Stress fractures occur when bone, typically in the lower extremities, is subjected to repeated mechanical stress that results in microscopic fractures. They often occur when the frequency or degree of physical activity is significantly increased. Therefore, stress fractures are commonly seen among military recruits, athletes, and runners. Stress fractures may be classified as a ‘fatigue reaction stress fracture’ or an ‘insufficiency reaction stress fracture’. Fatigue reaction stress fractures result from repetitive and excessive strain placed on structurally normal bone. Whereas fatigue reaction stress fractures occur when normal stress and straining are applied to a bone where bone formation is impaired.
Causes & Symptoms
If a patient experiences point tenderness, or when a specific bone is sore to the touch, that could signal a stress fracture. If you suspect a stress fracture in your foot, performing what is called “the hop test” is a fortunate way to figure out if you have point tenderness. Carefully, hop a few times on the injured foot. If you have certain pain when you land, it could be a stress fracture. Swelling in the affected area is another common sign. While you could see swelling anywhere, the most common place people experience noticeable swelling is on the top of the foot due to a stress reaction or fracture in the metatarsals. Changes in the biomechanics whilst running could also be a sign of a stress fracture. There are other things that could lead to a stress fracture, and most are related to putting too much loading force on the bones. Another common cause is when a patient has been currently living with either osteopenia (lower than average bone density) or osteoporosis (much lower than average bone density). Both genetics are not receiving enough calcium in the diet can cause these two issues.
Typically, too much, too soon, or not enough recovery causes stress fractures, although, other factors can contribute, such as:
- Training errors – Stress fractures often are the result of increasing the amount and / or the intensity of an athlete’s training too quickly; metabolic capacity (fitness) improves faster than structural capacity (the bones and joints). Normally doctors associate stress fractures with athletes involved in training, however, stress fractures do occur in previously inactive people that suddenly increase the amount of walking or activity they do. This is often seen with military recruits when they first start basic training or people go on a vacation with lots of walking.
- Equipment and biomechanics issues – Improper equipment (worn-out shoes / shoes that are too stiff) can further increase stress loads. Running with a heel strike style increases stress on the shins, femur, and hip. Excessive foot pronation and tight Achilles tendons also add extra stress to the tibia.
- Bone health issues – In addition, if overall bone health (measured as bone density or bone mass) is suboptimal (osteopenia or osteoporosis), the bones have less ability to withstand the training stress and the risk of developing a stress fracture is increased. Chronic low energy (calories) intake can decrease bone health and combined with inadequate calcium and vitamin D intake can increase the risk of experiencing stress fractures.
A stress fracture may also cause tenderness or swelling in the shin and hip of a patient. It can cause pain that increases when you touch your shin / hip or put weight on. Therefore, if you have shin or hip tenderness or pain, it is recommended to raise and rest your legs and apply an ice pack to recover rapidly.
Who Gets a Stress Fracture?
Risk factors for stress fracture can be classified as external or internal. Injuries occur as a result of a convergence of several factors at a given point in time. The type of exercise is among the possible external factors for a stress fracture, the most frequent being running or jogging. Some internal factors can be mechanical, such as malformations in the lower limbs or muscle fatigue. There can also be disturbances in sex hormones or other hormones that affect the balance between bone resorption and formation, or nutritional factors, such as diets with calorie restriction, alcohol, calcium, or vitamin D deficiency. A meta-analysis compared the serum level of this fat-soluble vitamin and the incidence of a stress fracture in nine observational studies suggest an association between these variables because calcium and vitamin D can have a positive influence on bone health, since vitamin D contributes to bone resorption and the absorption of calcium and phosphorus from the intestine. In addition to the independent effects of a given risk factor and its mechanism for contributing to bone injury, interactions between risk factors are possible. Stress fractures usually occur in young people who are active or undergoing training, such as athletes, dancers, or military recruits.
Other factors that can increase the risk of a stress fracture include:
- Certain sports – Stress fractures are more common in people who engage in high-impact sports, such as track and field, basketball, tennis, dance, or gymnastics.
- Increased activity – Stress fractures often occur in people who suddenly shift from a sedentary lifestyle to an active training regime, or who rapidly increase the intensity, duration, or frequency of their training sessions.
- Gender – Women, especially those who have abnormal or absent menstrual periods, are at higher risk of developing stress fractures.
- Foot problems – People who have flat feet or high, rigid arches are more likely to develop stress fractures. Worn footwear contributes to the problem.
- Weakened bones – Conditions such as osteoporosis can weaken your bones and make it easier for stress fractures to occur.
- Lack of nutrients – Eating disorders and lack of vitamin D and calcium can make bones more likely to develop stress fractures.
- Previous stress fractures – Having had one or more stress fractures puts you at a higher risk of having more.
How Does It Affect You? How Serious Is It?
Osteoporosis often progresses without any symptoms or is not diagnosed until a person experiences pain from a stress fracture. The nature of bones in people with osteoporosis makes them more susceptible to bone fractures, especially in the feet.
While osteoporosis is most commonly seen in women over the age of 50, younger people and men are also affected. Early symptoms can include increased pain with walking, accompanied by redness and swelling on the top of the foot.
Foot and ankle surgeons are able to diagnose osteoporosis through bone densitometry tests, which measure calcium and mineral levels in the bones through a low-dose radiation X-Ray. If you are diagnosed with osteoporosis, it is important to protect your feet from stress fractures.
Recommended Rehabilitation & Supporting Equipment
Before commencing any sort of treatment for stress fractures, a doctor may need to do several tests to see if you have a stress fracture and the severity of the fracture. These tests can include:
Physical examination – During your first visit, your doctor will do a physical exam and discuss your risk factors for developing a stress fracture. When discussing risk factors, you will be asked about:
- Medical history
- Work history
- Activity history
- Medications you might be taking
X-rays – Your doctor may order an X-Ray to look for a fracture. However, a stress fracture can be difficult to see on an X-Ray because the bone often appears normal, and the small cracks can’t be seen on the image. X-rays actually miss about two-thirds of stress fractures! X-Rays may not help diagnose a stress fracture unless it has started to heal; when the bone starts to heal, it creates a callus, or lump, that can be seen on X-Rays. With a high index of suspicion for a stress fracture, your doctor may recommend an imaging test that is more sensitive than an X-Ray and will pick up a stress reaction even before it may become a stress fracture. These tests include Magnetic Resonance Imaging (MRI) and bone scans…
Bone scan – A bone scan may be used to see stress fractures that cannot be seen on an X-Ray. During a bone scan, a tracer (a radioactive substance) is injected into your bloodstream. The tracer collects in the bone and settles in the areas where the bone is being repaired; the area that is affected by a stress fracture will appear darker on the bone scan than on an uninjured area.
Magnetic Resonance Imaging (MRI) – When your doctor needs very detailed images of the injury, an MRI may be used. Magnetic Resonance Imaging (MRI) is a test that uses a large magnet, radio waves, and a computer to produce very clear images of the human body. An MRI is preferred in many cases due to no radiation exposure; it takes less time than other imaging tests, and it is more precise at diagnosing different types of bone and / or soft tissue problems.
Most stress fractures will heal on their own if you reduce your level of activity and wear protective footwear for a period of time. The most important thing to do if you have or think you may have a stress fracture in your foot or ankle is to cease the activity that caused your problem in the first place – you should stop all high-impact activity for a time, typically for about six weeks.
Icing and elevating the affected area immediately following a stress fracture can help decrease swelling and pain. As for pain, it is best to take acetaminophen (Tylenol) instead of nonsteroidal anti-inflammatory drugs (NSAIDs), which include ibuprofen (Advil) and naproxen (Aleve). This is because some data suggest that taking NSAIDs can reduce the ability of bone to heal – however for any drug use you must seek advice from your doctor. Your orthopedist may also recommend that you wear a stiff-soled shoe, a wooden-soled sandal, or a removable short leg-fracture brace shoe. Many stress fractures of the foot or ankle will heal in 4 to 6 weeks. However, healing times vary, depending on which bone is broken. Some foot bones, such as the navicular or the fifth metatarsal, can take a much longer time to heal than do others. After weeks of rest, and once the pain is completely gone, you may gradually ease back into physical activity and sports. This gradual reintroduction period should span about 4 to 6 weeks. Switch to a sport or activity that puts less stress on the foot and leg until you have fully recovered. Examples of appropriate low-impact activity include swimming or cycling.
The worst choices for resumed activity while you recover from a foot or ankle stress fracture are running or even walking on hard surfaces. You can easily reopen your fracture and have to begin the recovery process again. During recovery, wear comfortable, supportive shoes without a raised heel. Footwear should be flexible, not stiff. If you are a runner, after you have resumed low-impact activity for 4 to 6 weeks, begin a conservative jogging regime – however, it is recommended to increase your running mileage very slowly over time. There are a few great exercises for anyone to try either at home or elsewhere – here are some examples of exercises for you to try for a foot fracture, given this is the most common fracture:
Calf wall stretch – First off, stand facing a wall with your hands on the wall at about eye level. Afterward, put your affected foot about a step behind your other foot. Keeping both heels on the floor, bend both knees. Then gently bring your hip and chest toward the wall until you feel a stretch in the calf of your back leg. Finally, hold the stretch for at least 15-30 seconds. Repeat this procedure 8-12 times.
Towel scrunches – Sit in a chair, placing both feet on a towel on the floor. Then scrunch the towel toward you with your toes. After this step, use your toes to push the towel back into place. Repeat this exercise 8-12 times.
Resisted ankle inversion – Sit on the floor with your good foot crossed over your affected foot. Secondly, hold both ends of an exercise band, and loop the band around the inside of your affected foot. Then press your other foot against the hand. Finally, keeping your feet crossed, slowly push your affected foot against the band so that the foot moves away from your other foot, then slowly relax after finishing this step. Repeat 8-12 times.
Towel inversion and version – Sit in a chair, and place both feet on a towel on the floor. Afterwards, swivel your feet from side to side to slide the towel. First slide your toes, then your heels, as you move the towel with your feet. Then change direction and swivel your feet from side to side to slide the towel back to the starting position. Finally, repeat the procedure 8-12 times.
Alternative & Homeopathic Treatment
Generally, after suffering from this type of injury, you may need to rest from the activity that caused the stress fracture and engage in a pain-free activity during the six to eight weeks it takes for the majority of stress fractures to heal. The following are some of the things you can do to take care of a stress fracture at home:
- Protecting the fracture site by reducing weight-bearing activities
- Using ice packs
- Wearing shock-absorbing shoes during exercise
- Running on soft surfaces (such as grass)
- Wearing a brace, walking boot, or cast