Epidemiology of stress fracture injuries among US high school athletes, 2005-2006 through 2012-2013

Am J Sports Med. 2015 Jan;43(1):26-33. doi: 10.1177/0363546514562739. Epub 2014 Dec 5.


Background: High school athletes in the United States sustain millions of injuries annually, approximately 10% of which are fractures. However, there is no clear estimate of the number of stress fractures sustained by high school athletes annually despite reports that stress fractures account for 0.7% to 20% of injuries seen in sports medicine clinics. This suggests a high utilization of resources for a potentially preventable injury. In addition, stress fractures have been associated with low energy availability and disordered eating in young athletes, highlighting the importance of early recognition and intervention.

Purpose: To investigate stress fracture rates and patterns in a large national sample of US high school athletes.

Study design: Descriptive epidemiologic study.

Methods: Data from High School RIO (Reporting Information Online), a national sports injury surveillance study, were analyzed to describe rates and patterns of stress fracture injury sustained from 2005-2006 through 2012-2013, across sports and by sex.

Results: From 2005-2006 through 2012-2013, a total of 51,773 injuries were sustained during 25,268,873 athlete-exposures, of which 389 (0.8%) were stress fractures, resulting in an overall stress fracture rate of 1.54 per 100,000 athlete-exposures. Rates per 100,000 athlete-exposures were highest in girls' cross country (10.62), girls' gymnastics (7.43), and boys' cross country (5.42). In sex-comparable sports, girls sustained more stress fractures (63.3%) than did boys (36.7%) and had higher rates of stress fracture (2.22 vs 1.27; rate ratio, 1.75; 95% CI, 1.38-2.23). The most commonly injured sites were the lower leg (40.3% of all stress fractures), foot (34.9%), and lower back/lumbar spine/pelvis (15.2%). Management was nonsurgical in 98.7% of the cases, and 65.3% of injuries resulted in ≥3 weeks of time loss, medical disqualification, or an end to the season before athletes could return to play.

Conclusion: Although a rare injury, stress fractures cause considerable morbidity for high school athletes of both sexes. Future research should evaluate risks of stress fractures to drive development of targeted prevention efforts.

Keywords: High School RIO; epidemiology; female athletes; injury surveillance; pediatric sports medicine; stress fractures.

MeSH terms

  • Adolescent
  • Athletic Injuries / diagnosis
  • Athletic Injuries / epidemiology*
  • Female
  • Fibula / injuries
  • Foot Bones / injuries
  • Fractures, Stress / diagnosis
  • Fractures, Stress / epidemiology*
  • Gymnastics / injuries
  • Humans
  • Lumbar Vertebrae / injuries
  • Male
  • Pelvic Bones / injuries
  • Running / injuries
  • Schools
  • Sex Factors
  • Tibial Fractures / epidemiology
  • United States / epidemiology
  • Young Adult