Must-Know Lower Extremity Stress Fractures in Elite Performers

Lower extremity stress fractures are common overuse injuries in athletes and military recruits due to repetitive mechanical activities. These fractures occur when bone remodeling fails to compensate for cumulative microdamage, leading to either fatigue-type fractures in healthy bone or insufficiency fractures in weakened bone. Early diagnosis is essential to prevent progression to a complete fracture, which may require prolonged recovery or surgical intervention. Imaging plays a crucial role in the early detection and timely management of stress fractures. Although radiography is often the initial modality used to evaluate the symptoms of stress fracture, MRI offers superior sensitivity for findings of early bone stress response like marrow edema. High-risk fractures, such as those located in the femoral neck (tension-side), anterior tibial cortex, and navicular bone, have a greater likelihood of complications such as nonunion or avascular necrosis. Low-risk fractures, including those of the posteromedial tibia and pubic rami, generally heal with conservative management. Management focuses on activity modification, immobilization for select cases, and surgical fixation for refractory or high-risk injuries. This Pictorial Essay highlights key imaging findings, classification systems, and management approaches for lower extremity stress fractures to aid in clinical decision-making.