Stress Fracture

A stress fracture is a small crack in a bone caused by repeated stress which are individually insufficient to cause a cross-sectional fracture. Stress fractures are not full thickness breaks (although without correct management they may progress to become full thickness breaks). They may involve the bony cortex only, and show up poorly on X-ray. They are sometimes referred to as hairline fractures.

Most stress fractures occur 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 long the dorsum.

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.

The principle of treatment is rest from the aggravating activity and removal or modification of the risk factors, usually for at least 4-8 weeks. Patients can maintain fitness by working out on fitness machines, water running and cycling (Romani et al., 2002).

Prompt diagnosis is important as continuing the aggravating activity will make things worse.

Phase 1 (1-3 weeks)

The first priority is a period of rest from the activity that is causing the symptoms. Rest is not absolute – allowing the athlete to exercise in a pain-free manner prevents muscle atrophy. 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.

Ice is used to decrease swelling alongside anti-inflammatory medication which may help with pain.

Ambulation should progress to full weight-bearing as soon as this is painless. In the meantime physiotherapy for muscle strengthening is advisable.

Phase 2 (typically 2 weeks)

Patients increase exercise but stay within what they can do without pain. Walking for at least thirty minutes three times a week, pain-free, is needed before progression to Phase 3.

If pain recurs, go back a step.

Phase 3

Gentle return to running or jogging. Running should start slowly in a programme based on the patient’s ultimate goals. Increase activity no more than 15-20% per week.

Pain is usually an indication that the level of activity is too high, and activity should be dropped back to the previous stage. Compliance is critical and is most difficult during the rest phase of phase 3. Because the treated person has been predominantly pain-free up to this point, stopping a pain-free functional activity is difficult to accept and athletes may overdo things and slip backwards.

Working with you, we can design an individualised exercise plan to help minimise overload. The reassurance and exercises given improve: participation with activity; strengthen the muscles and bones and improving confidence and mental health.

Measures that prevent osteopenia and osteoporosis are beneficial – e.g., avoidance of smoking, avoidance of excessive alcohol, and good calcium & vitamin D intake.

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.