Introduction The Israel Defense Forces (IDF) has strict protocols for the diagnosis and treatment of stress fractures wherein diagnosis is clinical with imaging used for persistent symptoms only. The purpose of this study was to examine the incidence of clinical and radiological stress fractures during IDF combat training.

Methods Medical records of all soldiers enlisted to combat training between 2014 and 2017 were scanned for the diagnosis of stress fractures. We examined the imaging tests ordered (plain radiographs and bone scans) and their results and the time between the clinical diagnosis to imaging tests.

Results During 4 years, 62 371 soldiers (10.1% women) had started combat training, and 3672 of them (5.9%) were diagnosed with clinical stress fractures. Radiographs were ordered for 53.5% of those diagnosed, of whom 29.7% also had a bone scan. Some 42% of radiographs were taken within 21 days. Radiographs were positive for stress fractures in 11.1% of tests. Bone scans showed evidence of stress fractures in 49.7%, of which 49.2% diagnosed stress fractures in multiple bones.

Conclusion The high percentage of negative radiographs may indicate towards alternative causes for symptoms. Performing the radiograph before or after 21 days did not affect workup results diverting from current belief that later radiographs will be more sensitive. Multiple stress fractures are a common finding, indicating that the increased training load puts the whole musculoskeletal system at increased risk for injury. Research results may necessitate a revision of clinical guidelines for the diagnosis of stress fractures in military trainees.