There is nothing more frustrating than a stress fracture, an injury that seems minor at first and ends up requiring time off the field! A Stress fracture is a bone injury that result from the body’s inability to absorb repetitive load. This results in bone structure fatigue, causing pain, decreased performance and at its worst, an actual fracture.
Stress fractures were first prevalent in the military in 1855 and were not frequently researched or treated until the mid 1950’s. Incidence rates in soccer players are under 5% and higher in runners at up to 28% in some studies. These numbers don’t seem troublesome at first but when a full season is threatened, you may think differently!
After a hard training session (run, game, etc), recovery is always imperative. Normally, after high load, bone breaks down, is then repaired and replaced with new bone. This is a typical reaction to training. Stress injuries occur when the body fails to recover prior to the next workout consisting of repeated high tensile and compressive forces on the bones. The outer layer of bone (periosteum) breaks down first, followed by the inner layer of cortex. Stress fractures therefore occur when:
- There is too much load applied
- Not enough recovery time
- Loading is applied too soon
- Load is applied to weakened bones (low bone density, osteoporosis)
- Young athletes do not have fully developed bone and older athletes start to have reduced bone density
Given this knowledge, risk factors include inappropriate training volumes or intensities as well as the type of surface the athlete is training on. Harder surfaces (pavement, cement) create more stress than softer surfaces (grass or turf field, track). Other factors are dietary issues–not enough calcium or caloric intake, hormonal factors (menstrual disturbances or reduced testosterone), osteoporosis, muscle weakness and leg length issues.This is why it is extremely important to take a detailed health history when managing someone who you might expect to have an underlying stress fracture.
The foot is the most common area for stress fractures in runners, soccer players and other field/court sports. Approximately 78% occur in the foot, 12% in the tibia and 6% to the pelvis. An x-ray is commonly used for diagnosis, however typically a stress fracture will not show up until healing begins. CT scans are also used when an x-ray cannot pick up a cortical bone issue.
In a clinical examination, localized tenderness (65%-100% of time time) followed by swelling are common signs. An athlete may feel gradually worse pain and describe it as dull or achy. Pain may also feel worse toward the end of a training session or at night. In movement screening, as mentioned earlier, leg length issues are common as well as muscle asymmetry from the involved to the non-involved side. An analysis of the foot is crucial, too.
How we approach treatment is of the utmost importance. Reducing overall load initially is imperative. Early in recovery, using modalities such as cycling or pool training are good supplements to maintain fitness, depending on your activity, while reducing the amount of cumulative stress to the body. During this time, we have clients working with a physical therapist to manage asymmetries and movement dysfunction. This is accomplished through techniques to normalize leg length, instrument assisted soft tissue work, dry needling to address pain and mobility deficits and programed strength & conditioning to reintroduce load. Keeping constant communication with coaches and trainers are also important when being reintroduced to activity.
When being integrated back into training, increasing loads approximately 10% per week as well as frequent communication with the athlete regarding their pain and fatigue are important feedback.
Managing stress fractures can be challenging. Even though their incidence is not the most prevalent, they require being extremely diligent with screening, recovery and reintroduction into training.
- Wright AA, Taylor JB, Ford KR, Siska L. Risk factors associated with lower extremity stress fractures in runners: A systematic review with meta-analysis. British Journal of Sports Medicine. 2015;49(23):1517–1523. doi:10.1136/bjsports-2015-094828.
- Warden S, Burr D, Brukner P. Stress Fractures: Pathophysiology, Epidemiology and Risk Factors. Current Osteoporosis Reports. 2006;4:103–109.