Stress Responses and Stress Fractures in Bones

Stress fractures occurs in bones when they undergo fatigue due to excessive repetitive loading through activities such as running or military training.  The bone will first start with a ‘stress response’ and then if the stress continues can increase to becoming a crack in the bone called a ‘stress fracture’. It will start as a microscopic crack and then enlarge with more stress. This is why the main treatment is ‘rest’ from the activity that is stressing the bone.  Stress is more likely in bones in the lower body due to being a result of weight bearing activities.

Which bones are most susceptible?

• Tibia (shin bone) (most common area)
• Fibula (smaller outside lower leg bone)
• Metatarsal (common)
• Calcaneus (heel bone)
• Navicular bone (inside of foot)
• Pelvis
• Femur (thigh bone)

Diagnosis

• tenderness/pain within the bone itself
• sometimes pain on firmly touching the bone/near the bone
• pain aggravated by a weight bearing activity eg. long distance walking, running, jumping or marching
• can be an ache in the bone at rest particularly at night
• can be swelling around the bone
• recent rapid increase in training or starting a new training programme
• history of decreased bone density – osteoporosis
• history of eating disorder or low vitamin D

How can it be confirmed?

A MRI scan is required which will show areas of white within the bone if a stress response/microscopic crack and a line will show if developed into a stress fracture.  The crack can increase in size with continued stress.  X-rays rarely show up up stress responses or micro stress fractures.

It is strongly recommended to see a Foot and Ankle Consultant if you suspect a stress fracture.  There are particular stress fractures ie. of the medial malleolus (inside ankle) that may require surgery to pin the fracture as they are prone to very slow and sometimes problematic healing.

Treatment Recommendations

Initial treatment should involve decreasing the abnormal loading on the bone to allow healing.  This usually consists of non-weight bearing or reduced weight bearing for 1-2 months depending on how severe the stress response or fracture is. Return to sport normally between 2-3 months.  It can take between 6-12 months to return to sport in some cases. Crutches or supportive boots may be required.  Once the pain has resolved and on advice of the consultant then gradual increase in weight bearing needs to be introduced to encourage remodelling of the bone.

To maintain fitness – activities such as indoor cycling with low resistance, swimming and upper body exercise can be carried out.  Once able to return to activity it is recommended to address factors that may contribute to this condition happening. Low vitamin D is one to watch out for often not thought of as a cause which can be diagnosed with a blood test.

Physiotherapy

Physiotherapists can help you with the following:

• soft tissue massage (particularly of the calf)
• advising on how to use crutches
• working on joint stiffness
• acupuncture for pain
• advising on the best supportive boot if required
• teaching hydrotherapy (pool) exercises
• teaching of gym exercises you can continue with while healing that help to maintain strength, fitness and flexibility
• taping
• advice on the return to activity plan when you are ready
• advise on the best footwear
• carry out an assessment to help correct issues that may have contributed to this condition such as:
  • • poor alignment of your lower body
    • muscle issues – tightness, weakness, fatigue
    • problematic running style
    • inadequate diet – lack of calcium and vit D
    • being overweight
    • ineffective training or overtraining problems
    • stiffness in joints

Products That Can Help Your Recovery

(click on the product picture to purchase)  

Physiotherapy at Home or Work

Take Home Points