Emerging Options for Biologic Enhancement of Stress Fracture Healing in Athletes

Timothy L. Miller, MD; Christopher C. Kaeding, MD; Scott A. Rodeo, MD


J Am Acad Orthop Surg. 2020;28(1):1-9. 

In This Article

Abstract and Introduction


In an era of continual single-sport specialization and year-round training, overuse injuries, including stress injuries of bone, are increasingly common. These injuries can be season- or even career-ending. For many elite and professional athletes, the traditional treatment strategy of immobilization and extended rest from sports participation is often not practical or acceptable. An understanding of modern strategies for evaluating and treating stress fractures is paramount for maintaining athletic participation and optimal athletic performance. This begins with the ability to categorize and stratify bony stress injuries by both severity and risk of fracture progression. Surgical procedures such as open reduction and internal fixation or intramedullary fixation with possible bone grafting remain the standard of care for chronic or severe stress fractures. However, emerging techniques to augment the biologic environment are a minimally invasive adjunct for stimulating and supporting bone healing in elite-level athletes to optimize bone health, expedite recovery, and decrease the risk of nonunion or catastrophic fracture.


Single-sport specialization is increasingly common among competitive athletes. Athletes as young as their pre-teen years choose to train and compete nearly year-round in one sport and often at a single position within that sport. As such, overuse injuries including stress fractures are increasingly common not only among distance runners but also among other field and arena sports such as soccer, lacrosse, basketball, ballet, and gymnastics.[1] In addition, the intense training that often accompanies single-sport specialization likely contributes to an increased severity of the stress fractures encountered among these athletes.[1,2] A robust understanding of emerging strategies for approaching and treating these injuries is paramount to maximize the athlete's participation, minimize time lost, and to optimize performance while mitigating the risk of worsening injury.