The Runner’s Guide to Stress Fractures

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

A stress fracture, fissure fracture, or 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 in time because of accumulated trauma after repeated physical activity of submaximal impacts like running and jumping. In this case, “fracture” 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, running or walking long distances with heavy weights, performing unnatural tensed movements etc. Furthermore, fatigued muscles are unable to absorb impacts, so the impact force is distributed to the bones, increasing injury risk. Stress fractures can also arise from normal use of a bone that’s weakened by a condition such as osteoporosis or other-bone-related diseases.

A stress fracture or fissure can be described as a small irregular crack/tearing in the bone’s structure. The dimensions, form, and severeness of the fracture largely depend on the event and bone health.

Who’s holds the highest risk of suffering from stress fractures?

More so, track and field athletes, ballet dancers, skaters, basketball players, volleyball players, military recruits, long distance backpackers and last but not least, long distance runners are particularly exposed. Also, old people, sedentary people or people with bone-related diseases such as osteoporosis and rheumatoid arthritis.

Where do stress fractures occur?

The injury mostly involves weight-bearing bones. Weight-bearing bones are the most common places for stress fractures, such as the tibia (longitudinal bone bellow the knee towards the inside), metatarsals, and navicular bones (bones of the foot), fibula (calf bone), pelvis, calcaneus (heel bone). In theory, a fracture can occur in any bone of the body, but it’s basically 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, warmness in the affected area are usually reported but rarely identified as a symptom. A certain sensitivity might manifest itself in the local area, but because of its subtleness, it’s rarely identified as a potential symptom.

Pain usually installs itself after a while, especially at night, after a couple of hours. In some cases, pain doesn’t manifest itself until a day or two. 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. 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.

  • Pain
  • Swelling/inflammation
  • Warmness
  • 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, medicamentation and supplementation, vices, lifestyle – basically everything. Don’t be afraid or embarrassed to disclosure information with your doctor, it’s very important that you supply him with extensive information to help him make a correct diagnosis which is vital towards your recovery. You’re always covered by the doctor-patient confidentiality clause.

  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.

Potential physical exams

  • Fulcrum test: The Fulcrum test is a physical exam through palpation in which the examiner pushes down the knee with one hand while creating leverage with the other hand placed bellow the patience’s tight, thus creating tension in the middle. Pain or sharp pain might suggest a stress fracture.

Fulcrum test

  • FABER test (Flexion, ABduction, and External Rotation): The FABER test is also a physical exam in which the patient lays horizontally on the back 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 fracture.

FABER test

  • X-rays

An X-ray scan can be the fastest and easiest method but it’s not the most foolproof as certain stress fractures require time to be successfully identified. In some cases, inflammation and weird 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.

  • 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. The procedure can pinpoint stress fractures within the first week of injury. It can also visualize and distinguish between stress and other soft tissue injuries, so it’s a pretty 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 intravenously. The specially designed radioactive substance accumulates in greater volumes wherever bones are being repaired, thus indicating the exact injury location as white bright spots. This technique may not be the first choice of your doctor but generates functional imaging and allows visualization of bone metabolism and bone remodeling.

A visualization that most scanning techniques such as X-ray, CTs are not capable of. Also, a bone scan is distributed as a cancer identifier.

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Prevention

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

Gradual linear progression is the keyword here. Never go overboard with high-impact sports activities, especially after a long period of inactivity. Just like your muscles, your bones adapt to increasing 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.

A general rule for linear progression when talking about high-impact sports such as running: do not exceed the training volume by 10% each week. So, each week you’ll add no more than 10% in distance from last week. This is a general, principal rule to make you understand the concept of training volume limitation as to avoid overtraining and injury relapse. If your changing terrains from one week to another, then add a little bit lass than 10% or at all. Caution is imperative here as rushing things can be extremely damaging.

  • Don’t overtrain
  • Use proper exercise form
  • Cross-train and lift weights
  • Use proper training equipment
  • Eat a plant-based diet
  • Don’t overindulge in vices

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Causes

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

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

  • Overuse of unadapted bones
  • Hard, irregular surfaces
  • Bone-related diseases
  • Hormonal imbalances
  • Improper diet, sleep pattern, and hydration
  • Previous history of fractures
  • Anatomical and biomechanic discrepancies
Improper training regiment

Often times, athletes fail do adapt their training regiments. A stress fracture may result from a combination of overtraining after a period of inactivity. Or just an abrupt increase in training intensity can catch your body off guard. The bone gradually adapts 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.

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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 form down. Analyze your past exercises and try to identify if the problem or part of it derives from incorrect exercise execution. Address improper form issues by getting another opinion from a more experienced athlete. Another alternative to form checking would be comparing yourself to trained professionals. Watch yourself into a mirror, film yourself, and ask for a second opinion on your form.

Overtraining

Fatigued muscles increase the chances of getting a bone fracture because both the muscle and bone absorb shocks. But when the muscle is 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 (osteoblast).

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Diet (Calcium and Vitamin D)

A changed diet, sleeping pattern or medicamentation can also further increase the chances of getting injured. Watch out for 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 fat and cholesterol.

Instead, focus on plant-based diets, especially in the rehabilitation phase. Eat greens, beans, and vegan fortified foods. Leafy vegetables, fruits, legumes, nuts, seeds such as Broccoli, Brussels sprouts, collards, mustard greens, chickpeas, spinach, tofu etc. 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.

Men and premenopausal 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.

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 in the body.

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Hydration

Furthermore, remember to properly hydrate yourself during the day. Drink eight 8-ounce (240 ml) glasses of fluid a day. 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.

AVOID caffeine, tobacco, excess salt, steroid medicamentations such as prednisone, and painkillers.

Equipment

People with particular physical characteristics may not benefit from standard sports equipment. Athletes with flat or overarched feet should buy specific shoes for their particular feet dimensions. Backpackers should also pay attention to the types of straps they’re using. Worn footwear or equipment may also expose you to injury. Runners are advised to use a low heel-to-top drop or minimalistic shoes. It’s also advised that runners replace their sneakers once every 300-700 miles (480-1200 km) to allows proper midsole cushioning. Don’t go overboard with the cushioning systems in the shoes because it may be contra-productive as it can reduce your body’s natural shock-absorbing capabilities.

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

Environmental factors

Rough terrains, cold, humid, windy climates can affect the bone system and predispose you to injuries.

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Previous stress fractures

Often times, past injuries can increase the chances of developing new ones. Some stress fractures don’t heal properly and leave structural vulnerabilities, scar tissue etc. Address any injuries accordingly because some injuries can lead to chronic pain if left untreated.

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 (paracetamol/acetaminophen, ben-gay, ibuprofen etc.)

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.

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. Ice decreases swelling and reduces pain. 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.

Elevation.

Keeping the affected area elevated especially after the actual injury has occurred is strongly advised. Bearing in mind that over 50% of stress fractures are in the lower leg, you should keep it elevated for some time, depending on your injury situation.

Therapy treatments for Stress Fractures

A stress fracture requires several months to completely heal, a minimum of 6 weeks, although rarely sufficient – most cases require a minimum of 12 weeks. In the meanwhile, you should perform physical activities to avoid further muscle and bone atrophy. Focus on performing low-impact activities such as cycling, swimming, shadow boxing etc. You’ll have to keep tabs on your diet, lifestyle, and sleep pattern to help the healing process.

Runners-Guide-Stress-Fracture-cast-orthotic-braceIt’s advised that the patient acquires an orthopedic and/or orthotics devices such as straps, bracings, casts, walking boots, crutches etc. Some devices have pre-inflated cells which compress the bone just enough to relieve stress and allow perfect blood flow, the latter being mandatory.

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.

Physiotherapy

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

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 but with a more targeted action with fewer side effects.

For men with normal levels of testosterone and testicular function but in need of a therapy for bone related issues such as osteopenia or osteoporosis, SARMs is a better alternative to most steroids or hormone replacement therapies: in this case, SARMs molecules are effectively targeting bone and muscle tissue but with less influence on the testes or prostate.

For women, SARMs molecules are a better alternative to standard steroids and growth factors, as SARMs successfully repairs bone and muscle tissue without undesirable side-effects such as virilization (development of male characteristics), increased cholesterol, liver dysfunction etc.

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 of fracture in post-menopausal women with osteoporosis.

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. The protein is present in almost all human and animal cells. It’s produced in higher concentration wherever tissue has been damaged and contains potent anti-inflammatory agents. It can be injected anywhere because of its very low molecular weight which doesn’t bind to the extracellular matrix.
The substance regulates Actin, the cell-building protein. Studies have shown large repairing benefits after a heart attack by reactivating cardiac progenitor cells to restore damaged heart tissue.

Calcitonin

Calcitonin (aka. thyrocalcitonin) is a 32-amino acid linear polypeptide hormone produced in humans, primarily by the parafollicular cells. It inhibits osteoclasts, the offending agents in imbalanced remodeling processes of stress fractures. There’s currently no sufficient evidence to demonstrate Calcitonin’s effectiveness in prevention or healing of stress fractures.

Bone Stimulators

There are 2 types of stimulators. Electromagnetic and ultrasound stimulators. Studies have shown moderate aid in recuperation.

Electromagnetic stimulators produce electromagnetic fields with coils on either side of the fractured zone. The procedure causes fluid flow around and through the bones which induce electrical currents in the proximity of cells, which can open calcium channels in cell membranes increasing calmodulin, thus increasing cell reproduction.

Pulsed ultrasound bone stimulators can increase vascular endothelial growth factor (VEGF) and fibroblast growth factor (FGF), which promote angiogenesis and increase alkaline phosphatase, bone sialoprotein, and intracellular calcium (markers of bone metabolism).

Studies have shown that electromagnetic stimulators moderately aid in recovery, while the latter has not yet been proven to aid in recuperation.

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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 in the lab, artificially. Ask your doctor about corticosteroids as they need to be prescribed. Injections should be administered around the affected area and never in Achilles tendon.

Surgery

With severe stress fractures, surgery may be needed for proper healing. The procedure involves percutaneous pinning of the fracture with a small local incision. Generally, the rehabilitation is faster, safer, and with less scar tissue.

Specific parts of injury

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

Tibial Shin Stress Fracture

HIGH-RISK

Tibia bone

The tibia is the most common part for stress fractures. Mainly, on the first third of the tibia, just above the ankle, called Medial Malleolus. A stress fracture can happen anywhere on the tibia but the first third is the most exposed part because of its thinness and because it’s the most shock-absorbing part of the leg.

Being a strongly vascularized zone, the shin bone has one of the highest potential for a fast and correct healing process. Although light cases can be successfully treated with non-invasive manner, athletes should consider surgery for a faster healing process.

Tibial stress fracture symptoms: 

An ordinary tibial stress fracture will be felt as “shin splints” or tibial stress syndrome. The symptoms are usually felt after the training session, 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 with lower leg stress fractures are the calves and shin muscles. Both compound and isometric exercises are advised. Squats, lunges, calf raises, but also isometric exercises with the help of wrap-around ankle weights and elastic bands which will allow you to work the front and side shin muscles.

A tibia stress fracture is difficult to identify in the middle of a training session as hormones are being released which mask pain and other related symptoms. If you feel pain, warmness, tingliness, or if you experience swelling, bruising, or if the area changes color 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 as you don’t know the specifics of the injury, so it’s better to play it safe;
  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, walking boot 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.

Femoral Stress Fracture

Femur bone

Stress fractures in the tight bone most often occur in 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. It’s associated with coxa vara (the reduction of the femoral neck-shaft angle.)

Medial femoral neck fractures are considered low-risk which can oftentimes be treated with non-invasive procedures.

Femoral stress fracture symptoms:

The patient should recognize exercise-induced pain in the groin, hip, or proximal thigh. He should stop training immediately. Other reported symptoms include pain, warmness, tingliness, inflammation, bruising, abnormal soreness and discomfort when putting pressure on the affected leg. Complications include delayed union, nonunion, displacement, or avascular necrosis fi left untreated.

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 as you don’t know the specifics of the injury, so it’s better to play it safe;
  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, full leg braces 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.

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 axial loading activities. Although considered a high-risk injury zone, successful treatments involved noninvasive procedures alongside the use of orthotics. Orthotics help reduce lateral loading stress, given the coincidence of pronation and lateral talar stress fractures.

Talar fracture stress symptoms:

Stress fractures in the zone should be fairly easy to identify as pain and severe discomfort are reported when moving the ankle and when standing on the affected foot. Usually, pain diminishes during rest but reoccurs and intensifies during normal activities. Swelling, tingliness, tenderness, 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 it extremely lightly;
  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 whole leg as you don’t know the specifics of the injury, so it’s better to play it safe;
  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, 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.

Navicular Stress fracture

Navicular bone

Just bellow the Talus, there’s the parallelepipedic bone named Navicular. Stress fractures in this area are currently considered high-risk due to the rate of nonunion because of the natural poor blood supply. Athletes who perform explosive sprinting or jumping are at risk. Invasive therapy might be necessary as to avoid the formation of subchondral degeneration and edema formation. Although instances have been successfully treated with noninvasive procedures.

Navicular stress fracture 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, tingliness are also common 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 as you don’t know the specifics of the injury, so it’s better to play it safe;
  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, 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.

Metatarsal Stress Fracture

Metatarsalia bones

Metatarsals stress fractures 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. 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.

Metatarsal stress fracture:

Common symptoms include forefoot pain, 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. Custom orthotics are superior in effectiveness. The addition of a stiff-soled shoe, short leg walking cast, walker boot, or midfoot taping are strongly advised. Functional bracing or orthotics upon return to sports may reduce the high rate of refracture.

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

  1. Identify the exact metatarsal “finger” 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, 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.

Sesamoid 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. Common therapy includes shoe adjustment, immobilization, compression, cessation of sport, systemic anti-inflammatories, steroid injections, and surgery.

Sesamoid stress fracture:

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

Treatment of a Sesamoid fracture:

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, 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

Stress fractures on the knee-cap bone called Patella are uncommon. Although rare, the injury is of high-risk and requires proper treatment through immobilization and stabilization with tension band wirings and adjunctive Iliotibial Band Release Surgery (IBRS). Nondisplaced fractures can be treated conservatively with orthopedic bracing and other noninvasive methods.

Patellar stress fracture symptoms: 

Knee fractures are rather easy to identify as pain occurs whenever the knee is being flexed. Redness, inflammation, bruising might be present as well.

What to do:

So, 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 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.

Calcaneal heel stress fracture

LOW-RISK

Calcaneous bone

Military personnel, backpackers, long-distance runners, and such are at risk. Considered a low-risk injury, diagnosis is often wrongly put because of similarities with other afflictions and injuries. Nonoperative management and basic noninvasive medical procedures seem to suffice an adequate healing.

Calcaneal heel stress fracture symptoms: 

Gradual onset heel pain is the most common reported injury. Pain and severe discomfort are to be expected when applying pressure on the heel. Rare cases might present swelling and bruising.

What to do:
  1. Identify the injured heel;
  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 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, 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.

Cuneiforms and Cuboid Bone fractures

Cuneiforms and Cuboid bones

They are low-risk parts which can be successfully treated with standard noninvasive procedures. Complete immobilization is usually not necessary. Nonoperative management is recommended for at least 6 weeks. Multiple scans may be needed for correct injury identification because unlike bones with a diaphysis, the cuneiform and cuboid don’t display periosteal callus.

Cuneiforms and Cuboid stress fracture symptoms: 

Pain when walking is almost always reported. Additionally, severe discomfort, swelling, bruising are also reported. Severe discomfort might present itself even when the foot is not being solicited.

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, even putting 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, 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.

Lateral Malleolus Fracture

Lateral Malleolus bone

The round protuberant bone on the exterior side of the ankle can suffer from stress fractures, although cases are uncommon. Depending on the specific location and injury severity, both invasive and noninvasive medical procedures may be deployed alongside subsequent physical therapy.

Malleolar stress fractures symptoms:

Pain, when walking or moving the ankle, is the most common reported symptom. Swelling and bruising might be present but not in all cases. Sometimes, pain manifests itself inside the ankle rather than on the outside.

What to do:

When in suspicion of a stress fracture, 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, even putting 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, 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.

Fibula Stress Fracture

Fibula bone

Fibula, the lateral bone of the lower leg, is pretty susceptible to stress fractures.

Athletes with unnecessary pronation or rolling in of the feet when running are more exposed because the peroneal muscles must work harder. In fact, any exercise that overfatigues the peroneal muscles is increasing the probability of injuries. 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 weight to strengthen the adjacent muscles, gradually.

Fibular stress fracture symptoms: 

Localized pain in the outer lower leg is the most common symptom which increases with weight bearing activities. Night ache and discomfort are also reported.

Treatment Fracture of  a fracture in the fibular bone:

Upon injury identification, physical activity should be halted immediately. The patient should 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 as walking alone 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, leg sleeves 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.

Pelvic Hip Stress Fracture

Pelvis bone

Stress fractures in the pelvic area are uncommon and are usually quite hard to detect. They’re classified as low-risk.

Women have a higher incidence of stress fractures alongside the pubic area with pain in the adductor, inguinal, and perineal areas.

Bone conditions such as osteoporosis and rheumatoid arthritis are huge enablers as the bone structure is quite sturdy and has natural low chances of developing stress fractures.

Standard noninvasive procedures such as high-velocity, low-amplitude chiropractic manipulation, and stretching of the psoas and piriformis muscles may not suffice. Surgery might be needed for adequate healing and union.

Pelvic stress fractures 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, tenderness are also common.

What to do:

Upon injury identification, stop training 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 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 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.

Conclusion

Upon injury identification, all physical activity must be halted, immediate first-aid R.I.C.E. therapy is advised. More so, you should promptly contact your doctor to set an appointment. In the meantime, immobilize the leg, follow the guide’s dietary advice and acquire over-the-counter symptom relievers if necessary.

Ask your doctor about orthopedic and orthotic devices to speed up the recovery time. Such devices include back supports and braces, foot and ankle supports, cervical collars, knee and elbow braces, hip supports, shoe inserts etc. Custom devices are superior as they’re tailored to your particular specifications.

Identify all extrinsic and intrinsic problems and seek to address them for future injury prevention.

Sources used while conducting our research

 

Sources

  1. Mayo Clinic Staff, Stress fractures: Symptoms and causes,
  2. Physicians Committee, Calcium and Strong Bones,
  3. Ortho Info, OrthoInfo Topic on Stress Fractures,
  4. Wikipedia, Selective androgen receptor modulator,
  5. Bak B |, Andreassen TT., The effect of growth hormone on fracture healing in old rats.,
  6. Stephanie W. Mayer, MD | Patrick W. Joyner, MD | Louis C. Almekinders, MD | Selene G. Parekh, MD, MBA, Stress Fractures of the Foot and Ankle in Athletes,
  7. John Davis, Changing your Stride Frequency,
  8. John Davis, Where Are You Most Likely to Get a Stress Fracture? Research to Help You Catch Potential Stress Fractures Early,
  9. Steve B. Behrens, MD | Matthew E. Deren, MD | Andrew Matson, BA | Paul D. Fadale, MD | Keith O. Monchik, MD, Stress Fractures of the Pelvis and Legs in Athletes,
  10. Mark Casterline, MS, ATC | Shawn Osowski, MS, LAT, ATC | Gary Ulrich, DO, Femoral Stress Fracture,