Stress Fractures – A Runner’s Approach to Diagnosis, Treatment & Prevention

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How to prevent & how to treat stress fractures + All susceptible regions covered!

A stress fracture, fissure, or what is more commonly known as a hairline fracture, is an overuse injury in the bones. Although called a “fracture”, the injury doesn’t result from a single causating event, but rather occurs over time because of accumulated trauma from repeated physical activity of submaximal impacts like running and jumping. In this case, it refers to a microscopic tearing in the bone tissue which doesn’t severely impact the overall structure of the particular bone, but can lead to complications or even to the complete fracture of the bone if a powerful impact or tension occurs.

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Stress fractures are tiny cracks in a bone. They’re caused by repetitive forces resulting in overuse, such as: repeatedly jumping or running, walking long distances with heavy weights, or performing unnatural tensed movements. Furthermore, fatigued muscles are unable to absorb impacts, so the impact force is distributed to the bones, increasing injury risk.  They can also arise from normal use of a bone that’s weakened by a condition as osteoporosis, osteoarthritis, or other-bone-related diseases. The information contained in this article is from authentic sources with quality control by cowriter by Mike Valverde and curated by Diana Rangaves, PharmD. Rph.  All information must be run by your physician for your individual circumstances.  A crack or fissure can be described as a small irregular crack or tear in the bone’s structure. The dimensions, form, and severity of the crack largely depend on the event that causes it, and the overall health of the bone.

Who holds the highest risk of suffering from stress fractures?

More so than others, track and field athletes, ballet dancers, skaters, basketball players, volleyball players, military recruits, long distance backpackers and long distance runners are particularly exposed. Additionally, the elderly, sedentary people or people with bone-related diseases such as osteoporosis and rheumatoid arthritis are at a greater risk.

Where do stress fractures occur?

This injury mostly affects weight-bearing bones. Weight-bearing bones are the most common places, such as the tibia (longitudinal bone bellow the knee towards the inside), metatarsalsnavicular bones (bones of the foot), fibula (calf bone), pelvis, and the calcaneus (heel bone). In theory, a crack can occur in any bone of the body, but it is essentially impossible to develop one on the upper body bones. The treatment and prevention of a stress fracture in your foot is a bit different than one in your shin or in your ankle.

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Symptoms of a Stress Fracture

Tenderness and warmth in the affected area are usually experienced but rarely identified as a symptom. A certain sensitivity might manifest itself in the local area, but because of its subtle nature, it’s rarely identified as a potential symptom.

Pain usually sets in after a couple of hours, more commonly in the evening. In some cases, pain doesn’t manifest itself until a day or two after the injury occurs. The pain intensity is relative, but it’s almost always identifiable through pressure palpation of the affected area. Some patients may find it difficult to sleep at night, due to the increased sensitivity later in the day. Symptom remediation and medical advice are obligatory at this stage.

Swelling is always a tardive symptom caused by the local tissue inflammation around the affected spot.

Common Symptoms of Stress Fracture:

  • Pain
  • Swelling/inflammation
  • Unusual warmth
  • Bruising
  • Tenderness/sensitivity
  • Tingliness
  • Discomfort

Stress-Fracture-Symptoms-Inflammation

When to seek professional medical help

Contact your doctor or go to the ER if the pain and/or inflammation disrupt your everyday activities. In advance, write down any relevant information about your current training, diet, medication and supplementation, vices, lifestyle – essentially everything. Don’t be afraid or embarrassed to disclose information with your doctor; it’s very important that you supply them with extensive information to help them make a correct diagnosis, which will be vital for your recovery. You’re always covered by the doctor-patient confidentiality clause, so don’t worry about this sensitive information being divulged to other parties.

Steps to Take Before Consulting a Doctor:

  1. Organize your medical history
  2. Prepare questions and anticipate your doctor’s informational needs
  3. Describe in detail your symptoms and how the injury took place
  4. Write down your medications, diet, supplements, vices
  5. Request a verbal/written summary

If you’re looking for the fastest recovery time, then you should consider going directly to a doctor who specializes in musculoskeletal problems, such as:

  • Orthopedic specialists
  • Physiotherapists
  • Occupational therapists
  • Rheumatologists
  • Podiatrists

Potential physical exams

  • Fulcrum test: The Fulcrum test is a physical exam through palpation. In this test, the examiner pushes down the knee with one hand while creating leverage with the other hand placed below the patience’s thigh, creating tension in the middle of the leg. Sharp pain may be suggestive of a hairline fracture.

Fulcrum test

  • FABER test (Flexion, ABduction, and External Rotation): The FABER test is another physical exam. In it, the patient lays horizontally on the back and forms a triangle with the affected leg by placing the external side of the ankle on the other knee. The examiner then presses the knee downwards and seeks signs of pain, often in the pelvic or groin area, which may indicate a break or tear.

FABER test

  • Gait analysis: In this test, a doctor or physical therapist will observe your gait, or natural walking form. With this test, they can determine if you have irregularities in your walking form. Some factors they will look for are discrepancies in posture, or if you tend to favor one leg while walking.

Potential Imaging Scans

If the physical tests performed by your doctor or medical professional results in pain indicative of a potential stress fracture, your doctor may require further scans of your body to determine the cause. These are some potential imaging scans they may try in order to gain a more detailed image of your body, allowing them to determine if there is damage caused by a hairline fracture.

  • X-rays

An X-ray scan can be the fastest and easiest method, but it’s not the most foolproof, and time is required to successfully identify any underlying causes. In some cases, inflammation and abnormal injury positioning can hide the injury from the X-ray. In some occasions, it can take as much as several weeks until the injury is fully identifiable to X-rays. Furthermore, for a better contrast, some X-rays scans involve a substance such as iodine or barium which is introduced into the body for a better color contrast and greater detailing.

  • CT scan

A Computed Tomography or Computer Assisted Tomography combines many X-ray images from different angles to form a cross-sectional (tomographic) image, allowing the viewer to see inside the object. It can be seen as a medium between standard X-ray scanning and an MRI scan.

  • Magnetic resonance imaging (MRI)

An MRI is an imaging technique which uses radio waves, strong magnetic fields, and field gradients to create detailed anatomic pictures. This scan will provide doctors with a full 360-degree view of the limb, providing a much more detailed image than standard X-ray scanning can obtain. The procedure can usually pinpoint the condition within the first week of injury. It can also visualize and distinguish between stress and other soft tissue injuries, so it’s a fairly accurate investigation method.

  • Bone scan

A (3-phase) bone scan or bone scintigraphy is a nuclear medicine imaging technique. The procedure uses a very small amount of a radioactive substance, called a tracer, which is injected into the targeted limb intravenously. This specially designed radioactive substance accumulates in greater volumes wherever bones are being repaired, thus indicating the exact injury location as white bright spots on the scan. This technique may not be the first choice for your doctor, but it generates functional imaging and allows visualization of bone metabolism and bone remodeling. This visualization provides greater detail than most scanning techniques such as X-rays or CT scans are capable of. Additionally, a bone scan can be used as a cancer identifier, ruling it out as a false positive.

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Prevention

To avoid hairline fractures, you’ll have to strengthen your bones’ shock absorbing capabilities. Gradual physical stimulation is needed to encourage bone and muscle strengthening, alongside a proper diet, sleep pattern, exercise equipment, exercise form, and training regimen. Muscle strength, fiber activation, and endurance are all very important in reducing injury chances.

Gradual linear progression is the key in this situation. It is important to avoid ever going overboard with high-impact sports activities, especially after a long period of inactivity. Just like your muscles, your bones will adapt to increased strain, but if the strain outweighs your bones’ shock-absorbing capabilities and remodeling processes, then structural integrity is going to suffer. Fatigued muscles accelerate the injury probability as they fail to absorb impacts, so adequate pacing is imperative in order to allow fatigued muscles enough time to recover.

A general rule for linear progression when it comes to high-impact sports such as running: do not exceed your training volume by 10% each week. This means that each week you should add no more than 10% to the distance you run from last week. This is a general, principle to help you understand the concept of training volume limitation, so as to avoid overtraining and injury relapse. If you’re changing your running terrain from one week to another, such as from grass to hard dirt or asphalt, then add a little bit less than 10% or none at all. Caution is imperative here, as rushing into things can be extremely damaging to your bones.

General Guidelines for Avoiding Stress Fractures:

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Causes

Potential causes include an improper training regimen, exercise form, diet, equipment, or environmental factors. Some medical conditions such as osteoporosis or other bone-related diseases can facilitate the injury. Furthermore, hormonal imbalances, either due to poor diet or genetic factors, can also weaken bones and expose them to injury. For this reason, females are slightly more exposed to these kinds of injuries than males. Keep an eye on your endocrine system: abnormal or absent menstruation (amenorrhea), abnormal emotional outbursts, unusual behavioral manifestations and so on can be indicative factors of hormonal issues.

Other intrinsic causes might include leg/arm length differences, excessive forefoot, cavus feet, a prominent posterior calcaneal process, tight heel cords, low bone density, and subnormal vascular supply.

Potential Causes of Stress Fractures:

  • Overuse of unadapted bones
  • Running on hard or irregular surfaces
  • Bone-related diseases
  • Hormonal imbalances
  • Improper diet, sleep pattern, and hydration
  • Previous history of fractures
  • Anatomical and biomechanic discrepancies
  • Genetic factors
Improper training regimen

Often times, athletes fail do adapt their training regimens. A break or hairline fracture may result from a combination of overtraining after an extended period of inactivity. It can also be caused merely by an abrupt increase in training intensity, which can catch your body off guard. The bones in your body gradually adapt to your activity by constantly remodeling the bone tissue; old tissue is eliminated (resorption) and new bone tissue is put in place, thus gradually increasing the load capacity and overall strength. Unaccustomed bones that are subjected to increased loads may not have the time to efficiently replace the bone tissue and can leave you exposed to injury. Pace yourself accordingly, and make sure to take frequent breaks.

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Exercise form

Performing a new exercise, a variation of a known exercise, a new training cycle, or a new sport exposes you to injury if you don’t have the proper form down. Analyze your past exercises and try to identify if the main problem or part of it derives from incorrect exercise execution. Address improper form issues by getting another opinion from a more experienced athlete, or by consulting a professional such as a kinesiologist or physical therapist. Watch yourself performing these exercises in a mirror, film yourself, and ask for a second opinion on your form.

Overtraining

Fatigued muscles increase the chances of getting a bone break. This is because both your muscles and your bones play a role in absorbing shock. However, when your muscles are over fatigued and unable to further absorb shocks, the majority of the forces are transferred to the bone. The repeated traumas, added together, overwhelm the bone remodeling cells in a process referred to as osteoblast.

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Diet (Calcium and Vitamin D)

A changed diet, sleeping pattern or medication can also further increase the chances of getting injured. Watch out for a dietary excess of animal-derived products, as they’re quite antagonistic towards calcium and bone health. Animal-derived products tend to decrease calcium from the bones and encourage its passage into the urine. They’re also cancerous, insulinogenic, full of lactose sugar, animal growth factors, contaminants, and contain substantial amounts of saturated fats and cholesterol.

Instead, focus on plant-based diets, especially in the rehabilitation phase. Eat leafy greens, beans, and vegan fortified foods. Leafy vegetables, fruits, legumes, nuts, and seeds such as broccoli, Brussels sprouts, collard greens, mustard greens, chickpeas, spinach, tofu, walnuts and cashews. It would be wise to monitor your micro and macro nutrients to see if you’re meeting your daily necessary and if you need to supplement your diet with additional foods or vitamin pills.

In order to prevent hairline fractures, adding foods to your diet that prevent inflammation is also recommended. Consuming fish such as mackerel, salmon and tuna will provide your body with higher levels of Omega-3 fatty acids, which go a long way toward preventing muscles from becoming inflamed. Additional anti-inflammatory foods to incorporate into your diet are fruits with bright colors, such as cherries and raspberries. These have bright colors because of their high concentrations of anthocyanins, which will also drastically reduce body inflammation.

Men and pre-menopausal women should consume at least 1000 mg of calcium. Postmenopausal women should consume 1200 mg of calcium. Don’t take more than 2000mg of calcium a day in total, or you can increase the likelihood of kidney injury.

Men and women should consume between 600 and 800 international units (IU) of vitamin D per day. Don’t take more than 800 IU of vitamin D a day as high doses can be toxic, especially after long periods of time.

Get at least 1 hour of sunlight, every day. Continue maintaining a physically active lifestyle to encourage calcium synthesis and Vitamin D production in the body.

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Foods to Incorporate Into Your Diet to Avoid Stress Fractures:

  • Broccoli
  • Spinach
  • Brussels sprouts
  • Kale
  • Cabbage
  • Lettuce
  • Celery
  • Walnuts
  • Cashews
  • Citrus fruits
  • Chickpeas
  • Tofu
  • Tomatoes
  • Cherries
  • Raspberries

Hydration

Remember to properly hydrate yourself during the day. Drink up to eight 8-ounce (240 ml) glasses of fluid a day, depending on what your body needs. Commonly known as the 8×8 rule, meaning a total of 64 ounces of water or almost 2L of water a day. Drink more if necessary, but don’t drink too much water if your body rejects it; over-hydration can also cause problems in your body. Every individual reacts to physical activity differently, and their needs for hydration aren’t always the same, so you will have to judge for yourself whether or not you are drinking enough water.

AVOID caffeine, tobacco, excessive salt, steroid medications such as prednisone and trenbolone, and painkillers. These can cause problems with your body’s ability to hydrate, so use them sparingly if you absolutely must.

Equipment

People with particular physical characteristics may not benefit from standard sports equipment. Athletes with flat or excessively arched feet should buy specific shoes for their particular feet dimensions. If you are unable to find shoes that adequately manage your foot discrepancies, you can find specially made orthotics that will correct these issues, such as medical shoe inserts. Backpackers should also pay attention to the types of straps they’re using, as improper strap placement can result in uneven weight distribution, leading to potential back problems or excessive amounts of weight being distributed to your feet. Worn footwear or equipment may also expose you to injury, as regular wear and tear can reduce the ability for this equipment to adequately absorb shock, moisture, or weight. Runners are advised to use a low heel-to-toe drop or minimalist shoes. It’s also advised that runners replace their sneakers once every 300-700 miles (480-1200 km) to allow proper midsole cushioning. Insoles and medical orthotics can help, but make sure to not go overboard with the cushioning systems in the shoes, because it may be counter-productive by reducing your body’s natural shock-absorbing capabilities.

Proper Running Equipment That Can Prevent Stress Fractures:

  • Orthotics (shoe inserts)
  • Crutches
  • Bracings
  • Compression sleeves
  • Pads
  • Casts
  • Straps

Environmental factors

Rough terrains, such as hard dirt or concrete, can cause excessive shock to your ankles and knees when running. Whenever possible, try to run on softer surfaces, such as Olympic-style track, grass, or asphalt. Cold, humid, or windy climates can also affect the bone and muscles in your body, potentially causing inflammation and predisposing you to hairline fractures or other injuries.

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Previous health history

Often times, past injuries can increase the chances of developing new ones. Sometimes, these conditions don’t heal properly and can leave structural vulnerabilities, such as scar tissue. Address any injuries accordingly, because some injuries can lead to chronic pain or much worse injuries if left untreated. Failure to properly manage prior injuries can also potentially lead to permanent injuries in the worst case scenario, so be sure to get the all-clear from a doctor or medical professional before running again.

First Aid

Rest, Ice, Compression, and Elevation (R.I.C.E.)

The standard R.I.C.E. therapy should be applied as soon as possible after the actual injury took place. If swelling occurs, then some analgesics or anti-inflammatory drugs might be useful as well, such as paracetamol, acetaminophen, BenGay, ibuprofen or Tylenol.

Rest

A resting period is needed both in the short and long term. Refrain from your usual training regiment and allow a minimum of 6 weeks for the injury to heal. Pay close attention to the affected area and try to alleviate as much weight and strain as possible. If you must continue exercising, be sure to take frequent breaks throughout and stop immediately if the pain worsens.

Ice

Apply ice for 10-15 minutes to the affected area as soon as possible after the injury has occurred. You can do this multiple times a day until you’ve seen a doctor; as a general rule, you should only apply ice for up to twenty minutes every hour in order to prevent skin damage due to exposure to extreme cold. Ice decreases swelling and reduces pain, and can be applied to the body with an ice pack, a bag of frozen vegetables, or a sandwich bag filled with ice. You may want to wrap the ice pack in some sort of cloth in order to prevent direct contact with your skin. Apply ice as many times a day as you wish, just take some breaks in between and don’t pass 15 minutes a time.

Compression

Manual compression or an orthopedic device is greatly advised, as it moves strain away for the affected area and aids in recuperation. Depending on your affected area, you’ll want to search for an orthopedic/sports device such as straps, crutches etc. There are also special medical compression sleeves or socks you can purchase from a sporting goods store. These are commonly used in cases of deep vein thrombosis, but they are also very effective at treating general swelling in your lower body.

Elevation

Keeping the affected area elevated especially after the actual injury has occurred is strongly advised. Bear in mind that over 50% of stress fractures occur in the lower leg, so you should keep it elevated for some time, depending on your injury situation. Make sure to use an ottoman or foot rest if you are seated, and prop up your affected limb with some pillows if you are lying down.

Therapy treatments for Stress Fractures

The condition requires several months to completely heal: a minimum of 6 weeks, although rarely sufficient because most cases require a minimum of 12 weeks. In the meanwhile, you should perform light physical activity in order to avoid further muscle and bone atrophy. Focus on performing low-impact activities such as cycling, swimming, shadow boxing or running on an elliptical. You’ll have to keep tabs on your diet, lifestyle, and sleep pattern as well, in order to help the healing process.

Runners-Guide-Stress-Fracture-cast-orthotic-braceIt’s advised that patients recovering from hairline fractures acquire an orthopedic and/or orthotic device. These include straps, bracings, casts, walking boots, crutches, or compression sleeves. Some devices have pre-inflated cells which compress the bone just enough to relieve pressure and allow perfect blood flow, which is incredibly important for the recovery process.

After 6-16 weeks, the patient can gradually resume impact activities. “Gradually” is the keyword here, as the incidence of re-fracturing the bone is very high in this sensitive recovery state.

Physiotherapy

Your doctor may prescribe you some physiotherapy in the recuperation phase in order to speed up the healing process. Treatment includes soft tissue massage, joint mobilization, electrotherapy (e.g. ultrasound), ice or heat treatment (cryotherapy), ankle taping or ankle bracing, usage of a protective boot or crutches, exercises to improve strength, flexibility, and balance, hydrotherapy, activity modification, a gradual return to activity plan, and alternative footwear.

Alternative therapies

Growth Hormone (GH)

Growth hormone, also known as somatotropin or as human growth hormone, is a peptide hormone that stimulates tissue growth, cell reproduction and regeneration in humans and other animals. Studies with lab rats have shown that GH can significantly aid in reconstruction and tensile strengthening of bones. Ask your doctor about GH therapy and consider running a short cycle while and after recuperation.

S.A.R.M

Selective androgen receptor modulators (SARMs) are a novel class of androgen receptor ligands. (The terminology is currently used for similar molecules targeting the estrogen receptor, such as tamoxifen.) SARMs are intended to replicate androgenic drugs like anabolic steroids. However, what differentiates SARMs from steroids is that they perform a more targeted action, with fewer side effects.

For men with normal levels of testosterone and testicular function that are still in need of therapy for bone related issues such as osteoarthritis or osteoporosis, SARMs are a better alternative to most steroids or hormone replacement therapies. In these sitautions, SARM molecules are effectively targeting bone and muscle tissue with less influence on the testes or prostate.

For women, SARM molecules are a better alternative to standard steroids and growth factors, as SARMs successfully fix bone and strengthen muscle tissue without adverse effects.

Bisphosphonates

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Bisphosphonates are a class of drugs that counteract the loss of bone mass. It’s used to treat osteoporosis and similar bone-related diseases. Studies show a reduced risk in post-menopausal women with osteoporosis after taking these regularly. If you are a post-menopausal woman experiencing a hairline fracture, you may wish to consult your doctor in order to determine if biphosponate treatment is right for you.

TB-500

TB-500 is a synthetic peptide molecule consisting of a fraction of the protein thymosin beta-4, which consists of 43 amino acids and is encoded by the gene TMSB4X. This protein is present in almost all human and animal cells, and is produced in higher concentration wherever tissue has been damaged, containing potent anti-inflammatory agents. It can be injected anywhere because of its very low molecular weight which doesn’t bind to the extracellular matrix. TB-500 regulates Actin, the cell-building protein, and studies have shown large repairing benefits after a heart attack by reactivating cardiac progenitor cells to restore damaged heart tissue. The same benefits this supplement provides to victims of heart-related injuries can provide benefits to individuals suffering from severe cases of stress fractures as well.

Calcitonin

Calcitonin (aka. thyrocalcitonin) is an amino hormone produced in humans.  It inhibits osteoclasts, the offending agents in imbalanced remodeling processes that can be caused by bone recovery in the body. There’s currently no sufficient evidence to demonstrate Calcitonin’s effectiveness in prevention or healing the injury, but it may be recommended to you by a doctor.

Bone Stimulators

There are 2 types of stimulators: electromagnetic and ultrasound. Studies have shown moderate aid in recuperation when using one or both of these methods.

Electromagnetic stimulators produce electromagnetic fields with coils on either side of the break zone. The procedure causes fluid flow around and through the bones, which induce electrical currents in the proximity of cells, This can result in opening calcium channels to cell membranes, increasing calmodulin which will aid in increasing cell reproduction.

Pulsed ultrasound bone stimulators can increase vascular endothelial growth factor (VEGF) and fibroblast growth factor (FGF), which promote bone growth and re-genesis.

Studies have shown that electromagnetic stimulators moderately aid in recovery, while the latter has not yet been proven to aid in recuperation. However, many patients have experienced relief from these methods, so your doctor may recommend that you try this as well.

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Corticosteroids

Corticosteroids are a class of steroid hormones that are constructed in the adrenal cortex of vertebrates. They’re usually made artificially, in a lab. Ask your doctor about corticosteroids, as they need to be prescribed. Injections should be administered around the affected area and never in the Achilles tendon.

Surgery

With severe breaks, surgery may be needed for proper healing. The procedures commonly involve percutaneous pinning of the bone with a small local incision. Generally, the rehabilitation is faster, safer, and causes the development of less scar tissue, so the recovery process is much easier than prior methods of treatment.

Specific parts of injury

Breaks are subdivided into high-risk and low-risk fractures. A high-risk designation has a greater risk of delayed union or nonunion.

Tibial Shin Stress Fracture

HIGH-RISK

Tibia bone

The tibia is the most common part of the bone that breaks. These breaks mainly occur on the first third of the tibia, just above the ankle, in an area called the Medial Malleolus. It can happen anywhere on the tibia, but the first third of it is the most exposed part because of its thinness and due to it being the most shock-absorbing part of the leg.

Being a zone with high vascular concentration, the shin bone has the highest potential for a fast and accurate healing process. Although light cases can be successfully treated with non-invasive manners such as RICE and corrective running equipment, athletes should consider surgery for a faster healing process, or in more severe cases.

Tibial Stress Symptoms:

An ordinary tibia break will be felt as “shin splints” or tibial stress syndrome. The symptoms are usually felt after the training session, either immediately or the day after. Initially, the pain is felt as a burning sensation over a large area along the shin bone, and gradually develops into an acute pain over a smaller portion of the shin bone.

What to do:

After recuperation, the key muscles that need strengthening are the calves and shin muscles. Both compound and isometric exercises are advised. Squats, lunges, calf raises, and isometric exercises with the help of wrap-around ankle weights and elastic bands will allow you to work the front and side shin muscles.

A tibia break is difficult to identify in the middle of a training session, as hormones are being released which will mask pain and other related symptoms. If you feel pain, unusual warmth, or tingling, or if you experience swelling, bruising, and discoloration then you should stop the activity immediately and do the following:

  1. Try to identify the exact location of the injury through palpation
  2. Immediately apply the R.I.C.E. first-aid treatment
  3. Immobilize the leg
  4. Set up a doctor’s appointment
  5. Aquire over-the-counter drugs (analgesics, anti-inflammatories) if the pain is unbearable or if it affects your everyday schedule
  6. Acquire medical devices such as crutches, compression sleeve, or a walking boot
  7. Prepare for your doctor’s appointment by compiling an extensive medical history file as indicated at the beginning of this guide
  8. Revise your dietary/lifestyle decisions – consider supplementing with Calcium and vitamin D
  9. Take into account the fact that you’ll be in recuperation for several weeks/months and organize your schedule accordingly

Femoral Stress Fracture

Femur bone

This most often occurs in the tight bone of the femoral neck, which is the flattened pyramidal process of the bone. It can also occur at the shaft and condyle. It’s a high-risk feature that may require surgery, and is associated with coxa vara (the reduction of the femoral neck-shaft angle.)

Medial femoral neck cracks are considered low-risk, which can oftentimes be treated with non-invasive procedures. If procedures such as RICE, prescription medicine or orthotics fail to properly fix the problem, you may need to attempt a more invasive treatment method such as surgery.

Femoral Stress Symptoms:

The patient should recognize exercise-induced pain in the groin, hip, or proximal thigh. They should stop training immediately if this pain is recognized. Other reported symptoms include pain, warmth, tingling senstaions, inflammation, bruising, abnormal soreness and discomfort when putting pressure on the affected leg. Complications include delayed union, nonunion, displacement, or avascular necrosis if left untreated, so be sure to seek treatment as soon as possible to avoid these complications.

What to do:

Upon discovery of the injury, the patient should immediately stop training and do the following:

  1. Try to identify the exact location of the injury through palpation
  2. Immediately apply the R.I.C.E. first-aid treatment
  3. Immobilize the whole leg
  4. Set up a doctor’s appointment or go directly to the ER if you suspect you’ve injured the femoral neck, which is the top part of the bone in the upper hip area
  5. Aquire over-the-counter drugs (analgesics, anti-inflammatories) if the pain is unbearable or if it affects your everyday schedule
  6. Acquire medical devices such as crutches, hip braces, or full leg braces
  7. Prepare for your doctor’s appointment by compiling an extensive medical history file as indicated at the beginning of this guide
  8. Revise your dietary/lifestyle decisions – consider supplementing with Calcium and vitamin D
  9. Take into account the fact that you’ll be in recuperation for several weeks/months and organize your schedule accordingly

Talus Stress Fracture

Talus bone

The Talus bone is at the base of the ankle. Injury incidence is low and seen most commonly in athletes, backpackers, and military recruits performing repetitive tasks.  Although considered a high-risk injury zone, successful treatments involve noninvasive procedures alongside the use of orthotics. Orthotics help reduce lateral loading pressures, given the coincidence of pronation and lateral talar cracks, so consider implementing insoles or special shoes as prescribed by a podiatrist.

Talar Stress Symptoms:

It is fairly easy to identify this condition, as pain and severe discomfort are reported when moving the ankle or when standing on the affected foot. Usually, pain diminishes during rest, but reoccurs and intensifies during normal activities. Swelling, tingling, tenderness, and bruising are also possible symptoms.

What to do:

In this case, the patient should immediately refrain from physical activities and do the following:

  1. Palpation is not advised in the case of smaller bones, so don’t touch the area or do so extremely lightly
  2. Immediately apply the R.I.C.E. first-aid treatment in the surrounding area. Submerging your whole foot in ice water is an acceptable method
  3. Immobilize the whole leg
  4. Set up a doctor’s appointment or go directly to the ER if you suspect the injury is severe
  5. Aquire over-the-counter drugs (analgesics, anti-inflammatories) if the pain is unbearable or if it affects your everyday schedule
  6. Acquire medical devices such as crutches, ankle sleeves, ankle braces, or foot inserts (orthotics)
  7. Prepare for your doctor’s appointment by compiling an extensive medical history file as indicated at the beginning of this guide
  8. Revise your dietary/lifestyle decisions – consider supplementing with Calcium and vitamin D
  9. Take into account the fact that you’ll be in recuperation for several weeks/months and organize your schedule accordingly

Navicular Stress Fracture

Navicular bone

Just bellow the Talus, there’s the parallelepipedic bone named Navicular.  This area is currently considered high-risk due to the rate of nonunion from poor blood supply. Athletes who perform explosive movements such as sprinting or jumping are at risk of developing navicular stress fractures. Invasive therapy might be necessary so as to avoid the formation of subchondral degeneration and edema formation. Although instances have been successfully treated with noninvasive procedures, the most common form of treatment for this condition is surgery.

Navicular Stress Symptoms:

Swelling and inflammation are more common for this injury zone than other parts of the body. Pain is usually reported, especially when moving the ankle or standing on it. Bruising, tenderness, and tingling sensations are also commonly reported symptoms.

What to do:

Upon the discovery of the injury, the patient should immediately stop training and do the following:

  1. No need for exact injury identification, so palpation is not advised in the case of smaller bones
  2. Immediately apply the R.I.C.E. first-aid treatment in the surrounding area, even putting your whole foot in ice water is an acceptable method
  3. Immobilize the ankle and don’t step on it
  4. Set up a doctor’s appointment or go directly to the ER if you suspect the injury is severe
  5. Aquire over-the-counter drugs (analgesics, anti-inflammatories) if the pain is unbearable or if it affects your everyday schedule
  6. Acquire medical devices such as crutches, ankle sleeves, ankle braces, or foot inserts (orthotics)
  7. Prepare for your doctor’s appointment by compiling an extensive medical history file as indicated at the beginning of this guide
  8. Revise your dietary/lifestyle decisions – consider supplementing with Calcium and vitamin D
  9. Take into account the fact that you’ll be in recuperation for several weeks/months and organize your schedule accordingly

Metatarsal Stress Fracture

Metatarsalia bones

Metatarsals cracks occur most frequently in the second, third, and fifth metatarsals, and are relatively common in ballet dancers. In the case of metatarsal fracture, the vague symptoms are oftentimes overlooked or misdiagnosed, and can even be confused with other conditions. Ballerinas are at risk when executing the “en pointe” position because of the extreme plantar flexion of the foot.

Due to the nature of the thin metatarsal bones and the location of the injury, surgery might be necessary for correct healing. Multiple scans are required for injury identification and deciding therapy strategy, so don’t be afraid to conduct thorough examinations of your foot with several doctor visits if you are a high-risk individual and suspect that this may be the cause of your pain.

Metatarsal Stress Symptoms:

Common symptoms include forefoot pain, an inability to toe walk, point tenderness, and swelling. Women are anatomically more exposed because women have a higher middle forefoot loading force than men.

What to do:

A contemporary cadaveric biomechanical research showed that both custom and semi-custom orthotics decrease tension and strain on the metatarsal area. Custom orthotics are superior in effectiveness, so try consulting a podiatrist to create one specifically manufactured to fit your foot. The addition of a stiff-soled shoe, short leg walking cast, walker boot, or midfoot taping are also strongly advised. Functional bracing or orthotics upon return to sports may reduce the high rate of refracture, at least in the initial stages.

Upon injury detection, the athlete should immediately halt their training regimen and do the following:

  1. Identify the exact metatarsal “finger” affected through gentle palpation
  2. Immediately apply the R.I.C.E. first-aid treatment in the surrounding area; even putting your whole foot in ice water is an acceptable method
  3. Immobilize the bottom half of the foot and gently step on your heel, if possible. If not, immobilize the whole leg to avoid complications
  4. Set up a doctor’s appointment or go directly to the ER if you suspect the injury is severe
  5. Aquire over-the-counter drugs (analgesics, anti-inflammatories) if the pain is unbearable or if it affects your everyday schedule
  6. Acquire medical devices such as crutches, walking boots or similar devices, or foot inserts (orthotics)
  7. Prepare for your doctor’s appointment by compiling an extensive medical history file as indicated at the beginning of this guide
  8. Revise your dietary/lifestyle decisions – consider supplementing with Calcium and vitamin D
  9. Take into account the fact that you’ll be in recuperation for several weeks/months and organize your schedule accordingly

Sesamoid Stress Fracture

Sesamoid bone

Positioned directly under the first metatarsal head, the sesamoid is a high-risk injury zone which can be treated with both invasive and noninvasive manners. Activities that require a powerful dorsiflexion of the toes are at risk, such as running or stair climbing. Common therapy methods include shoe adjustment, immobilization, compression, cessation of sport, use of systemic anti-inflammatories, steroid injections, and potentially surgery.

Sesamoid Symptoms:

The injury should be quite easy to identify as pain and discomfort are constant when walking, especially when performing the dorsiflexion part of the stepping movement. Some swelling might be present, but not always.

Treatment of a Sesamoid:

Upon injury realization, the patient should stop all sports activity and should do the following:

  1. Palpation shouldn’t be needed as the injury should be fairly easy do identify
  2. Immediately apply the R.I.C.E. first-aid treatment in the surrounding area; even putting your whole foot in ice water is an acceptable method
  3. Immobilize the bottom half of the foot and gently step on your heel, if possible. If not, immobilize the whole leg to avoid complications
  4. Set up a doctor’s appointment or go directly to the ER if you suspect the injury is severe
  5. Aquire over-the-counter drugs (analgesics, anti-inflammatories) if the pain is unbearable or if it affects your everyday schedule
  6. Acquire medical devices such as crutches, walking boots or similar devices, or foot inserts (orthotics) etc
  7. Prepare for your doctor’s appointment by compiling an extensive medical history file as indicated at the beginning of this guide
  8. Revise your dietary/lifestyle decisions – consider supplementing with Calcium and vitamin D
  9. Take into account the fact that you’ll be in recuperation for several weeks/months and organize your schedule accordingly

Patella Fracture

Patella bone

Immense pressure on the kneecap bone, called the Patella, is uncommon. Although rare, this injury is high-risk and requires proper treatment through immobilization and stabilization with tension band wirings and adjunctive Iliotibial Band Release Surgery (IBRS). Fractures that don’t involve displacement can be treated conservatively, with the use of orthopedic bracing and other noninvasive methods.

Patellar Stress Symptoms:

Knee fractures are rather easy to identify, as pain occurs whenever the knee is being flexed. Redness, inflammation, and bruising might be present as well. Although pain and swelling are common symptoms of a patellar stress fracture, they can also be indicative of other conditions, such as patellofemoral pain syndrome, so be sure to rule it out before pursuing treatment.

What to do:

Upon injury identification, the patient should do the following:

  1. Identify the injured knee
  2. Immediately apply the R.I.C.E. first-aid treatment in the surrounding area
  3. Immobilize the affected knee as to avoid complications
  4. Set up a doctor’s appointment or go directly to the ER if you suspect the injury is severe
  5. Aquire over-the-counter drugs (analgesics, anti-inflammatories) if the pain is unbearable or if it affects your everyday schedule
  6. Acquire medical devices such as crutches, walking boots, knee braces, knee pads, or compression sleeves
  7. Prepare for your doctor’s appointment by compiling an extensive medical history file as indicated at the beginning of this guide
  8. Revise your dietary/lifestyle decisions – consider supplementing with Calcium and vitamin D
  9. Take into account the fact that you’ll be in recuperation for several weeks/months and organize your schedule accordingly

Calcaneal Heel Stress Fracture

LOW-RISK

Calcaneous bone

Individuals at risk of calcaneal heel stress fractures are military personnel, backpackers, long-distance runners, and other individuals who find themselves performing repetitive foot motions associated with long distance hiking or marching. Considered a low-risk injury, diagnosis is often inaccurate because of similarities with other afflictions and injuries, such as plantar fasciitis. Nonoperative management and basic noninvasive medical procedures seem to provide adequate healing for these injuries.

Calcaneal Heel Stress Symptoms: 

Gradual onset heel pain is the most commonly reported injury. Pain and severe discomfort are to be expected when applying pressure on the heel, and rare cases might present swelling and bruising. Be sure to rule out plantar fasciitis when diagnosing this injury; some common symptoms that differentiate plantar fasciitis from a fracture are increased tightness on the sole of the foot and a change in pain levels throughout the day.

What to do:
  1. Identify the injured heel
  2. Immediately apply the R.I.C.E. first-aid treatment in the surrounding area; submerging your whole foot in ice water is an acceptable method
  3. Immobilize the affected foot as to avoid complications
  4. Set up a doctor’s appointment or go directly to the ER if you suspect the injury is severe
  5. Aquire over-the-counter drugs (analgesics, anti-inflammatories) if the pain is unbearable or if it affects your everyday schedule
  6. Acquire medical devices such as crutches, walking boots, plaster casts, KT tape, or inserts (orthotics)
  7. Prepare for your doctor’s appointment by compiling an extensive medical history file as indicated at the beginning of this guide
  8. Revise your dietary/lifestyle decisions – consider supplementing with Calcium and vitamin D
  9. Take into account the fact that you’ll be in recuperation for several weeks or months and organize your schedule accordingly

Cuneiforms and Cuboid Bone fractures

Cuneiforms and Cuboid bones

These are low-risk parts of your foot’s skeletal structure, and they can be successfully treated with standard noninvasive procedures. Complete immobilization is usually not necessary, but nonoperative management is recommended for at least 6 weeks. Multiple diagnostic scans may be needed for correct injury identification because unlike bones with a diaphysis, the cuneiform and cuboid don’t display periosteal callus: a webbing of material your body produces that will eventually become bone, and a clear identifier of prior bone injury.

Cuneiforms and Cuboid Stress Symptoms: 

Pain when walking is almost always reported. Additionally, severe discomfort, swelling, and bruising are also commonly reported in cases of cuneiform or cuboid fracture. Severe discomfort might present itself even when the foot is not being used, which can differentiate this injury from standard inflammation-based conditions.

What to do:

The athlete should cease all sports activity upon identifying the injury and do the following:

  1. Palpation is not advised as it’s not really necessary to exactly identify the damaged area
  2. Immediately apply the R.I.C.E. first-aid treatment in the surrounding area; submerging your whole foot in ice water is an acceptable method
  3. Immobilize the affected foot as to avoid complications
  4. Set up a doctor’s appointment or go directly to the ER if you suspect the injury is severe
  5. Aquire over-the-counter drugs (analgesics, anti-inflammatories) if the pain is unbearable or if it affects your everyday schedule
  6. Acquire medical devices such as crutches, walking boots, KT tape or inserts (orthotics)
  7. Prepare for your doctor’s appointment by compiling an extensive medical history file as indicated at the beginning of this guide
  8. Revise your dietary/lifestyle decisions – consider supplementing with Calcium and vitamin D
  9. Take into account the fact that you’ll be in recuperation for several weeks/months and organize your schedule accordingly

Lateral Malleolus Fracture

Lateral Malleolus bone

The round protuberant bone on the exterior side of the ankle can suffer pressure breaks, although cases are uncommon. This bone is called the lateral malleolus, and depending on the specific location and severity of the fracture, both invasive and noninvasive medical procedures may be needed along with subsequent physical therapy.

Malleolar Stress Symptoms:

Pain, when walking or moving the ankle, is the most commonly reported symptom. Swelling and bruising may be present, but not in all cases. Sometimes, pain manifests itself inside the ankle rather than on the outside. This injury affects the same area as another common running injury known as Achilles tendonitis. In order to differentiate a stress fracture from this condition, your doctor may require imaging scans such as an X-ray to properly rule it out. However, some differences in symptoms between the two conditions are that Achilles tendonitis cases will involve stiffness and the development of bone spurs.

What to do:

When there is the possibility of this injury, all physical activity should be stopped. Subsequently, the patient should do the following:

  1. Identify the injured ankle bone
  2. Immediately apply the R.I.C.E. first-aid treatment in the surrounding area; submerging your whole foot in ice water is an acceptable method
  3. Immobilize the affected knee as to avoid complications
  4. Set up a doctor’s appointment or go directly to the ER if you suspect the injury is severe
  5. Aquire over-the-counter drugs (analgesics, anti-inflammatories) if the pain is unbearable or if it affects your everyday schedule
  6. Acquire medical devices such as crutches, walking boots, KT tape or inserts (orthotics)
  7. Prepare for your doctor’s appointment by compiling an extensive medical history file as indicated at the beginning of this guide
  8. Revise your dietary/lifestyle decisions – consider supplementing with Calcium and vitamin D
  9. Take into account the fact that you’ll be in recuperation for several weeks/months and organize your schedule accordingly

Fibula Stress Fracture

Fibula bone

The fibula is the lateral bone of the lower leg, located on the outside-facing parts of your lower legs. These bones are thin and bear a great deal of weight, so they are susceptible to stress fracture.

Athletes with unnecessary pronation or rolling in their feet when running are more exposed to this injury because their peroneal muscles must work harder. In fact, any exercise that excessively fatigues the peroneal muscles increases the probability of injury. The injury zone is considered low-risk, so if diagnosed early, noninvasive procedures should suffice.

In the recuperation phase, the patient should perform isometric exercises with the ankle using ankle weights to gradually strengthen the adjacent muscles. This will assist in rehabilitating the legs, allowing the patient to resume running regularly afterward.

Fibula Stress Symptoms: 

Localized pain in the outer lower leg is the most common symptom, which will increase with weight bearing activities. Night aches and discomfort are also commonly reported. A milder and more common form of this injury is known as shin splints.

What to do:

Upon injury identification, physical activity should be halted immediately. The patient should then do the following:

  1. Identify the injured area through palpation
  2. Immediately apply the R.I.C.E. first-aid treatment in the surrounding area
  3. Immobilize the affected leg as to avoid complications; simply walking normally may be enough to aggravate the injury
  4. Set up a doctor’s appointment or go directly to the ER if you suspect the injury is severe
  5. Aquire over-the-counter drugs (analgesics, anti-inflammatories) if the pain is unbearable or if it affects your everyday schedule
  6. Acquire medical devices such as crutches, walking boots, leg braces, KT tape or compression sleeves
  7. Prepare for your doctor’s appointment by compiling an extensive medical history file as indicated at the beginning of this guide
  8. Revise your dietary/lifestyle decisions – consider supplementing with Calcium and vitamin D
  9. Take into account the fact that you’ll be in recuperation for several weeks/months and organize your schedule accordingly

Pelvic Hip Stress Fracture

Pelvis bone

Cracks and breaks in the pelvic area are uncommon, and usually quite hard to detect. They’re classified as low-risk due to their uncommon nature and fairly simple treatment methods. Women have a higher incidence of stress fractures alongside the pubic area with pain in the adductor, inguinal, and perineal areas, but men have also been known to experience these injuries. Bone conditions such as osteoporosis and rheumatoid arthritis are common risk factors for this injury ,as the bone structure becomes much more brittle and prone to breakage in these conditions.

Standard noninvasive procedures include high-velocity, low-amplitude chiropractic manipulation, as well as stretching of the psoas and piriformis muscles. However, these procedures may not suffice in treating more severe forms of this injury; surgery might be needed for adequate healing and union in these cases.

Pelvic Stress Symptoms: 

Pain in the adductor, inguinal, and perineal areas are usually reported. The athlete might experience diminished strength and movement in the pelvic area. A burning sensation, stiffness, and tenderness are also common. If the injury was caused by trauma, the pain is incredibly severe, and the shape of the pelvic area is deformed, it is possible that hip dislocation has occurred.

What to do:

Upon injury identification, stop training immediately and do the following:

  1. Approximately identify the injured zone
  2. Immediately apply the R.I.C.E. first-aid treatment in the surrounding area
  3. Drastically reduce your mobility so as to avoid complications
  4. Set up a doctor’s appointment or go directly to the ER if you suspect the injury is severe
  5. Aquire over-the-counter drugs (analgesics, anti-inflammatories) if the pain is unbearable or if it affects your everyday schedule
  6. Acquire medical devices such as crutches, hip braces, hip supports or other assisted walking devices
  7. Prepare for your doctor’s appointment by compiling an extensive medical history file as indicated at the beginning of this guide
  8. Revise your dietary/lifestyle decisions – consider supplementing with Calcium and vitamin D
  9. Take into account the fact that you’ll be in recuperation for several weeks/months and organize your schedule accordingly

Conclusion

Upon injury identification, all physical activity must be halted, and immediate first-aid R.I.C.E. therapy is advised. From that point, the next course of action should be to promptly contact your doctor in order to set an appointment. In the meantime, immobilize the leg, follow the dietary advice listed above and acquire over-the-counter symptom relievers if necessary.

During your appointment, ask your doctor about orthopedic and orthotic devices that can speed up your recovery time. Such devices include back supports and braces, foot and ankle supports, cervical collars, knee and elbow braces, hip supports, and shoe inserts, depending on the location and severity of your injury. Custom devices are superior to generic ones, as they are tailored to your particular specifications. Identify all extrinsic and intrinsic problems and seek to address them for future injury prevention. If you follow the steps and guidelines listed above, you should be able to recover from your injury without much difficulty, and resume your regular running routine in short order. One important thing to note is that while this article has been thoroughly researched and cites many articles written by doctors, it should not be taken as medical advice. Always talk to a doctor or medical professional if you are experiencing unknown spontaneous pain.

Co-written by Mike Valverde

Curated by Diana Rangaves, PharmD. Rph

Sources used while conducting our research

Sources

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