What Are Stress Fractures?

Stress fractures are a common type of overuse injury that mainly arises due to repetitive stress caused by an abrupt and rapid increase in the volume and, or intensity of physical activity (too much, too soon!). Weight-bearing bones in the lower extremities, including the shin bone (tibia), foot bone and heel bone, are most likely to be affected. 

‘Stressed’ about stress fractures? Read on to find out whether you are at risk and what to do if you are, the main signs and symptoms, management, treatment and prevention strategies of stress fractures, and much more! 

The overview of stress fractures

Stress fractures¹ are tiny cracks in bones that occur as a repetitive stress (mechanical) outcome, trauma, or overuse. The bones found in the lower extremities are most prone to stress fractures along with the shin bone or the tibia (23.6%),² foot bone (metatarsal bones; 5 in each foot) (16.2%),² and heel bone (calcaneus).  However, less common stress fractures can also occur in the hip (proximal femur) (6.6%),² pelvis (1.6%),² and the lower back.

According to recent research studies, stress fractures account for approximately 20% of all sports medicine injuries.² 

A report from the mid-19th century named the military personnel demonstrates stress fractures referred to as ‘’march foot’’. 

What causes stress fractures?

The primary cause of stress fractures is a sudden, rapid and non-gradual increase in the volume and  ,or the intensity of physical activity. However, there are also many risk factors, including both extrinsic and intrinsic, that can predispose an individual to stress fractures. The risk factors will be in the ‘’Risk Factors’’ section below. 

What are the signs and symptoms of stress fractures?

Stress fractures can cause a long list of signs and symptoms, including:¹  

• Pain, swelling, and, or aching at the site of the stress fracture
• Tenderness when touching the bone 
• Pain that begins and worsens upon the activity but resolves with rest 
• Pain that persists throughout a  physical activity and does not resolve after this  activity has finished
• Pain that occurs during rest, whilst doing normal day-to-day activities or walking 
• Pain that worsens when hopping on one leg 

How do you manage and treat stress fractures?

Management for stress fractures

The management strategy for stress fractures is to rest from high-impact and weight-bearing activities for approximately 2 to 6 weeks and then re-introduce activity at a slow and gradual pace once the patient or athlete becomes pain-free.² 

Treatment for stress fractures.

Stress fracture treatment depends on specific factors such as the location and severity of the stress fractures.

The treatment for stress fractures may include: 

• Avoiding activities that cause pain 
• Applying an ice pack (10 minutes) or rubbing an ice cube (3 to 5 minutes) on the injured area 
• Physical therapy 
• Performing non-impact exercise (cross training),  for example, bike or pool, if advised and approved by your doctor 
• Considering taking non-steroidal anti-inflammatory medicines  to decrease pain and swellings
• Raising your lower leg whilst lying on your back  to decrease swelling 
• Wearing protective footwear: for instance, wooden-sole sandals, stiff-soled shoes and others.
• Using crutches removes stress on the affected foot and leg and promotes bone healing.
• Performing surgery (‘’internal fixation’’): Surgery is  recommended for  the patient has a complete fracture in ‘’high-risk’’ areas with poor blood supply, including the femoral neck (part of the thigh bone that connects the femoral head with the femoral shaft), anterior tibia (front leg muscle), tarsal navicular (midfoot), talus (small bone in the ankle), sesamoid bones (bones embedded in a tendon or muscles), and 1^st and 5^th metatarsal bones (feet)²

What are the tools for the diagnosis of stress fractures?

To diagnose a stress fracture, a general practitioner (GP), doctor and healthcare provider will perform a series of tests in the following order:¹ 

1. Medical history and physical examination
2. X-rays: Unfortunately, X-rays miss up to ⅔ of stress fractures as they cannot be seen or detected in the image. X-rays can only detect stress fractures once they have started to heal, which will appear on the scan.
3. Bone scan: In a scenario where stress fractures are detected using X-ray images, a doctor might order a bone scan. During a bone scan, the doctor injects a small dose of a radioactive substance, or ‘’tracer’’ into your bloodstream. The ‘’tracer’’ will be absorbed in areas where the bone is getting fixed and will appear as a bright white spot on the scanner.

4. Imaging tests: The principal imaging test used to diagnose stress fractures and distinguish them from other bone and/or soft tissue injuries is magnetic resonance imaging (MRI). As suggested by its name, MRI uses radio waves, a strong magnetic field and a computer to produce detailed images of your bones. The MRI test is currently considered the most efficient test to diagnose stress fractures.

What are the risk factors to know?

Stress fractures have both extrinsic and intrinsic risk factors.¹ 

The extrinsic risk factors of stress fractures

Extrinsic means that the stress fractures appear to  environmental factors¹ ‘outside’ the body, including: 

• Sudden, rapid and non-gradual increase in physical activity (  severe risk factor and cause)
• Performing exercises with bad form and poor technique
• Having a strenuous higher -volume training programme 
• Wearing poor footwear 
• Using poor equipment 
• Regular engagement in high-impact sports activities such as:
  • Running (especially long-distance): According to research, running accounts for 16% of stress fractures, putting runners who average around 25 miles per week (approx. 40 km) at ‘’high risk’’²
  • Basketball
  • Tennis 
  • Track and field
  • Gymnastics
  • Dance 

• Eating an unbalanced, calorie-restrictive diet that does not allow for proper recovery from the high volume of sports is often termed ‘’energy deficiency syndrome’’ and is a condition commonly seen as part of the ‘’female athlete triad’’. The female athlete triad occurs when females present with the following  three conditions:² 
  • Low energy availability and disordered eating
  • Menstrual disturbance ., for instance,  missing (amenorrhea) or irregular (oligomenorrhea) periods
  • Low bone density (osteoporosis) or decreased bone density (osteopenia)

• Having a low vitamin D and calcium level
• Specialising in sports at an early age: Young athletes who play sports consistently for over a year without a break-in period are more likely to develop stress fractures  

Intrinsic risk factors of stress fractures. 

Intrinsic means that the risk of stress fractures is increased by factors that occur ‘inside’ the body of the patient or athlete including:¹ 

• Age: Older people have a higher risk of developing stress fractures compared to younger people; their bone density is lower
• Sex: Females with irregular (oligomenorrhea) or missing (amenorrhea) periods are at risk of stress fractures since hormones, particularly oestrogen, the levels of which are low in females with menstrual dysfunction, have been demonstrated to have bone-protective effects²
• Weight: This includes both people with either a low weight (underweight) or high weight (overweight or obese)
• Anatomy: Foot issues. Such as inflexibility, muscle weakness, blisters and so on can all increase susceptibility to stress fractures.
• Medical conditions: e.g. osteoporosis or osteopenia, which both lower bone density, thus making bones more fragile and prone to breakage 

What are the complications you need to know?

Complications depend on the severity of the stress fractures, whether they are deemed ‘’low-risk’’ or ‘’high risk’’.²

Complications for ‘’low-risk’’ stress fractures. 

• Residual pain, also known as chronic pain 

Complications for ‘’high-risk’’ stress fractures 

• Greater pain
• Longer post-recovery 
• Activity modification or cessation: Although necessary, this can represent a challenge for the athlete in decision-making. Depending on the severity, the athlete may be required to reduce or stop all activity altogether. 
• Surgery 
• Bone non-union: Occurs when fractured bones refuse to heal despite the passing of a long period of time (minimum of 9 months), thus requiring immediate surgical intervention. 

FAQs

How can I prevent stress fractures?

To prevent a stress fracture, consider implementing the following steps:¹ 

• Stop exercising once you feel pain, and do not return to exercise unless you are pain-free. If re-introducing sports or exercise, decrease the intensity level by 50% and do not increase the intensity level by more than 10% every week.
• Wear proper footwear. Running shoes need replacement every 300 miles (around 483 km) and should not exceed more than six months. 
• Use appropriate sports equipment. 
• Add new sports activities into your routine slowly and gradually.
• Switch up running with swimming activities.
• Always warm up and cool down before any workout to prevent injury.
• Perform strength training and weight-bearing bone activities to maintain bone density and promote muscle and bone strength.
• Eat a healthy, nutritious, well-balanced diet that is particularly rich in calcium and vitamin D. 

How common are stress fractures?

Unfortunately, stress fractures are quite common, especially in runners (16%), US military personnel (5.69 per 1000 people from the years 2009-2012), the elderly and women (particularly female athletes).²

When should I see a doctor?

See a doctor immediately if you meet any of the following criteria:¹

• Experience any pain and, or discomfort that does not go away, especially during rest.
•  Stress fracture suspicion.
• Have an underlying medical condition like diabetes or neuropathy and have pain in your feet, ankles,  or legs (VERY IMPORTANT!)
• Plan to start a new demanding exercise programme or plan to increase your overall activity level. 
• Have a history of stress fractures, osteoporosis, or osteopenia and want advice on managing these conditions effectively. 
• Are you a female athlete or non-athlete, and lost your period (amenorrhea), or experienced irregular menstrual cycles?

Summary

Stress fractures are tiny cracks in bones that mainly occur due to repeated stress from incorporating sports, exercise, or physical activity at an abrupt and rapid pace. Stress fractures account for 20% of discipline in sports, showing that females suffer from medical injuries. Long-distance runners, military personnel, gymnasts and dancers are deemed ‘’high-risk’’. 

Stress fractures include tibial stress fractures 23.6% and foot stress fractures 16.2%, the most common type of stress fractures.

The signs, symptoms, and complications of stress fractures vary depending on the severity and location of the stress fracture. Managing stress fractures takes 2-6 weeks of complete rest before any exercise. Physical activity comes later on. 

X-rays, bone scans and MRIs are diagnosis tools. MRI acts as the most efficient diagnostic test for stress fractures to date. 

Current stress fracture treatment mainly involves rest, physical therapy, surgery and non-steroidal anti-inflammatory medicines, including crutches. 

Stress fractures are preventable. An appointment with a GP will be if the condition worsens.