Stress Fracture

A stress fracture is a small crack in a bone. They are not full thickness breaks (although without correct management they may progress to become full thickness breaks). Stress fractures typically involve the bony cortex only and show up poorly on X-ray. They are sometimes referred to as hairline fractures and occur far more commonly in the lower limbs.

Typical presentation is with a history of exercise-related pain, often associated with a change in athletic activity.

Tibia (Shin Bone)

This typically presents with gradual onset of localised pain on the inner ridge of the tibia. Fractures of the middle third of the anterior region of the tibia may heal poorly, in which case internal fixation (screws or pins) may be required to prevent a complete fracture occurring.

Talus (Ankle Bone)

Presents with a deep ankle pain that increases with weight-bearing activity. Other symptoms may include night ache, pain during movements of the foot and ankle or pain on firmly touching the talus (located directly below the shin bone where the ankle crease is situated). Treatment typically involves an initial period of rest with crutches or a protective boot. Exercises to maintain flexibility, strength and balance are also important to ensure the ankle is functioning correctly.

Calcaneus (Heel Bone)

Patients typically experience pain on either the inner or outer aspect of the heel bone which increases with impact activity. Treatment typically involves an initial period of rest, which may include the use of crutches or a protective boot.

Fifth Metatarsal (Outside of the Foot)

Patients typically experience pain in the forefoot that increases with impact activity and may decrease with rest. Symptoms may also radiate to other areas of the foot. Occasionally there is swelling or discolouration at the stress fracture site. These are common in runners, jumpers and basketball players, and usually present with insidious onset of foot pain along the medial arch or along the dorsum (top of the foot).

Stress fractures commonly result from repeated bouts of stress which are individually insufficient to cause a cross-sectional fracture. Stress fractures often arise in those who are training when they suddenly increase distance or change running shoes. They also present in sedentary people who suddenly start to exercise, and in elite athletes who exercise regularly and heavily.

Female gender, lower bone density, less lean body mass in the lower limbs, a low-fat diet and a history of menstrual disturbance are all significant risk factors for stress fractures. Tenforde et al. (2013) found body mass index <19, late periods (age ≥15 years) and previous participation in gymnastics or dance are also predictors in girls. There is a relationship to eating disorders, amenorrhea and osteoporosis, which is also referred to as the female athlete triad.

Your Physiotherapist will take a detailed history of your symptoms so the can understand the nature and severity of your symptoms. They will then perform a full physical assessment to help identify the origin of your pain. You will be provided with a fast and accurate diagnosis which is important as continuing aggravating activity will make things worse. Having a prompt diagnosis will also allow the most effective and appropriate treatment to be implemented to achieve the best possible outcomes.

The first priority is a period of rest from the activity that is causing the symptoms, usually for several weeks. Rest is not absolute, you can continue to exercise in a pain-free manner under the guidance of your Physiotherapist to prevent muscle weakness. Patients can maintain fitness by working out on fitness machines, water running and cycling (Romani et al., 2002).

The goals of active rest are described by the acronym REST:

• Removal of the abnormal stress.

• Exercise to maintain fitness and prevent atrophy.

• Safe pain-free return to usual activity.

• Time for maturity of healed bone to catch up with increased bone remodelling.

Your Physiotherapist may also suggest using ice to decrease swelling alongside anti-inflammatory medication which may help with pain.

All of our Physios are highly skilled and experience in exercise prescription and will design a personalised and progressive exercise and activity plan. Your Physiotherapist will initially prescribe non and partial weight bearing exercises whilst you employ relative rest. This will be essential to maintain and develop strength. As your symptoms settle, you will be advised to gradually increase exercise within pain-free limits. This will include a progressive return to walking. When you can walk for at least thirty minutes three times a week pain-free, your rehabilitation can move forward.

Regular re-assessment will ensure that you are making suitable progress and are working well towards achieving your personal goals that will be made in collaboration with your Physiotherapists. Your individual aims will be at the centre of your treatment and your clinician will make every effort to assist you in achieving those goals that you set.

As you progress further, your Physio will recommend introducing gentle running or jogging (if appropriate to your goals). Running should start slowly in a programme based on the patient’s ultimate goals. The increase in activity in relation to your symptoms will be monitored closely. Pain is usually an indication that the level of activity is too high, and activity should be reduced. Compliance is critical and is most difficult as you are able to do more, predominantly because patients are typically pain-free up to this point. Stopping a pain-free functional activity is difficult to accept and patients may overdo things and slip backwards. You Physiotherapist will provide ongoing support and advice to ensure you can manage independently and prevent future occurrence.

Romani, W. A., Gieck, J. H., Perrin, D. H., Saliba, E. N., & Kahler, D. M. (2002). Mechanisms and management of stress fractures in physically active persons. Journal of athletic training, 37(3), 306.

Tenforde, A. S., Sayres, L. C., McCurdy, M. L., Sainani, K. L., & Fredericson, M. (2013). Identifying sex-specific risk factors for stress fractures in adolescent runners. Medicine & Science in Sports & Exercise, 45(10), 1843-1851.