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

Biologic Healing Enhancement

Once the risk and severity levels have been determined for a bony stress injury in an athlete, healing optimization must be initiated and biologic healing enhancement options may be considered. Osteobiologics is a term used to describe materials that have been identified and developed to promote bone healing. The following is a general overview of biologic options that are approved by the FDA and readily available for healing enhancement of bone. These options can be divided into two groups: direct injectable modalities and indirect systemic stimulating treatments. Tables A1 and A2 (Appendix, Supplemental Digital Content 1, http://links.lww.com/JAAOS/A371) summarize the evidence to support each option's use. It should be borne in mind that not every option is ideal for every bone or even each area of the affected bone. Some options may be used in combination or as an adjunct to internal fixation with implant. Each option carries its own risks and benefits, and the appropriate indications and long-term outcomes of these treatment options are yet to be determined. A general approach to guide the treatment of these fractures and when to consider emerging osteobiologic options to enhance healing is shown in Figure 1.

Figure 1.

Chart showing the recommended treatment algorithm for application of osteobiologic treatments to stress fractures in athletes. ESWT = extracorporeal shock wave therapy, PTH = parathyroid hormone