Pharmacologic Adjuncts for Bone Stress Injuries in Athletes: A Narrative Review of Current Evidence and Clinical Practice.
There is currently no strong evidence to support the use of abaloparatide or similar agents for treating bone stress injuries in athletes. Addressing nutritional and metabolic issues remains essential in managing these injuries.
Where it sits
this study against the rest of the abaloparatide (tymlos) corpusSummary and findings
This narrative review evaluates the evidence for pharmacologic adjuncts in managing bone stress injuries (BSIs) in athletes. It highlights the lack of direct evidence for newer agents like abaloparatide in this specific context. The review emphasizes the importance of addressing nutritional and metabolic factors in the management of BSIs.
Abstract
Bone stress injuries (BSIs) are common in athletes, carry substantial time-loss and recurrence risk, and are increasingly managed with bone-active drugs despite a limited evidence base. This narrative review appraises the evidence for pharmacologic adjuncts in BSI, distinguishes the separate clinical indications for which they are proposed, and defines where current evidence does and does not support their use. This is a narrative review; therefore ethical approval was not required. PubMed/MEDLINE, Embase, and the Cochrane Library were searched from inception to June 2026 combining terms for BSI, stress fracture and athletes. Evidence is summarized in an evidence table that states whether each source is directly applicable to BSI in athletes or extrapolated from osteoporosis, traumatic fracture, spinal surgery, military, or animal studies. Greatest weight is given to controlled studies conducted in patients with BSI. Contemporary practice is illustrated by a previously published survey of 126 clinicians working in professional football and by the 2025 international Delphi consensus. The evidence base for treatment options in BSI varies substantially based on the clinical context. Correction of a documented abnormality of energy availability, calcium or protein intake, vitamin D status is a key initial step, but there is no clear evidence that supplementation of replete athletes accelerates healing of an established injury. Evidence for bisphosphonates in BSI is limited to small uncontrolled case series and may even impair bone healing or risk reinjury. Teriparatide data derive predominantly from osteoporotic, fragility fracture, and spinal fusion populations, with a single randomized controlled trial in stress fracture in progress. Newer agents, abaloparatide and romosozumab have no direct evidence in BSI, likely because of their novelty. Across all agents, apparent benefit may represent analgesia and earlier controlled loading rather than accelerated biological healing, given that return-to-play timing is determined by numerous clinical, occupational, and organizational factors. There is currently insufficient evidence to recommend routine use of bisphosphonates or osteoanabolic agents as treatment for an uncomplicated acute BSI in an otherwise healthy athlete. Assessment and correction of nutritional, and metabolic abnormalities, together with load management and rehabilitation, remain the foundation of care. Off-label treatment adjuncts discussed should be considered in recurrent, high-risk or delayed-healing BSI, with shared decision-making focus. Prospective outcome collection is likely to be the most pragmatic way to advance available evidence.
Background
Bone stress injuries (BSIs) are prevalent among athletes and can lead to significant time loss and recurrence. Previous studies have explored various treatment options, but the evidence supporting pharmacologic adjuncts remains limited. This review aims to clarify the current understanding and application of these agents in the context of BSIs, which is crucial for informing clinical practice.
Methods
This narrative review synthesized existing literature on pharmacologic adjuncts for BSIs by searching PubMed/MEDLINE, Embase, and the Cochrane Library up to June 2026. The review focused on studies relevant to BSIs in athletes while also considering evidence from osteoporosis, traumatic fractures, and animal studies. The review did not involve a specific clinical trial or controlled study design.
Results
The review indicates that the evidence base for pharmacologic treatments in BSIs varies significantly depending on the clinical context. It highlights that bisphosphonates may impair bone healing or increase reinjury risk, while teriparatide data are primarily from non-athletic populations. No direct evidence supports the use of newer agents like abaloparatide and romosozumab in BSIs.
Interpretation
The findings suggest that while some pharmacologic agents may provide analgesic benefits, they do not necessarily accelerate biological healing in BSIs. The lack of robust evidence, particularly for newer agents, limits the ability to draw definitive conclusions. The review underscores the importance of addressing nutritional and metabolic factors in managing BSIs, which may be more critical than pharmacologic interventions.
Key findings
- Evidence for bisphosphonates in BSI is limited to small uncontrolled case series.
- Teriparatide data derive predominantly from osteoporotic, fragility fracture, and spinal fusion populations.
- A single randomized controlled trial in stress fracture is in progress.
- No direct evidence for abaloparatide and romosozumab in BSI due to their novelty.
- Assessment and correction of nutritional and metabolic abnormalities remain the foundation of care.
Limitations
- Narrative review, not a systematic review.
- Limited evidence base for pharmacologic adjuncts.
- No direct evidence for newer agents in BSIs.
- Small uncontrolled case series for bisphosphonates.
- Single ongoing randomized controlled trial for teriparatide.