STRESS FRACTURE MANAGEMENT 

Stress fractures are usually the result of overload on a bone. Also known as “fatigue fractures,” they differ from high-velocity fractures resulting from a fall or similar trauma. Typically, common areas affected by stress fractures include the foot, shin, hip, and lower back. How do we diagnose a stress fracture, and what is the most effective treatment for stress fractures?

Stress fractures cause 

In general, stress fractures are caused by too much load on the bone at one time. Excessive loading can be induced by increasing training intensity, volume, or frequency. Additionally, excessive pounding on inappropriate surfaces or wearing worn-out shoes is not beneficial. Usually, we see stress fractures in military personnel, active sportspeople, or elite athletes. However, anyone who increases training suddenly over a short period is at risk.

Sometimes, people might have other causes unrelated to their training. For example, weakening bones, also known as osteoporosis, can place you at increased risk. Weakening of bones can be secondary to vitamin deficiencies (such as vitamin D and calcium), hormonal imbalances, or the use of certain medications. In women, a condition known as ‘female athletic triad,’ poor nutrition, eating disorders, and irregular periods can lead to weakened bones and an increased risk of stress fractures.

How do we diagnose stress fractures? 

Generally, pain occurs with impact activity such as walking, running, or sports. Initially, pain can be mild and vague, meaning that stress fractures may be misdiagnosed as a muscle strain or joint arthritis. As the condition progresses, rest and night pain are common. Often, people with more severe stress fractures limp and have difficulty walking at any time.

Typically, a thorough examination is necessary to confirm the diagnosis and rule out other potential causes of pain. Touching the bone is often painful. Hopping or jumping reproduces pain at the fracture site.

We use imaging to confirm a diagnosis. A simple X-ray may reveal changes of periosteal bone thickening and a fracture line. However, in the early stages, an X-ray may be normal. Then, we use a bone scan or, more commonly, an MRI to see bone swelling and microfracture.

Stress fracture treatment

Rest from impact activity is the best treatment. In some high-risk stress fractures, non- or partial weight-bearing with crutches is needed. Taking some time away from running or traditional sports will often allow the bone to heal. Cross-training with non-impact activities, such as swimming or cycling, will help keep you fit even when you’re resting. Icing the fracture site can reduce swelling. Finally, we generally advise against medications such as ibuprofen, as anti-inflammatories have been shown to slow bone healing.

Overall, during this time of bone healing, we recommend consulting your therapist to perform rehabilitation exercises. Exercise therapy is essential to develop a more robust pelvis and lower body to cope with the demands of running.

We suggest gradually reintroducing fitness activities, such as going to the gym and walking, as the pain improves. Rather than starting to run, we recommend a slower progression using a walk-run program or an anti-gravity machine, such as the Alter-G.

Example of a return to running program for stress fracture treatment:

Return to running must be gradual and guided by symptoms, and where indicated.
A typical programme may include:

Progress should be symptom-led — any pain should lead to regression to the previous stage.

We recommend further investigation to assess your hormonal and bone health in some cases. For example, in patients with suspected bone weakness, we recommend hormonal blood tests and a bone density X-ray (also known as a DEXA scan). Generally, hormonal or vitamin deficiencies must be treated before returning to full activity. For example, vitamin D deficiency is common in the UK and requires high-dose supplementation over many weeks.

Stress fracture treatment and prevention

There are a few simple tips to prevent future stress fractures. First and foremost, controlling the amount you do, also known as load management, is crucial. We suggest you use the 10% rule, i.e., try not to increase your load by more than 10% per week. Secondly, eat healthily and increase your intake of foods containing calcium (such as dairy products) and Vitamin D (such as eggs and fatty fish). Finally, avoid exercising through pain and seek medical advice if your musculoskeletal pain does not settle with a few rest days.

Dr Masci discusses specific stress fractures in these blogs:

• Stress fractures of the hip: Beware hip pain in runners
• Pars stress fractures of the lumbar spine
• Stress fractures of the heel/Calcaneal stress fracture
• Stress fractures of the navicular bone/mid-foot
• Vit D and the Athlete