Stress Fractures: Symptoms, Diagnosis, Treatment and Prevention

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Early diagnosis and proper care from a sports medicine trained physician are essential for good management of a stress fracture. This will help avoid complications in the future.

Stress fractures are a serious condition that can affect training and performance. They occur most commonly in runners and usually affect the legs and feet. Stress fractures generally need only conservative management (rest) to heal, but some stress fractures may require bracing, casting or even surgical intervention.

What is a stress fracture
A stress fracture is a break in a bone caused by repetitive forces. Stress fractures do no go completely through a bone as other fractures sometimes do. Since they are associated with heavy training, stress fractures can be mimicked by injuries to the muscles, tendons, ligaments and other fractures.

How a stress fracture forms
Resorption and new formation of bone occurs in response to mechanical stresses. This is called bone remodeling. During periods of intense exercise, bone formation lags behind resorption. Without adequate rest, bones become susceptible to micro-fractures. With continued stress, micro-fractures may combine into stress fractures.

Risk factors for developing a stress fracture
A sudden or substantial increase in duration and/or intensity of training is the most significant risk factor for developing a stress fracture. Inadequate muscle strength, inflexible joints and low bone density may play a role when in the formation of stress fractures.

In general, females are at greater risk to develop stress fractures. Although the reasons for this discrepancy remain unclear, possible causes include eating disorders, pre-activity conditioning levels, endocrine (hormone) factors, skeletal alignment and lower bone density.

Lower bone mineral density is associated with the following: regular intake of carbonated drinks, white race, alcohol and/or tobacco use, low for weight/height ratio, steroid use (prednisone-type, not anabolic steroids) and use of depo-provera injectable contraceptive.

Symptoms
The most common complaint for a stress fracture is pain. The pain is usually mild and related to strenuous or jarring activities initially. As severity of the injury progresses, an athlete may have pain with less strenuous activity. The pain can become sharp, localized and worse with weight bearing. Eventually, pain may occur with walking or at rest.

The most common sites for stress fractures in runners and triathletes are on the tibia (shin) and metatarsal (midfoot) bones. Most fractures are not associated with swelling or redness on the skin overlying the area of pain. However, pain may be experienced by pressing directly on the area.

Diagnosis
Early diagnosis and proper care from a sports medicine trained physician are essential for good management of a stress fracture. This will help avoid complications in the future, and will help return an athlete to their best form most quickly. A thorough history and physical exam by a physician is generally sufficient to diagnose a stress fracture. The diagnosis may be confirmed with an x-ray, but these are often normal for the first two to three weeks. After this period, the x-ray may show thickening of the bone and possibly a fracture line. An MRI or a bone scan can show evidence of a stress fracture within two to three days of injury. These tests are expensive but may be warranted depending on each personal situation.

Treatment
The treatment for a stress fracture is rest from the offending activity. Four to six weeks of rest is usually sufficient, followed by a gradual increase to full activity. Immobilization in a brace or cast is done for situations in which there is pain with walking or at rest. Non-stress/non-impact training such as swimming or bicycling is generally safe and helps maintain fitness. For certain fractures, orthopedic referral is necessary if there is a risk that the fracture will not heal properly.

Pain control is important. Regular ice application to the affected area can reduce both pain and inflammation. Some advocate very little pain medication as it may slow healing. Gentle massage can relieve pain and help increase blood flow. Dietary supplementation with Calcium (1200 to 1500 mg) and Vitamin D (400-800 IU) should be encouraged during the acute phase.

Prevention
Preventing stress fractures is very important. Avoiding significant changes in frequency or intensity of training will help avoid multiple types of injuries, including stress fractures. Good footwear with limited wear and shoe inserts that absorb shock are helpful. A diet with substantial vitamin D and calcium can help improve bone density for individuals with this risk factor. Eating disorders rob the body of essential nutrients and hormones needed to maintain good bone health. If any problem exists with eating behavior or if a woman is having no periods, these issues should be addressed immediately. Avoiding carbonated beverages, alcohol and tobacco helps to reduce the risk of low bone mineral density.

Ronald Hanson, MD,
Christian Millward, MD and
David Cassat, MD

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date: January 1, 2006