Stress Fractures

Joe Fleming provides an overview of stress fractures of the foot.

One fitness injury that can severely impact a training routine is a stress fracture in the foot. Many athletes think of shin splints as the primary stress fracture to be concerned about; however, the repercussions of developing a stress fracture in the foot can be just as consequential.

What is a Stress Fracture?

Clinically referred to as bone failure in fatigue, stress fractures are tiny cracks in the surface of a bone. Stress fractures are not the result of a sudden acute injury but rather the product of repetitive stress that overwhelms the bone remodeling process. They are most common in the lower extremities of athletes from the pelvis to the tibia, femur, tarsals, and metatarsals.

In the foot, stress fractures are most likely to develop in the metatarsals, the long bones in the foot which connect the toes and ankle. Repetitive submaximal loading of the bone over time, especially in athletes involved in plenty of jumping and running, like long-distance runners and basketball players, can lead to imbalances in bone resorption and bone formation.

The integrity of the human skeleton is maintained through a metabolically active and continuous remodeling process that extends through an entire life. As bone is stressed through physical activity or when it becomes old, it is digested by cells called osteoclasts in a process known as resorption. In the reversal phase that occurs next, mononuclear cells show up on the surface of the bone upon which formation takes place, and finally, osteoblast cells lay new bone down until the old is wholly replaced^[1]. A host of hormones and other key signaling factors are at play to facilitate the entire bone remodeling process.

When a sufficient magnitude of a load is applied to the foot, the bone itself can swell and become strained and deformed. Continued loading leads to an accumulation of microdamage to the vulnerable tissue that cannot be adequately repaired through the normal adaptive bone remodeling process. Eventually, stress fractures develop^[2].

Risk Factors for Stress Fractures

Both intrinsic and extrinsic players are at work when it comes to increasing the risk of developing stress fractures in the foot:

The physical activity involved in repeated loading of the lower extremities, i.e. marching, running, dancing, basketball, gymnastics, tennis, track, and field^[3]
Increasing training volume or intensity over a short amount of time (days, weeks, or months
Changes in playing surface (i.e. running more hills or switching from trail running to road running)
Nervous system disorders (like peripheral neuropathy) that impact feeling in the feet
Being female - girls and women have a higher incidence of stress fracture. Competitive athletes may experience bone remodeling deficiencies as part of the female athlete triad while others are more susceptible due to anatomical differences, like a wider pelvis, which affect foot pronation and body mechanics.
Existing medical conditions that affect the bones like osteoporosis or arthritis
Having flat feet or cavus foot (high arches) that alter normal body mechanics
A lack of nutrients like vitamin D and calcium can inhibit the bone remodeling process that prevents stress fractures.

Symptoms of a Stress Fracture in the Foot

The most notable symptom of a stress fracture will be a pain. Perhaps it's just a twinge at first, but over time, the pain will become more prominent, and the focal point of injury may even swell and feel tender to the touch. Discomfort in the foot that increases with activity and decreases with rest can indicate an underlying stress fracture.

Gone untreated, stress fractures can weaken the adjacent structures of the foot and lead to more stress fractures that compromise the integrity of the bones in the foot. Issues with shearing forces against the foot, poor blood supply, and persistent weight-bearing can prevent the body from effectively healing the stress fracture, which can lead to chronic pain.

Diagnosing and Treating a Stress Fracture in the Foot

A doctor may only require a physical exam and medical history of a patient to diagnose stress fractures; however, advancements in imaging technology have made scanning for stress fractures more reliable as well. Because stress fractures often present as very subtle lines on a scan, an x-ray may not pick up on them until 2 or 3 weeks after the incidence.

MRI (magnetic resonance imaging) is more sensitive, however, and can reveal bone oedema as well as soft tissue in a scan. MRI's are considered safer than bone scans (scintigraphy) because of bone scans' radiation exposure risk^[4].

The first step in helping a stress fracture heal is avoiding the weight-bearing activities that contributed to its development in the first place.

Rest - in addition to limiting certain physical activities, a doctor may recommend a patient also utilize a walking boot, crutches, or an alternative to crutches like a knee walker scooter to reduce loading on the foot
Ice - cryotherapy, or cold therapy, may help with swelling and pain. Applying an ice pack for 15 minutes at a time can mitigate inflammation and temporarily numb the local area of tenderness
Elevation - elevating your foot can help relieve some symptoms of pain and swelling
Over-the-counter pain medication and anti-inflammatories - this may be recommended by a doctor but should only be used as directed
Alternative remedies to reduce pain and help speed healing include acupuncture, electrotherapy, soft tissue massage, and sports taping to offload stress on certain areas in the foot

High-risk fractures may require surgical intervention especially if the prognosis is that the stress fracture will lead to a complete fracture.

After a stress fracture has healed, the recovery process will be aimed at restoring normal muscle control and function to the foot as well as protecting against future stress fractures. An athlete will not be able to jump right back into their previous activities but instead will need to start slow and build up gradual progress, volume, and intensity over time. Modifications in nutrition as well as working with a physiotherapist to adjust body mechanics and form may also be recommended for preventing more stress fractures from developing.

Incidence rates of stress fractures are on the rise. In addition to people getting started at younger ages in sports and sticking with them longer and longer, more extreme sporting activities are emerging and becoming popular. Clinicians are getting better at diagnosing stress fractures.

References

HADJIDAKIS, D. J. and ANDROULAKIS, I. I. (2006), Bone remodelling. Annals of the New York Academy of Sciences, 1092: 385-396. doi:10.1196/annals.1365.035
HUGHES, J. M. et al. (2016) The role of adaptive bone formation in the etiology of stress fracture. Exp Biol Med (Maywood). 242(9):897–906. doi:10.1177/1535370216661646
MAYER, SW et al. (2014) Stress fractures of the foot and ankle in athletes [published correction appears in Sports Health. 2015 Nov;7(6):557]. Sports Health. 6(6):481–491. doi:10.1177/1941738113486588
KAHANOV, L. et al. (2015) Diagnosis, treatment, and rehabilitation of stress fractures in the lower extremity in runners. Open Access J Sports Med. 6:87–95. Published 2015 Mar 27. doi:10.2147/OAJSM.S39512

Page Reference

If you quote information from this page in your work, then the reference for this page is:

FLEMING, J. (2019) Stress Fractures [WWW] Available from: https://www.brianmac.co.uk/articles/article431.htm [Accessed

About the Author

Joe Fleming is the President of ViveHealth.com. Passionate about healthy lifestyles and living a full life, he enjoys sharing and expressing these interests through his writing. To inspire others and fight ageism, Joe writes to help people of all backgrounds and ages overcome life's challenges. His work ranges from articles on wellness, holistic health, and ageing to social narratives, motivational pieces, and news stories. For Joe, helping others is vital.


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One fitness injury that can severely impact a training routine is a stress fracture in the foot. Many athletes think of shin splints as the primary stress fracture to be concerned about; however, the repercussions of developing a stress fracture in the foot can be just as consequential. What is a Stress Fracture? Clinically referred to as bone failure in fatigue, stress fractures are tiny cracks in the surface of a bone. Stress fractures are not the result of a sudden acute injury but rather the product of repetitive stress that overwhelms the bone remodeling process. They are most common in the lower extremities of athletes from the pelvis to the tibia, femur, tarsals, and metatarsals. In the foot, stress fractures are most likely to develop in the metatarsals, the long bones in the foot which connect the toes and ankle. Repetitive submaximal loading of the bone over time, especially in athletes involved in plenty of jumping and running, like long-distance runners and basketball players, can lead to imbalances in bone resorption and bone formation. The integrity of the human skeleton is maintained through a metabolically active and continuous remodeling process that extends through an entire life. As bone is stressed through physical activity or when it becomes old, it is digested by cells called osteoclasts in a process known as resorption. In the reversal phase that occurs next, mononuclear cells show up on the surface of the bone upon which formation takes place, and finally, osteoblast cells lay new bone down until the old is wholly replaced^[1]. A host of hormones and other key signaling factors are at play to facilitate the entire bone remodeling process. When a sufficient magnitude of a load is applied to the foot, the bone itself can swell and become strained and deformed. Continued loading leads to an accumulation of microdamage to the vulnerable tissue that cannot be adequately repaired through the normal adaptive bone remodeling process. Eventually, stress fractures develop^[2]. Risk Factors for Stress Fractures Both intrinsic and extrinsic players are at work when it comes to increasing the risk of developing stress fractures in the foot: The physical activity involved in repeated loading of the lower extremities, i.e. marching, running, dancing, basketball, gymnastics, tennis, track, and field^[3] Increasing training volume or intensity over a short amount of time (days, weeks, or months Changes in playing surface (i.e. running more hills or switching from trail running to road running) Nervous system disorders (like peripheral neuropathy) that impact feeling in the feet Being female - girls and women have a higher incidence of stress fracture. Competitive athletes may experience bone remodeling deficiencies as part of the female athlete triad while others are more susceptible due to anatomical differences, like a wider pelvis, which affect foot pronation and body mechanics. Existing medical conditions that affect the bones like osteoporosis or arthritis Having flat feet or cavus foot (high arches) that alter normal body mechanics A lack of nutrients like vitamin D and calcium can inhibit the bone remodeling process that prevents stress fractures. Symptoms of a Stress Fracture in the Foot The most notable symptom of a stress fracture will be a pain. Perhaps it's just a twinge at first, but over time, the pain will become more prominent, and the focal point of injury may even swell and feel tender to the touch. Discomfort in the foot that increases with activity and decreases with rest can indicate an underlying stress fracture. Gone untreated, stress fractures can weaken the adjacent structures of the foot and lead to more stress fractures that compromise the integrity of the bones in the foot. Issues with shearing forces against the foot, poor blood supply, and persistent weight-bearing can prevent the body from effectively healing the stress fracture, which can lead to chronic pain. Diagnosing and Treating a Stress Fracture in the Foot A doctor may only require a physical exam and medical history of a patient to diagnose stress fractures; however, advancements in imaging technology have made scanning for stress fractures more reliable as well. Because stress fractures often present as very subtle lines on a scan, an x-ray may not pick up on them until 2 or 3 weeks after the incidence. MRI (magnetic resonance imaging) is more sensitive, however, and can reveal bone oedema as well as soft tissue in a scan. MRI's are considered safer than bone scans (scintigraphy) because of bone scans' radiation exposure risk^[4]. The first step in helping a stress fracture heal is avoiding the weight-bearing activities that contributed to its development in the first place. Rest - in addition to limiting certain physical activities, a doctor may recommend a patient also utilize a walking boot, crutches, or an alternative to crutches like a knee walker scooter to reduce loading on the foot Ice - cryotherapy, or cold therapy, may help with swelling and pain. Applying an ice pack for 15 minutes at a time can mitigate inflammation and temporarily numb the local area of tenderness Elevation - elevating your foot can help relieve some symptoms of pain and swelling Over-the-counter pain medication and anti-inflammatories - this may be recommended by a doctor but should only be used as directed Alternative remedies to reduce pain and help speed healing include acupuncture, electrotherapy, soft tissue massage, and sports taping to offload stress on certain areas in the foot High-risk fractures may require surgical intervention especially if the prognosis is that the stress fracture will lead to a complete fracture. After a stress fracture has healed, the recovery process will be aimed at restoring normal muscle control and function to the foot as well as protecting against future stress fractures. An athlete will not be able to jump right back into their previous activities but instead will need to start slow and build up gradual progress, volume, and intensity over time. Modifications in nutrition as well as working with a physiotherapist to adjust body mechanics and form may also be recommended for preventing more stress fractures from developing. Incidence rates of stress fractures are on the rise. In addition to people getting started at younger ages in sports and sticking with them longer and longer, more extreme sporting activities are emerging and becoming popular. Clinicians are getting better at diagnosing stress fractures. References HADJIDAKIS, D. J. and ANDROULAKIS, I. I. (2006), Bone remodelling. Annals of the New York Academy of Sciences, 1092: 385-396. doi:10.1196/annals.1365.035 HUGHES, J. M. et al. (2016) The role of adaptive bone formation in the etiology of stress fracture. Exp Biol Med (Maywood). 242(9):897–906. doi:10.1177/1535370216661646 MAYER, SW et al. (2014) Stress fractures of the foot and ankle in athletes [published correction appears in Sports Health. 2015 Nov;7(6):557]. Sports Health. 6(6):481–491. doi:10.1177/1941738113486588 KAHANOV, L. et al. (2015) Diagnosis, treatment, and rehabilitation of stress fractures in the lower extremity in runners. Open Access J Sports Med. 6:87–95. Published 2015 Mar 27. doi:10.2147/OAJSM.S39512 Page Reference If you quote information from this page in your work, then the reference for this page is: FLEMING, J. (2019) Stress Fractures [WWW] Available from: https://www.brianmac.co.uk/articles/article431.htm [Accessed About the Author Joe Fleming is the President of ViveHealth.com. Passionate about healthy lifestyles and living a full life, he enjoys sharing and expressing these interests through his writing. To inspire others and fight ageism, Joe writes to help people of all backgrounds and ages overcome life's challenges. His work ranges from articles on wellness, holistic health, and ageing to social narratives, motivational pieces, and news stories. For Joe, helping others is vital.