Raiyyan Tahsan

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TC(956).(05).Orthopedics Case No 34. Stress fracture

Stress fracture — বাংলা Clinical Note

সতর্কতা: Stress fracture-এর মূল চিকিৎসা medicine নয়—মূল চিকিৎসা হলো activity modification, off-loading/immobilization, nutrition correction, physiotherapy এবং high-risk fracture হলে orthopedic referral। নিচের drug dose adult general reference; patient-specific renal/liver disease, pregnancy, ulcer, anticoagulant use, allergy অনুযায়ী পরিবর্তন হবে।

1) Definition / সংজ্ঞা

Stress fracture হলো হাড়ে বারবার repetitive load/overuse-এর কারণে তৈরি হওয়া small crack বা microscopic fracture। এটি bone stress injury spectrum-এর অংশ—প্রথমে stress reaction, পরে untreated থাকলে true stress fracture/complete fracture হতে পারে। Stress fracture সাধারণত lower limb—tibia, metatarsal, fibula, femoral neck, calcaneus—এ বেশি হয়। Mayo Clinic এটিকে “tiny cracks in bone” হিসেবে বর্ণনা করেছে, যা বেশি দেখা যায় lower leg ও foot-এর weight-bearing bones-এ।

2) Causes / কারণগুলো

A. Mechanical / Overuse causes

  • হঠাৎ training বাড়ানো: running distance, marching, jumping, gym load দ্রুত বাড়ালে।
  • Repeated impact: long-distance running, football, basketball, military training, dance।
  • Poor footwear: worn-out shoes, hard surface-এ দৌড়ানো।
  • Biomechanical problem: flat foot, high arch, leg length discrepancy, abnormal gait।
  • Muscle fatigue: muscle shock absorb করতে না পারলে load bone-এ যায়।

B. Bone weakness / Insufficiency causes

  • Vitamin D deficiency
  • Low calcium intake
  • Osteopenia / osteoporosis
  • Female athlete triad / RED-S: low energy intake, menstrual disturbance, low bone density।
  • Chronic steroid use
  • Hyperthyroidism / hyperparathyroidism
  • Renal disease, malabsorption, celiac disease

C. High-risk stress fracture sites

এগুলোতে nonunion/complete fracture risk বেশি, তাই early MRI + orthopedic review দরকার:

  • Femoral neck, especially tension side
  • Anterior tibial cortex
  • Navicular
  • Talus
  • 5th metatarsal base
  • Medial malleolus
  • Patella / sesamoid

3) Symptoms / লক্ষণগুলো

  • Activity-related localized pain: হাঁটা/দৌড়/লোড দিলে ব্যথা বাড়ে, rest নিলে কমে।
  • Point tenderness: নির্দিষ্ট হাড়ের জায়গায় আঙুল দিয়ে চাপ দিলে sharp pain।
  • Swelling: painful area-তে mild swelling থাকতে পারে।
  • Pain progression: শুরুতে exercise শেষে ব্যথা, পরে exercise চলাকালীন, শেষে rest pain।
  • Limping / altered gait: lower limb stress fracture-এ খুঁড়িয়ে হাঁটা।
  • Hop test painful: এক পায়ে লাফ দিলে ব্যথা বাড়তে পারে, তবে এটি confirmatory test নয়।
  • Night/rest pain: severe বা progressing lesion-এর warning sign।

4) Clinical diagnosis — কীভাবে সন্দেহ করবেন

Clinical suspicion হবে যখন:

  • Recent training/load increase আছে।
  • Pain localized এবং reproducible point tenderness আছে।
  • Soft tissue injury মনে হলেও ১–২ সপ্তাহে ভালো হচ্ছে না।
  • Tibia/metatarsal/femoral neck region-এ exercise-related pain।
  • Female athlete/low BMI/menstrual irregularity/osteoporosis/steroid history আছে।

Differential diagnosis

  • Shin splints / medial tibial stress syndrome
  • Tendinopathy
  • Ligament sprain
  • Muscle strain
  • Osteomyelitis
  • Bone tumor
  • DVT, especially calf swelling/pain
  • Compartment syndrome
  • Neuropathy / radiculopathy

5) Investigations — specific approach

1. X-ray — first-line baseline

  • AP/lateral view of painful bone/joint।
  • Early stage-এ X-ray normal হতে পারে।
  • ২–৩ সপ্তাহ পরে periosteal reaction/callus দেখা যেতে পারে।
  • AAFP অনুযায়ী suspected stress fracture-এ initial plain radiograph করা উচিত; negative হলে ২–৩ সপ্তাহ পরে repeat করা যায়।

2. MRI — best early test

  • Early marrow edema, stress reaction, fracture line detect করে।
  • High-risk site, athlete, severe pain, negative X-ray but high suspicion—MRI preferred।
  • ACR 2024 update বলছে radiography baseline imaging, আর MRI radiographically occult stress fracture diagnosis-এ খুব গুরুত্বপূর্ণ।

3. CT scan

  • Cortical fracture line, navicular/anterior tibial cortex detail, surgical planning-এর জন্য।
  • Early marrow edema detect-এ MRI-এর চেয়ে কম sensitive।

4. Bone scan

  • MRI unavailable হলে useful।
  • Sensitive কিন্তু specific কম; infection/tumor/other bone turnoverেও positive হতে পারে। Mayo Clinic notes bone scan is less specific and not commonly first choice.

5. Lab tests — recurrent/insufficiency stress fracture হলে

  • CBC, ESR/CRP: infection/inflammatory/tumor suspicion।
  • Serum calcium, phosphate, ALP
  • 25-OH vitamin D
  • PTH
  • TSH
  • Renal function, LFT
  • Ferritin/iron profile if athlete/fatigue
  • Testosterone in male hypogonadism suspicion
  • Female: menstrual history, pregnancy test before radiation-based imaging

6. DEXA scan

  • Osteoporosis risk, recurrent stress fracture, steroid use, postmenopausal, RED-S/female athlete triad—এই ক্ষেত্রে।

6) Complications / জটিলতা

  • Complete fracture: load চালিয়ে গেলে small crack full fracture হতে পারে।
  • Nonunion / delayed union: বিশেষ করে navicular, anterior tibia, femoral neck।
  • Displacement: femoral neck stress fracture displace হলে emergency surgery লাগতে পারে।
  • Chronic pain: early diagnosis না হলে long-term pain।
  • Recurrent stress fracture: nutrition/biomechanics/training error ঠিক না করলে।
  • Loss of sports/work time
  • Avascular necrosis: femoral neck involvement হলে rare but serious।
  • Surgery need: high-risk fracture, displaced fracture, failed conservative treatment।

7) Treatment management — core

A. Non-pharmacological management

Low-risk stress fracture

  • Painful activity বন্ধ: running/jumping/marching stop।
  • Relative rest: usually 4–8 weeks depending site/severity।
  • Crutch/boot/cast if pain on walking।
  • Ice 10–15 min, 2–3 times/day for acute pain।
  • Cross-training: swimming/cycling only if pain-free।
  • Physiotherapy: calf/hip/core strengthening, gait correction।
  • Gradual return: pain-free walking 30 minutes → slow return to running/activity।

High-risk stress fracture

  • Immediate non-weight-bearing।
  • MRI/CT confirmation।
  • Orthopedic/sports medicine referral।
  • Femoral neck/navicular/anterior tibia/5th metatarsal base—delay করলে complication বেশি।

8) Pharmacological drugs — Bangladesh practice-oriented list

Important prescribing principle

Stress fracture healing-এর জন্য paracetamol preferred first-line analgesic। NSAID/COX-2 drugs ব্যথা কমায়, কিন্তু prolonged use fracture healing নিয়ে concern থাকে; therefore shortest duration, lowest effective dose। NSAID risk নিয়ে literature-এ concern আছে, especially long-term/high-dose use।

1. Paracetamol / Acetaminophen

  1. Generic name: Paracetamol
  2. Therapeutic category: Analgesic, antipyretic
  3. Pharmacological class: Para-aminophenol derivative; central analgesic
  4. Why used: Stress fracture pain control; inflammation কমায় না, কিন্তু bone healing concern NSAID-এর মতো নয়।
  5. Adult dose: 500 mg every 6–8 hours PRN; max usually 3–4 g/day. Liver disease/alcohol use হলে lower max।
  6. Duration: 3–7 days PRN; persistent pain হলে reassess।
  7. Side effects: Nausea, rash; overdose হলে severe hepatotoxicity।
  8. Interactions: Warfarin effect increase with regular high-dose use; alcohol/hepatotoxic drugs increase liver injury risk।
  9. Bangladesh available brand examples: Napa 500 mg, Napa Extend 665 mg, Napa One 1000 mg, Renova 500 mg, Xcel 500 mg, Tamen 500 mg, Pyralgin 500 mg. MedEx/Osudpotro list multiple paracetamol brands including Napa 500, Napa Extend 665, Napa One 1000, Renova 500, Xcel 500, Tamen 500.

2. Ibuprofen

  1. Generic name: Ibuprofen
  2. Therapeutic category: Analgesic, anti-inflammatory
  3. Pharmacological class: NSAID; non-selective COX inhibitor
  4. Why used: Short course pain + inflammation control when paracetamol inadequate।
  5. Adult dose: 400 mg 2–3 times daily after food.
  6. Duration: 3–5 days; avoid prolonged use unless doctor decides।
  7. Side effects: Gastritis, ulcer/bleeding, renal injury, BP rise, edema, bronchospasm in NSAID-sensitive asthma।
  8. Interactions: Anticoagulant/antiplatelet, steroid, SSRI → bleeding risk; ACEI/ARB + diuretic → renal risk; lithium/methotrexate toxicity risk।
  9. Bangladesh available brand examples: Profen 400 mg, Intaflam 400 mg, Reumafen 400 mg, Rapofen 400 mg, Iburex 400 mg, Inflam 400 mg. MedEx lists ibuprofen 400 mg brands including Profen, Rapofen, Iburex, Inflam; Incepta lists Intaflam 400 as ibuprofen.

3. Naproxen / Naproxen sodium

  1. Generic name: Naproxen / Naproxen sodium
  2. Therapeutic category: Analgesic, anti-inflammatory
  3. Pharmacological class: NSAID; non-selective COX inhibitor
  4. Why used: Longer-acting NSAID for moderate pain; usually BID dosing।
  5. Adult dose: Naproxen 250–500 mg twice daily after food.
  6. Duration: 3–5 days initially; prolonged use avoid unless indicated।
  7. Side effects: Dyspepsia, ulcer/bleeding, renal impairment, BP rise, edema।
  8. Interactions: Same NSAID interactions—warfarin/DOAC, aspirin, steroid, ACEI/ARB, diuretic, lithium, methotrexate।
  9. Bangladesh available brand examples: Napro 250/500 mg, Napryn 250/500 mg, Naxin 250/500 mg, Naspro 250/500 mg, Nuprafen 250/500 mg, Naproxen 500 mg, Naproxin 250/500 mg. MedEx lists multiple naproxen sodium brands and strengths.

4. Diclofenac

  1. Generic name: Diclofenac sodium / potassium
  2. Therapeutic category: Analgesic, anti-inflammatory
  3. Pharmacological class: NSAID
  4. Why used: Acute pain/inflammation; Bangladesh prescription-এ musculoskeletal pain-এ common। Stress fracture-এ routine long course উচিত নয়।
  5. Adult dose: Diclofenac sodium 50 mg 2–3 times daily after food; max 150 mg/day. Topical gel 1% apply 3–4 times/day.
  6. Duration: Oral 3–5 days; topical 5–7 days.
  7. Side effects: Gastric ulcer/bleeding, renal injury, BP rise, edema; diclofenac has relatively higher CV risk than some NSAIDs।
  8. Interactions: Anticoagulants, antiplatelets, steroid, ACEI/ARB, diuretics, lithium, methotrexate।
  9. Bangladesh available brand examples: Diclofen 50 mg, Diclorex 50 mg, Dilock 50 mg, Fengel 50 mg/SR 100 mg, Erdon gel 1%, Fastfit gel 1%, Voltagel DS 2%. MedEx lists diclofenac brands including Diclofen 50 mg, Diclorex, Dilock, Fastfit gel, Fengel gel, Erdon gel, Voltagel DS.

5. Aceclofenac

  1. Generic name: Aceclofenac
  2. Therapeutic category: Analgesic, anti-inflammatory
  3. Pharmacological class: NSAID; COX inhibitor
  4. Why used: Musculoskeletal pain/inflammation; stress fracture pain severe হলে short course হিসেবে কিছু physician দেন।
  5. Adult dose: 100 mg twice daily after food.
  6. Duration: 3–5 days initially.
  7. Side effects: Dyspepsia, ulcer, dizziness, renal impairment, edema।
  8. Interactions: Same NSAID interactions; avoid with other NSAIDs।
  9. Bangladesh available brand examples: Flexi 100 mg, Reservix 100 mg, Avenac 100 mg, Ceclofen 100 mg, Celofen 100 mg, Paino 100 mg, Aceclofenac 100 mg. MedEx lists many aceclofenac 100 mg brands, and Arogga lists Flexi/Reservix/Ternilla/Zolfin examples.

6. Etoricoxib

  1. Generic name: Etoricoxib
  2. Therapeutic category: Analgesic, anti-inflammatory
  3. Pharmacological class: Selective COX-2 inhibitor NSAID
  4. Why used: Moderate pain with less GI irritation than non-selective NSAIDs, but CV/BP risk exists।
  5. Adult dose: 60 mg once daily; severe acute pain sometimes 90 mg once daily short course.
  6. Duration: 3–5 days; avoid prolonged use without indication।
  7. Side effects: Hypertension, edema, dyspepsia, renal impairment, increased CV risk in high-risk patients।
  8. Interactions: Warfarin/anticoagulants, ACEI/ARB, diuretics, lithium, methotrexate; avoid with other NSAIDs।
  9. Bangladesh available brand examples: Etorix 60/90/120 mg, Oricox 60/90/120 mg, Recox 60/90/120 mg, Ribox 60/90/120 mg, Rito 60/90/120 mg, Danilo 60/90/120 mg, Etrib 60/90 mg. MedEx lists these etoricoxib strengths and brands.

7. Topical diclofenac / analgesic gel

  1. Generic name: Diclofenac sodium gel or diclofenac combination gel
  2. Therapeutic category: Topical analgesic, anti-inflammatory
  3. Pharmacological class: Topical NSAID
  4. Why used: Local pain relief with lower systemic GI/renal risk than oral NSAIDs।
  5. Dose: Thin layer over painful soft-tissue area 3–4 times daily; avoid open wound.
  6. Duration: 5–7 days; persistent bony pain হলে reassess।
  7. Side effects: Skin irritation, rash, photosensitivity।
  8. Interactions: Systemic interaction কম, তবে oral NSAID + topical NSAID একসাথে দিলে total NSAID exposure বাড়তে পারে।
  9. Bangladesh available brand examples: Fastfit gel 1%, Fengel gel 1%, Erdon gel 1%, Voltagel DS 2%, VOLINAC Max 2%, VOLINI 1%. MedEx lists topical diclofenac/combination brands.

8. Pantoprazole — gastroprotection if NSAID used

  1. Generic name: Pantoprazole sodium
  2. Therapeutic category: Anti-ulcerant
  3. Pharmacological class: Proton pump inhibitor, PPI
  4. Why used: NSAID-induced gastritis/ulcer risk কমাতে; GERD/PUD থাকলে।
  5. Adult dose: 20–40 mg once daily before breakfast; high-risk NSAID user হলে clinician decides।
  6. Duration: NSAID course চলাকালীন; often 5–14 days short course.
  7. Side effects: Headache, diarrhea/constipation; long-term useে hypomagnesemia, B12 deficiency, fracture/infection risk।
  8. Interactions: May reduce absorption of drugs needing acidic pH; high-dose/long-term PPI with clopidogrel issue mainly omeprazole/esomeprazole বেশি আলোচিত, but clinician review দরকার।
  9. Bangladesh available brand examples: Pantonix 20/40 mg, Pantolok 20/40 mg, Pantopra 20/40 mg, Pantomak 20/40 mg, Pregel 20/40 mg, Protocid 20/40 mg, Pantogut 20/40 mg. MedEx lists pantoprazole brands and confirms Pantonix 20/40 mg.

9. Calcium + Vitamin D3

  1. Generic name: Calcium carbonate/citrate + Vitamin D3
  2. Therapeutic category: Bone health supplement
  3. Pharmacological class: Mineral + vitamin supplement
  4. Why used: Low calcium intake, vitamin D deficiency, osteopenia/osteoporosis risk, recurrent stress fracture।
  5. Adult dose: Elemental calcium 500–600 mg once/twice daily + Vitamin D3 200–400 IU per tablet, depending diet/lab।
  6. Duration: 8–12 weeks or longer if deficiency/osteoporosis risk।
  7. Side effects: Constipation, bloating, kidney stone risk in predisposed, hypercalcemia if excessive।
  8. Interactions: Levothyroxine, tetracycline/quinolone antibiotics, iron, bisphosphonate—২–৪ ঘণ্টা gap দরকার।
  9. Bangladesh available brand examples: Shelcal-D 500+200 IU, Shelcal-DX 600+400 IU, Calbo-D 500+200 IU, Coralcal-D 500+200 IU, Calboral-DX 600+400 IU, Organical-D/DX, Maacal-D/DX, Ovocal-D/DX. MedEx/Arogga list multiple calcium + vitamin D3 brands and strengths.

10. Cholecalciferol / Vitamin D3

  1. Generic name: Cholecalciferol
  2. Therapeutic category: Vitamin supplement
  3. Pharmacological class: Vitamin D3
  4. Why used: Vitamin D deficiency correct করলে calcium absorption ও bone mineralization improve হয়।
  5. Adult dose if deficiency: Common regimen: 40,000 IU once weekly for 7 weeks, then maintenance 1400–2000 IU/day or clinician-directed. MedEx lists this regimen for vitamin D3 deficiency.
  6. Duration: 7 weeks loading, then maintenance; 25-OH vitamin D recheck after ~3 months.
  7. Side effects: Hypercalcemia, nausea, constipation, polyuria, kidney stone risk if excessive।
  8. Interactions: Thiazide diuretics → hypercalcemia risk; digoxin toxicity risk if hypercalcemia; anticonvulsants/rifampicin reduce vitamin D effect।
  9. Bangladesh available brand examples: D-Rise 20,000/40,000/50,000 IU, D-Cap 20,000/40,000 IU, Hi-D 20,000/40,000 IU, D-Build 20,000/40,000 IU, D-Fill 2,000/20,000/40,000 IU, Max D 1,000/20,000/40,000 IU. MedEx lists these cholecalciferol brands and strengths.

11. Alendronic acid — only if osteoporosis/insufficiency fracture context

  1. Generic name: Alendronic acid
  2. Therapeutic category: Anti-osteoporotic
  3. Pharmacological class: Bisphosphonate
  4. Why used: Stress fracture-এর routine drug নয়; osteoporosis/low BMD/insufficiency fracture থাকলে fracture prevention-এর জন্য।
  5. Adult dose: 70 mg once weekly or 10 mg daily; osteoporosis indication অনুযায়ী। MedEx lists 70 mg once weekly regimen.
  6. Duration: Usually long-term 3–5 years review-based; specialist decision।
  7. Side effects: Esophagitis, gastritis, musculoskeletal pain, rare osteonecrosis jaw, atypical femur fracture।
  8. Interactions/administration: Empty stomachে full glass water; 30 min upright; calcium/iron/antacid/food absorption কমায়—same time নয়।
  9. Bangladesh available brand examples: Alendon 10 mg/70 mg; Bonemass-D 70 mg + 2800 IU; Ostel-D 70 mg + 2800 IU. MedEx lists alendronic acid and combination brands.

12. Teriparatide — specialist-only

  1. Generic name: Teriparatide
  2. Therapeutic category: Anti-osteoporotic anabolic agent
  3. Pharmacological class: Recombinant PTH 1-34 analogue
  4. Why used: Severe osteoporosis/high fracture risk, recurrent insufficiency fracture, delayed healing selected cases—orthopedic/endocrine specialist decision।
  5. Adult dose: 20 mcg SC once daily. MedEx lists this recommended dose.
  6. Duration: Specialist protocol; often up to 24 months maximum depending guideline/context।
  7. Side effects: Nausea, dizziness, leg cramps, hypercalcemia, orthostatic hypotension after injection।
  8. Interactions: Digoxin caution if hypercalcemia; avoid in bone malignancy, unexplained high ALP, prior skeletal radiation।
  9. Bangladesh available brand examples: Teripen 20 mcg/80 mcl prefilled pen, Forteo 20 mcg/80 mcl. MedEx lists both brands.

9) Bangladesh doctors commonly prescribe — practical list

Stress fracture suspected হলে Bangladesh clinical practice-এ commonly দেখা যায়:

  1. Paracetamol 500 mg PRN
    • Purpose: pain control; safest first option।
  2. Short-course NSAID — ibuprofen/naproxen/diclofenac/aceclofenac/etoricoxib
    • Purpose: acute pain/inflammation control।
    • Caution: ulcer, kidney disease, uncontrolled HTN, CVD, anticoagulant, asthma, pregnancy, elderly—avoid/doctor review।
  3. PPI — pantoprazole/esomeprazole/rabeprazole
    • Purpose: NSAID-induced gastritis/ulcer prevention in high-risk patient।
  4. Calcium + Vitamin D3
    • Purpose: bone mineral support, dietary deficiency correction।
  5. High-dose Vitamin D3
    • Purpose: confirmed/suspected deficiency correction।
  6. Bisphosphonate/teriparatide
    • Purpose: osteoporosis/insufficiency fracture management; not routine stress fracture drug।
  7. No routine antibiotic
    • Stress fracture infection নয়; osteomyelitis suspicion না থাকলে antibiotic দরকার নেই।
  8. No routine steroid
    • Steroid bone weakening করতে পারে; stress fracture pain management-এ steroid routine নয়।

10) Prevention / কীভাবে প্রতিরোধ করবেন

  • Training load প্রতি সপ্তাহে ধীরে বাড়ানো; sudden mileage/intensity jump নয়।
  • Running/jumping-এর মাঝে rest day রাখা।
  • Proper footwear এবং hard surface কমানো।
  • Pain শুরু হলে early rest; pain ignore করে training continue না করা।
  • Calcium-rich diet: milk, yogurt, small fish with bone, leafy greens।
  • Vitamin D: safe sunlight exposure + deficiency হলে supplement।
  • Female athlete হলে menstrual irregularity, low energy intake, eating disorder screen।
  • Strength training: calf, quadriceps, glute, core।
  • Gait/foot biomechanics correction: flat foot/high arch হলে orthotic consideration।
  • Recurrent stress fracture হলে DEXA + metabolic workup।
  • Smoking avoid; adequate sleep।

Overview / Summary

Stress fracture হলো repetitive loading-এর কারণে bone microdamage থেকে তৈরি fracture। Clinical clue হলো activity-related localized bony pain + point tenderness। Initial X-ray করা হয়, কিন্তু early X-ray normal হতে পারে; high suspicion বা high-risk site হলে MRI best investigation। Treatment-এর মূল হলো rest/off-loading/immobilization + gradual return + nutrition correction। Drug শুধু pain control ও deficiency correction-এর জন্য।

Actionable Plan / Steps

  1. Painful activity immediately stop করুন।
  2. Painful walking হলে crutch/boot দিয়ে off-loading করুন।
  3. X-ray করুন; high suspicion বা high-risk site হলে MRI করুন।
  4. Pain control: paracetamol first-line; NSAID only short course if appropriate।
  5. Vitamin D, calcium, renal function, thyroid/PTH/DEXA consider করুন if recurrent/insufficiency suspicion।
  6. High-risk site—femoral neck, navicular, anterior tibia, 5th metatarsal base—orthopedic referral।
  7. Pain-free walking না হওয়া পর্যন্ত running/jumping restart করবেন না।

Reference List

Textbook

  1. Harrison’s Principles of Internal Medicine, 21st ed. Sections on bone biology, osteoporosis, musculoskeletal pain/fracture risk.
  2. Davidson’s Principles and Practice of Medicine, 24th ed. Musculoskeletal disorders and metabolic bone disease sections.
  3. Robbins & Cotran Pathologic Basis of Disease, 10th ed. Bone remodeling, fracture healing, metabolic bone disease.
  4. Campbell’s Operative Orthopaedics, 14th ed. Stress fractures and sports-related fracture management.

Guideline / Clinical reference

  1. American College of Radiology. ACR Appropriateness Criteria: Stress (Fatigue/Insufficiency) Fracture, 2024 update — baseline radiography and MRI for occult stress fractures.
  2. American Family Physician. Patel DS, Roth M, Kapil N. Stress Fractures: Diagnosis, Treatment, and Prevention. Am Fam Physician. 2011;83(1):39–46.
  3. Mayo Clinic. Stress fractures: symptoms, causes, diagnosis and treatment, updated 2025.

Peer-reviewed journals with DOI

  1. McCormick F, Nwachukwu BU, Provencher MT. Stress fractures in runners. Clin Sports Med. 2012;31(2):291–306. DOI: 10.1016/j.csm.2011.09.012.
  2. Beck B, Drysdale L. Risk factors, diagnosis and management of bone stress injuries in adolescent athletes. Sports. 2021;9(4):52. DOI: 10.3390/sports9040052.
  3. Robertson GAJ, Wood AM. Lower limb stress fractures in sport. World J Orthop. 2017;8(12):808–817. DOI: 10.5312/wjo.v8.i12.808.
  4. Kahanov L, Eberman LE, Games KE, Wasik M. Diagnosis, treatment, and rehabilitation of stress fractures in the lower extremity in runners. Open Access J Sports Med. 2015;6:87–95. DOI: 10.2147/OAJSM.S39512

Md.Rafiqul Islam Lipu,Date:-05-06-2026 Saturday ,Time:-09-56-49 Am

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