to the editor: The article by Drs. Sanderlin and Raspa, “Common Stress Fractures,”1 reports, quite correctly, on the frequency and potential seriousness of stress fractures. We compliment American Family Physician for making it the cover article of the October 15, 2003, issue. However, we feel a need to comment on the author’s recommendation of the use of nonsteroidal anti-inflammatory drugs (NSAIDs) as a treatment for stress fractures.
The article repeatedly lists NSAIDs as a recommended treatment for “all stress fractures.” We are unaware of any data that suggest that NSAIDs are beneficial in the treatment of stress fractures. In fact, there is an increasing amount of literature suggesting that they may be harmful. A retrospective study of a cohort of more than 700,000 cases found that regular use of NSAIDs was associated with a 1.47 relative risk of nonvertebral fractures compared with control patients who did not receive NSAIDs.2 Another study compared 32 patients with nonunion of femoral fractures with 67 patients whose fractures had united. The results demonstrated a “marked association” between nonunion and the use of NSAIDs.3 These retrospective analyses are consistent with some prospective animal data demonstrating that NSAIDs retard fracture healing.4 Finally, it has been well established that NSAIDs inhibit heterotopic ossification (i.e., new bone formation) after total hip replacement and acetabular fractures.5
There is biologic plausibility for a detrimental effect of NSAIDs on bone healing. Inflammation is a necessary step in the healing of normal body tissues, and osteoblasts specifically require prostaglandins for osteogenesis and differentiation. By inhibiting these prostaglandins, NSAIDs may delay osteoblastic formation of new bone.
Additionally, NSAIDs have a strong analgesic effect. The article1 correctly encourages using the symptom of pain as a guide to increasing activity. A 10-year review6 of stress fractures in varsity athletes at the University of Minnesota validates this recommendation. While we want our patients to be pain free, masking the pain of stress fractures may compromise recovery. This is especially true of more dangerous stress fractures such as those of the femoral neck.
In our clinical practices we discourage the use of NSAIDs in patients with stress fractures. Based on our understanding of the physiology of bone healing and the clinical data available, we urge your readers to do the same.
editor’s note: This letter was sent to the authors of “Common Stress Fractures,” who declined to reply.