What is a stress fracture?
A stress fracture is a small break in the bone. In a stress fracture, a thin crack develops from repetitive force, which is usually caused by overuse. Most stress fractures occur in the bones of the foot and lower leg, which carry the weight of the body.
The most common locations of stress fractures are the second and third metatarsals of the foot. Stress fractures are also common in the heel, in the outer bone of the lower leg, and in the navicular (a bone in the top of the foot). (See illustration.)
The bones of the foot
Stress fractures make up 2% of all sports injuries in athletes.
What are the symptoms of a stress fracture?
The symptoms of a stress fracture include the following:
- Minor pain and/or weakness in the area where the break is located
- Pain deep within the foot, ankle, or toe
- “Pinpoint pain” (tenderness at the site of the fracture when it is touched)
- Swelling on top of the foot or in the ankle
- Pain that occurs during or after normal activity
- Pain that is brought on by activity and relieved by rest
If the stress fracture is not treated, the pain can become severe. The fracture can also become displaced (the fractured bone moves out of normal alignment)
What causes a stress fracture?
When bones are involved in a new activity that can cause stress, such as a new exercise routine, they may have trouble adjusting. This can cause them to crack.
Other causes of stress fractures include the following:
- Muscles become tired from repeated impact and transfer the impact to the bone.
- Change in activities; for example, an increase in exercise and athletics, or different job duties without a gradual break-in period.
- Errors in training or technique
- Changes in surface; for instance, going from a soft surface (an indoor running track) to a harder surface (sidewalk or street)
- Repetitive activity in certain high-impact sports, such as long-distance running, basketball, tennis, track and field, gymnastics, and dance
- Improper footwear (shoes that are too worn out, too flimsy, or too stiff)
- Foot problems, such as bunions, blisters, or tendonitis, that can affect the way the foot strikes the ground
- Osteoporosis or other diseases that weaken bone strength and density (thickness). The weak or soft bones may not be able to handle the changes in activity. Female athletes who have irregular menstrual periods, or no periods, may also have lower bone density.
- Low vitamin D levels
How is a stress fracture diagnosed?
During a patient’s first visit to the doctor, the doctor will want to have a full understanding of the patient’s risk factors for stress fractures. The patient will be asked about his or her medical history, work, activities, and the medications he or she is taking. The doctor will examine the patient’s foot and/or ankle. The doctor may then schedule a follow-up appointment for further testing.
A stress fracture can be difficult to see on an X-ray, because the bone often appears normal in the X-ray, and the small cracks can’t be seen. X-rays may not help diagnose a stress fracture unless it has started to heal. When the bone starts to heal, it creates a callus, or lump, that can be seen on X-rays. The doctors may recommend a bone scan or magnetic resonance imaging (MRI), which is more sensitive than an X-ray and can spot stress fractures early.
During a bone scan, a tracer (a radioactive substance) is injected into the patient’s bloodstream. The tracer collects in the bone and settles in the areas where the bone is being repaired. The area that is affected by a stress fracture will appear darker on the bone scan than an uninjured area.
Magnetic resonance imaging
Magnetic resonance imaging (MRI) is a test that produces very clear pictures, or images, of the human body with a large magnet, radio waves, and a computer to produce these images.
A MRI is preferred in many cases because there is no radiation exposure, it takes less time, and it is better at diagnosing different types of bone and/or soft tissue abnormalities.
How is a stress fracture treated?
If you think you have a stress fracture, see your doctor and follow the treatment guidelines he or she gives you. Do not ignore the pain, because it can cause serious problems.
These are some of the treatments your doctor may recommend:
- Stop the activity that is causing pain. Stress fractures happen because of repetitive stress, so it is important to avoid the activity that led to the fracture.
- Apply an ice pack to the injured area.
- Rest for one to six weeks. Once you can perform low-impact activities for extended periods without pain, you can start doing high-impact exercises.
- When you are lying down, raise your foot above the level of your heart.
- Take nonsteroidal anti-inflammatory medicines to help relieve pain and swelling.
- Use protective footwear to reduce stress on your foot or leg. This may be a stiff-soled shoe, a wooden-soled sandal, or a removable short-leg fracture brace shoe.
- Your doctor may put a cast or fracture boot on your foot to keep the bones in a fixed position and to remove the stress on the leg.
- Use of crutches to keep weight off your foot or leg until the bone heals may be required.
- Some stress fractures need surgery to heal properly. This is called internal fixation. Pins, screws, and/or plates can be used to hold the bones of the foot and ankle together during the healing process.
- If you have diabetes, see your doctor right away if you have pain or other problems with your legs, ankles, or toes.
During the early phase of healing, the doctor may recommend that you change your schedule so that you rest one day, do an activity the next day, then rest the next day. You should slowly increase how often and how vigorously you exercise. If the activity that caused the stress fracture is resumed too quickly, you may develop a larger stress fracture that is harder to heal. If you re-injure the bone, it can lead to long-term problems, and the stress fracture might never heal properly.
Change the types of aerobic exercise you do to help avoid repeated stress on the foot and ankle. Switch to aerobic activities that place less stress on your foot and leg so that the stress fracture can heal properly. Swimming and cycling are good alternative activities.
How long does it take to recover from a stress fracture?
As long as you can feel pain, the bone is still fragile in that area, and can break again in the same place. It takes 6-8 weeks for a stress fracture to heal, so it is important to stop the activities that caused the stress fracture. Always ask your doctor before you do any physical activity on the injured foot or ankle.
How can a stress fracture be prevented?
These steps can help prevent a stress fracture:
- Once you feel pain, stop exercising.
- See your doctor as soon as possible if you have a persistent problem with your feet, ankles, or toes.
- Use the correct sports equipment.
- Wear the proper running shoes.
- Add new physical activities. For example, switch running with swimming.
- Start new sports activities slowly, and gradually increase the time, speed, and distance.
- Practice strength training to help prevent early muscle fatigue, and to help prevent the loss of bone density that comes with aging.
- Follow a healthy diet full of calcium and vitamin D foods that will keep your bones strong.
- If you decide to increase your activity level, ask your doctor for a recommendation of how much to add and when to add it.
- If pain or swelling returns, stop the activity and rest for a few days. If pain continues, see your doctor.
- Check with your doctor before starting an exercise program or before taking a job that will involve a higher level of physical activity than you are used to.
- Follow all the rules your doctor gives you.
What can happen if a stress fracture is not treated?
If a stress fracture is not properly treated, serious problems may develop. For example:
- The fracture can get worse. Eventually, it can become a complete break if you do not change your activities. If the break does not receive professional medical attention, it can heal improperly and become a source of pain and disability.
- The fracture can cause a defect in the bone that can limit the ability to move the foot, or make it difficult to find properly fitting shoes.
- You can develop arthritis, which may be caused by fractures that extend into a joint (the juncture where two bones meet).
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