Repetitive pressure on a bone like the shin or foot can actually cause your bone to become fractured, and many people don’t know to look for the signs of this. When you imagine breaking a bone, you likely imagine something like sports or car accident injuries, sudden and obvious events that cause the break. Continuing to place stress onto the bones will worsen these injuries, called stress fractures, until they become more serious and lead to chronic pain. Identifying and treating a stress fracture is critical to preventing further injuries.
About Stress Fractures
Injuries to the bone due to repetitive stress can be classified on a spectrum during diagnosis, with early incidences being called stress reactions, and later stages becoming a stress fracture. A stress reaction is similar to a deep bone bruise arising from trauma or overuse, and will turn into a stress fracture if it is not properly addressed.
Stress fractures occur when a small crack develops in response to repetitive trauma. This can be something like walking with improper form or playing a high-impact sport. In fact, almost half of all sports injuries are caused by overuse rather than a traumatic event.
Anywhere the body is susceptible to overuse can experience a stress fracture, but they are most commonly found below the waist because of the impact of weight-bearing activities. Running injuries are extremely common examples, usually leading to fractures in the shin bone or tibia. The foot is also made up of several small bones, which are commonly fractured in this way. The bones that run down the toes, called metatarsals, are often impacted, especially the second and third. The heel, hip, and even the lower back are all other places you may encounter a stress fracture.
Causes and Risk Factors
Stress fractures often occur in response to certain activities and injuries, but there are also people who will be at risk for them even without these external factors.
The most common way someone will develop a stress fracture is by doing a repetitive, high-impact activity such as running, basketball, tennis, gymnastics, or dancing. Other activities or situations that can lead to stress factors include:
- Using incorrect techniques during training or sports
- Increasing the volume of your activity too quickly or changing activity levels without a gradual breaking-in period
- Changing the surface you exercise on, like going from an indoor track to running on the concrete outside
- Running on a track or road with a sloped surface
- Using improper footwear or shoes that are worn out and flimsy
- A diet with insufficient caloric intake for the volume of physical activity you do
- Low vitamin D levels
- Early specialization in sports- playing one sport year-round without a break at a young age
Even for those who aren’t athletic or don’t regularly engage in physical activity, a range of risk factors can cause stress fractures.
- Age: Older individuals often have underlying bone density issues, like osteoporosis. A weakened bone will develop a stress reaction with less stress than it would take a healthy bone to reach the same point.
- Weight: Someone with a low BMI or who is considered underweight can experience weakened bones as a result of nutritional deficits, which leave the bones more easily damaged by stress reactions. On the other hand, someone who is obese or has a high BMI is putting additional weight onto their bones and doing repetitive loading, which may make stress reactions more likely.
- Anatomy: The shape of one’s foot can change the way it strikes the ground, leading to uneven weight distribution and ultimately stress fractures. Bunions, blisters, tendonitis, and low or high arches are common examples. General muscle weakness, imbalances, or a lack of flexibility can also contribute to these issues.
- Sex: Females are at greater risk if they have irregular menstrual cycles or no periods at all.
Medical conditions: Any disease that weakens bone strength and density, like osteoporosis, puts someone at greater risk for stress fractures.
Identifying a Stress Fracture
Symptoms of a stress fracture can include:
- Pain, swelling, or aching at the site of the fracture
- Tenderness or a pins and needles feeling when touching the injured bone
- Pain that begins after starting an activity and resolves with rest
- Pain that is present during an activity and does not resolve when the activity ends
- Pain that occurs at rest, during normal activity, or during everyday movements like walking
- Pain that is worse when hopping on one leg, or an inability to shift weight to the impacted leg or foot
When a stress reaction is not treated at the first signs of an issue, the pain will worsen as the injury becomes more severe. In extreme cases, the bone can even move out of normal alignment. Some stress fractures, like those in the hip, are considered high risk because they are more likely to need surgical intervention or have a poor prognosis if not treated early. To avoid this, it is critical to seek care at the first sign of any stress reaction.
Diagnosing a Stress Fracture
When you visit a doctor about these symptoms, they will first want to determine if what you are experiencing is, in fact, a stress fracture or another injury. They will start by asking you about your symptoms and medical history, as well as any risk factors that you may exhibit that can contribute to these issues. They may also perform a physical examination of the impacted area or ask you to perform certain movements and activities for them to observe.
An x-ray may be the first scan used to look for a fracture; however, they are not a reliable method of identifying stress fractures because of how small they can be. X-rays actually miss about 2 out of every 3 stress fractures and are more likely to identify those that have already started to heal. When the bone begins to heal, it creates a callus or lump that is visible on x-rays. If a stress fracture is what your doctor suspects, an x-ray will usually not do much more than rule out other fractures. More commonly, they will send you for a more sensitive scan like an MRI or a bone scan.
A bone scan is more likely to show tiny fractures than an x-ray. When this is performed, a radioactive substance known as a tracer is injected into your bloodstream. The tracer then collects in your bones, settling into areas that are being repaired. Stress fractures will therefore appear darker than the surrounding bones on a scan.
If your doctor needs very detailed images of your injury, they may opt for an MRI. Magnetic resonance imaging, or MRIs, use a combination of magnetic fields and radio waves to produce very clear images of the human body. These scans are often preferred because they do not use radiation and are faster than alternatives like bone scans while producing better images for diagnosis.
Treating a Stress Fracture
Unlike a traditional broken bone, stress fractures do not usually lead to you being in a cast. However, it is critical to address these injuries to prevent them from worsening or healing improperly, which can cause further issues like arthritis.
Once your doctor has confirmed you have a stress fracture, they will lay out a treatment plan based on the location and severity of your fracture. This treatment plan will focus first on healing the issue you have presented with, as well as treating any risk factors for future injuries.
Treatments that may be a part of your plan include:
- Stopping any activity that causes pain or puts stress on the bone. This will always be the first thing you should do when a stress reaction occurs to prevent the worsening of the issue. The recommended period of rest can range from 2 to 8 weeks, depending on your circumstances.
- Using ice packs and ice massages to reduce pain and swelling in the injured area.
- Training with non-impact exercises like a pool or bike once your doctor has cleared you. Eventually, you will be able to perform low-impact activities for extended periods and then return to high-impact activities.
- Physical therapy to assist with the return to activities.
- Adjusting positioning to address swelling, such as elevating your leg above the level of your heart.
- Using nonsteroidal anti-inflammatory medicines to relieve pain and swelling.
- Using protective footwear to reduce stress on your foot and leg. This may include a shoe with stiff soles, a sandal with a wooden sole, or orthotics.
- Using crutches and braces to keep weight off the limb until your bone heals.
In rare cases, a stress fracture may require surgery called internal fixation. A surgeon would use pins, screws, or metal plates to reinforce the bones.
Returning to Activities
In the aftermath of a stress fracture, you’ll want to discuss with your doctor after a car accident the best plan for recovery and returning to your normal activities. It is critical to follow your plan, as returning too quickly can lead to more serious injuries. It is important to take the return slowly and introduce activities that place less stress on the injury, in some cases replacing old activities with these.
A common method will be to alternate between rest days and active days as you return to your sport. The level of activity can slowly increase over time, allowing you to ease back into fitness. You will not be able to start up at the same level of intensity you were at prior to the injury but can create a plan to work back up to that level.
If your team has determined improper form or environmental factors to be a cause of your injury, it is important to adjust these before returning as well. This may include getting new footwear, finding a new surface to run on, or correcting your form.
The amount of time it takes to heal a fracture can vary by location and how advanced the injury was. If you still feel any pain, it is a sign that the bone is still fragile and is likely to break again in the same place. Most stress fractures take between six and eight weeks to heal enough to return to activities.
Preventing Stress Fractures
While a stress fracture can be treated, it is best to avoid the issue in the first place. For those who are at risk, including athletes, a number of adjustments and steps in your routine can help prevent stress reactions from occurring. Some examples include:
- Stop exercising as soon as you feel any pain and return only if you are pain-free.
- See your doctor as soon as you notice a persistent concern or discomfort.
Always use the correct sports equipment, including wearing the proper running shoes and replacing them every 300 miles. - Add new physical activities and alternate between them rather than doing the same ones every day.
When adding a new activity, slowly and gradually increase the time, speed, intensity, and distance. Follow the 10% rule – no more than 10% increase per week. - Properly warm-up and cool down before any physical activity.
- Use strength training to avoid early muscle fatigue and prevent loss of bone density due to aging.
- Eat a diet full of calcium and vitamin D to keep your bones strong.
- Optimize your bone health, especially if you have a history of osteopenia or osteoporosis.
- Check with a doctor or physical therapist before adding in new exercise programs or increasing your daily physical activity.
- Work with a sports therapist or personal trainer to ensure you are using the proper techniques during physical activities.
For guidance on your exercise program, treatment for stress fractures, and any other concerns, AICA College Park is here to help. Our physical therapists, orthopedists, pain management specialists, and chiropractors can work with you to develop a personalized plan that allows you to maintain your activity while avoiding stress fractures and overuse injuries. Contact us today to begin your plan!