Stress Fractures

A stress fracture is a relatively common happening in those who pursue sport and in military personnel who march and train vigorously. Stress fractures are mostly a feature of the lower limb bones but can be present in other areas of the body. The foot metatarsals, the fibula and the tibia show the greatest frequency of this type of injury, with decreasing likelihood further up the leg. The application of repetitive strains to the bone at a level insufficient to cause immediate fracture can do so over time as the activity proceeds.

The affected area may be the source of increasing pain levels during exercise and activity, with the sufferer often reporting they have increased their training levels in intensity or frequency. Conservative treatment is usually straightforward with limitation of activity of the part and in some fractures immobilisation is required. Healing is often also straightforward although there is the danger of non-union in some fractures, with some needing internal fixation. Orthopaedic fixation and careful immobilisation will lead to healing in the vast majority of cases.

These types of fractures occur because bone has been loaded again and again and there is rarely any specific traumatic event responsible for the fracture. Bones remodel to reinforce themselves when they are subjected to loads involving tension or compression, with minor damage of the bone occurring due to the stresses. If the remodelling process gets behind as the microscopic bone damage occurs then a fracture can result. The most common occurrence is for the person to have significantly increased their activities recently.

Risk factors for this injury include the elevation in how often the stresses occur, the raising of the strength of those stresses or a change in the tissue areas to which the forces are being applied. If the cross sectional area of bone which is being stressed is smaller then this will cause an increase in the stresses through that area, or the area can stay the same and the force be increased. Jumping and running are activities with a higher risk along with changes in the way activities are performed or the type of surface used.

Many of the mechanical factors are presumed to be the important issues in stress fracture but there may be many others including changes in diet with low calorie intake, reduced bone density or osteoporosis, muscle weakness, being female and perhaps a series of other factors. Female runners have a particularly high incidence of this kind of injury as they may have restricted calorie intake, changes in their menstrual cycle and reduction in density of bone, typical in sports people who have a low bodily weight like a ballet dancer.

Stress fractures present with unexpected onset whilst undergoing an activity, worse as the limb is loaded repetitively, without any traumatic occurrence. When the patient rests the pain will ease and be absent but will recur once the aggravating activity is restarted. The area around the fracture will be tender and perhaps swollen, with x-ray findings elusive initially, perhaps taking two to four weeks to become apparent. Bone scanning can be more sensitive to finding a stress fracture within three days of the initial event, but can be positive for other reasons.

The usual management of stress fractures is conservative care, with the simplest and often the most effective method being a reduction in the responsible activity for 4 to 6 weeks. If there is a significant degree of pain on weight bearing then they can be placed in a brace, a rigid walking boot or a below knee cast, with crutch use as required. Orthoses in the shoes have been studied and found to allow a reduction in fracture incidence of a certain amount, with shock absorbing insoles having less clear benefits but potential.

Most commonly these fractures heal well and without complications but there can be problems with non-union in some particular areas. The base areas of the second and the fifth foot metatarsals are areas which can suffer from poor healing and which should be followed up for more prolonged immobilisation or surgical intervention if they do not heal.

Jonathan Blood Smyth, editor of the Physiotherapy Site, writes articles about Physiotherapist, back pain, orthopaedic conditions, neck pain, injury management and physiotherapists in Leicester. Jonathan is a superintendant physiotherapist at an NHS hospital in the South-West of the UK.

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