Stress Fractures in Military Recruits: Current Concepts, Risk Stratification, Prevention, Evidence-Based Management, and Future Directions.

Stress fracture is a major cause of morbidity, training loss, retarded graduation, and military loss in recruits where there is an abrupt increase in repetitive mechanical loading. This narrative review synthesized up-to-date data on mechanobiology, risk factors, risk stratification, clinical signs and symptoms, diagnosis, prevention, management, rehabilitation, return to duty, and future directions for stress fracture in military populations. A literature search in PubMed/MEDLINE and Google Scholar identified 35 English-language studies used in the final narrative synthesis.  Existing data indicate a load-capacity model involving dynamic relationships among external mechanical dose, local skeletal strain, and biological repair capacity. Factors contributing to susceptibility are a history of stress fracture, being female, age, menstrual malfunction, pre-entry conditioning, poor body composition, lack of vitamin D, exposure to medication, and site-specific biomechanics. In cases of negative radiographs and a high rate of clinical suspicion, such as activity-related and localized early symptoms, advanced imaging, including MRI, is the choice. Implement site-specific management, with greater protection and surgical attention for high-risk fractures. Rehabilitation should depend on pain-free work, strength recovery, progressive exposure to impact, and signs of healing rather than time.  Prevention should focus on pre-entry conditioning, gradual training loads, adequate rest, adequate nutrition, and early symptom reporting. Future studies should test dynamic prediction models that integrate skeletal imaging, load measures from wearables, and known fracture outcomes to inform prevention and safe return to military service at the individual level.