finnish male military recruits demonstrated a higher level of high intense activity before entering training helped protect against a stress fracture. The most common risk factor is an abrupt increase in activity. Extrinsic factors include high-impact sports activities like running, jumping, abrupt increase in physical activity, irregular or angled running surface, poor footwear, running shoe wear older than 6 months, deficient vitamin D and calcium, and smoking. Intrinsic factors include poor physical conditioning, female, hormonal disorder, menstrual disorder, poor bone density, reduced muscle mass, genu valgum knees, and a short leg. There are intrinsic and extrinsic factors contributing to the development of the injury, with the bulk of the information coming from studies on military personnel. Stress fractures are due to an abrupt increase in activity or training patterns. It generally starts with pain after activity, and then the pain will last for progressively longer periods of time. When an abrupt change in physical activity occurs, there is about a 3-week lag before symptoms begin to manifest. If the activity persists, the bone eventually develops a fracture. During military training, for instance, the body cannot adapt fast enough, so the bone develops microfractures. A stress fracture occurs when the adaptive ability of the bone is unbalanced. Normal bone is constantly being remodeled by osteoclasts absorbing and osteoblasts laying down new bone. Julius Wolff (1836-1902) was a German surgeon who proposed bones will remodel and adapt to the loads being placed on them. Stress or fatigue fractures occur in normal bone when it is subjected to abnormal forces like military training. It was seen in military recruits and was diagnosed with foot pain and swelling. Stress fractures were first reported in military personnel as "march foot" in the mid-19th century.
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