Bisphosphonate-related stress fractures

Case contributed by Dr Matt Skalski


Leg and hip pain bilaterally, left greater than right

Patient Data

Age: 70 years
Gender: Female

There are focal areas of cortical thickening along the lateral surface of the proximal third of the bilateral femoral diaphyses. On the right there is one area showing this change, but on the left there are at least two (see arrows on subsequent slide). Also, subjacent to these areas, there is subtle endosteal sclerosis.

Annotated image

The stress (insufficiency) fractures are indicated by arrows. 

Case Discussion

The lateral aspect of the femurs are under tension, while the medial sides are more affected by compressive forces. Tension-sided stress fractures are more concerning because normal biomechanical forces do not facilitate apposition. Also, it is strange to get enough chronic stress on the distractive side of a bone to cause a stress fracture, as stress fractures usually occur at critical sites of chronic compressive stress. Because of this, an underlying etiology should be sought, as this is suggestive of an insufficiency type of stress fracture (vs overuse). Bisphosphonate therapy has a known association with these atypical stress-fracture patterns, and should be a primary consideration in elderly female patients. 

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Case information

rID: 46147
Published: 19th Jun 2017
Last edited: 6th Jul 2020
Inclusion in quiz mode: Included

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