STRESS FRACTURE MANAGEMENT

Causes of stress fractures

In general, stress fractures result from too much load on the bone at once. Excessive loading can result from increased training intensity, volume, or frequency. Extreme pounding on inappropriate surfaces or wearing old shoes can also cause them. 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 step in stress fracture management is determining why a person developed the injury. 

Sometimes, individuals may have causes unrelated to their training. For example, bone weakening, or osteoporosis, can increase your risk. This weakening can result from vitamin deficiencies, hormonal imbalances, or 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 impact activities 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.

A thorough examination is typically needed 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 such as periosteal bone thickening and a fracture line. However, in the early stages, an X-ray may be normal. Our first imaging choice is an MRI, which can show bone swelling and microfractures. Sometimes, we use a bone scan, such as a SPECT CT bone scan, if the MRI is uncertain. 

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 allow the bone to heal. Cross-training with non-impact activities, such as swimming or cycling, can help you maintain fitness even when you’re not actively exercising. 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.

During this bone-healing period, we recommend consulting your therapist for rehabilitation exercises. Exercise therapy is essential to strengthen your legs and lower body so you can 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, guided by symptoms, and as 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 in Sport. Athletes who don’t consume enough calories to meet their energy expenditure are at risk of RED-S. If RED-S is suspected, we recommend blood tests and a bone density scan (DEXA). Low bone mineral density in athletes is defined as a Z-score below -1.0. 

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

Generally, doctors must treat hormonal or vitamin deficiencies before athletes return 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 calcium intake of 1,200 mg. 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?

A few simple tips can help prevent future stress fractures. First, 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