STRESS FRACTURE MANAGEMENT

Causes of stress fractures

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. Extreme pounding on inappropriate surfaces or wearing old shoes does not provide adequate support. We usually see stress fractures in military personnel, active sportspeople, or elite athletes. However, anyone who suddenly increases training over a short period is at risk. Therefore, the first part of stress fracture management is determining why a person has developed the injury. 

Sometimes, individuals may have causes unrelated to their training. For example, bone weakening, also known as osteoporosis, can increase your risk. The weakening can result from vitamin deficiencies, hormonal imbalances, or the use of other medications. In women, a condition known as the ‘female athletic triad,’ a combination of 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 activities that involve impact, such as walking, running, or sports. Initially, pain can be mild and vague, which may lead to stress fractures being misdiagnosed as 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, and jumping or hopping constantly reproduces pain at the fracture site. Studies suggest that the hop test has the highest sensitivity compared to other tests (such as the palpation test). However, combining these tests further increases sensitivity. 

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 management

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, can help maintain your fitness even when you’re not actively engaged in exercise. 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 period of bone healing, we recommend consulting your therapist for rehabilitation exercises. Exercise therapy is essential for developing a stronger pelvis and lower body to better cope with the demands of running.

As the pain improves, we recommend gradually reintroducing physical activity, such as going to the gym and walking. Rather than starting to run, we recommend a slower progression using a walk-run program or an anti-gravity treadmill, such as AlterG. 

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 prompt regression to the previous stage.

Other treatments that can assist with bony healing include focused shockwave therapy, LIPUS therapy, and an anti-gravity treadmill. 

Further investigations after the diagnosis of stress fractures

We sometimes recommend further investigations to check your hormonal and bone health. In young people, a diagnosis of a stress fracture could be an early sign of RED-s syndrome, which stands for Relative Energy Deficiency Syndrome in Sport. Athletes who don’t consume enough calories to meet their energy expenditure are at risk of RED-s. In suspected RED-s, we recommend blood tests and a bone density scan (DEXA). Low bone mineral density in athletes has been defined as a Z-score less than -1.0. 

If athletes have reduced bone mineral density, doctors often perform blood tests to rule out secondary causes such as Vit D deficiency, coeliac disease, thyroid disease, and hyperparathyroidism. 

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. We can also obtain vitamin D from sunlight and our diet. Adequate calcium intake is also critical. We recommend a minimum daily intake of 1,200 mg of calcium. As a guide, one serving of dairy products—such as a glass of milk, a block of cheese, or a tube of yoghurt—provides 400mg of calcium. 

In cases of REDS, athletes must increase their caloric intake to prevent energy deficiency and its effects on bone and overall health. 

How do you prevent stress fractures?

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 the most critical factor. We recommend using the 10% rule to avoid increasing your load by more than 10% per week. Secondly, eat a healthy diet and increase your intake of calcium-rich foods (such as dairy products) and Vitamin D-rich foods (such as eggs and fatty fish). Finally, avoid exercising through pain and seek medical advice if your musculoskeletal pain does not settle within a few days of rest.

Click on the image below to find more information about specific stress fractures