Does your pain increase the more you put weight through the affected area?

Is your pain now present when sleeping or resting?

Do you struggle to hop let alone run?!

WHAT IS A STRESS FRACTURE?

Bone is a living tissue, it contains a blood supply that feeds cells that build new bone (osteoblasts) and cells that break down bone (osteoclasts). The structure created is made robust enough to withstand that forces applied to it on a daily basis.

Normally bone will be in homeostasis i.e. the rate of bone built to that breaking down is balanced but on some occasions the bone becomes subjected to a sudden increase in load that it struggles to cope with. This stresses the structure and it struggles to repair itself leading to an increase in the rate of osteoclasts and thus the formation of microscopic damage. If the stresses imposed continue then the areas of structural damage increase in size leading to the formation of a stress fracture.

NOTE: A STRESS FRACTURE WILL START AS A STRESS RESPONSE AND CAN DEVELOP INTO A LARGER, COMPLETE FRACTURE. THE EARLIER IT IS SPOTTED THE FASTER YOUR RECOVERY.

Stress fractures are very common in high impact sports. In clinic I most frequently see them in runners. Especially those who have had a sudden increase in training frequency (running more often) or intensity in their training programme. The most common sites for stress fractures include:

  • Bones of the foot (especially the metatarsals)
  • Fibula and tibia (most commonly in the 3rd of the bone closest to the ankle)
  • Femur (especially the femoral neck)

WHAT SYMPTOMS DO YOU GET WITH A STRESS FRACTURE AND HOW IS IT DIAGNOSED?

The first thing you will notice is pain. This may be sudden in onset but more commonly patient’s recall an insidious onset of the pain that they could initially ignore but eventually becomes more acute (sharp). The pain will start to limit your ability to exercise and as it worsens it also starts to effect daily activities.  Lastly, the most common reason for seeking medical advice is the development of pain when resting and/ or sleeping.

 

To form a diagnosis a detailed assessment is necessary which will involve the following:

  1. History of symptoms: you will be asked a few questions about when the problem started and the nature of symptoms. You will also be asked about your activity levels the type of training you do and if there have been any changes to your usual routine.
  2. General Health: you will be asked questions about your general health including whether you have had a history of fractures or if any members of your family suffer from issues affecting their bone health. Questions about your diet are also important as well as spotting any changes in your body mass.
  3. Footwear: your trainers will be looked at as well as the shoes you wear day to day. A change in shoes or worn/ old footwear can be a strong causative factor of pain as they change where we load the limb and thus the stresses imposed on the bones.
  4. Movement analysis: you will be asked to perform various movements of the effected area to see what causes pain. In severe cases, walking alone can be sore but in more subtle cases greater load is required to reproduce the pain i.e. jumping, hopping or running.
  5. Palpation: the healthcare professional assessing you should try to locate the site of pain. If acute pain is felt over a bony area and you struggle to load the area then further investigation is often needed.
  6. Imaging: I often see patient’s that have stress fractures that have initially been referred for an X ray. Only in more severe cases will this be positive as the microscopic damage develops to form an established fracture.

NOTE: A CLEAR X RAY DOES NOT MEAN YOU DO NOT HAVE A STRESS FRACTURE. TO HIGHLIGHT A STRESS FRACRURE AN MRI OR CT SCAN IS NEEDED.

WHAT CAUSES A STRESS FRACTURE?

Many factors can contribute to the development of a stress fracture as stated below:

1: Diet: a balanced diet will provide all the nutrients necessary for adequate bone health. If certain food groups are avoided or if you fail to eat enough to replenish the energy expelled during daily activities and exercise then bone will struggle to replenish. Calcium and Vitamins D and K are often diminished in those with stress fractures.

2: Body Mass/ hormonal links: in combination with the above, a restrictive diet can lead to weight loss. This can affect the production of hormones that control the menstrual cycle and in turn can deplete your bones of calcium causing bone weakness. If you are aiming to drop weight and reducing your diet but training the same or even harder then this can be a strong risk factor in the development of stress fractures. Working closely with a sports physician and Dietician can help you address and reduce future risk.

3: Training: this has been mentioned a few times so far but is a strong cause of a stress fracture. An increase in training frequency, duration and intensity as well as changes in playing surface or training footwear can all effect the amount of load a bone is subjected to. Even a change in the number of steps you take each day can play a role i.e. changing jobs which involves an additional 1 hr of walking every day which you do in a ‘ballet flat’ shoe! I will commonly see patients that enjoy 2-3 5 K runs a week, then decide to enter a marathon and end up doubling the distance they are running in one week as well as running up to 5 times a week. These things take time! Train smart.

4: Poor technique and poor condition: poor landing techniques in sports such as gymnastics or individuals who try to adapt their movement patterns to improve performance i.e. in hurdles or long jump are potential causes. Some patients also lack the strength in their muscles to do the events they have entered. With inadequate energy absorption from your muscles bone becomes subjected to higher stress.

TREATMENT

A reduction in load is the first stage of treatment for a stress fracture. In some circumstances this may require the use of crutches or an orthopaedic boot to offload the area and it will be necessary until walking becomes pain free. In the mean-time it is important to address any causative factors i.e. dietary issues, footwear or training issues. Further investigation into bone health may be required if the cause is not clear. Diet plays a very important role in restoring the energy required for bone healing and must not be ignored. I encourage all my patients to seek professional guidance from a qualified Dietician to aid recovery both in the sort and long term.

When a ‘normal’, pain free gait pattern is restored load must be progressively re introduced. The injured area will have decreased muscle strength and movement patterns are affected due to pain. Working with a physiotherapist to restore this is essential if a further injury is to be avoided. Exercises will initially involve no impact and resistance will increase to build strength. Working on landing control will then be introduced and when your physiotherapist feels you have adequate strength and optimal movement control a return to running programme will ensue.

As I have said in most my blogs, a return to full fitness takes time. Bone may heal in 6 weeks but it is the secondary effects of the injury that take a lot longer. I can not emphasise enough, the importance of following this full recovery programme. As I always say: THE FASTEST TREATMENT IS THE RIGHT ONE. There are no shortcuts and you have to allow your musculoskeletal system to recover from the trauma.

SO IN SUMMARY……….

  • Stress fractures do not always show up on X rays
  • Bony pain and an inability to hop on the affected side are strong warning signs of a stress fracture
  • A full rehabilitation programme is essential for a full recovery
Davina Sherwood
Specialist Musculoskeletal Physiotherapist