Stress fractures are normally the result of repetitive loads on bones, which on a microscopic level interrupts its normal healing and formation. It is an over-ruse injury.

There are 2 types of Stress Fractures: .

Fatigue – Our Focus
Where there is abnormally high levels of stress to normal bone. For example, marathon runners are at higher risks of developing lower limb stress fractures due to the repetitive pounding/load.

Insufficiency
Where stress is normal, but the bone is abnormal. For example, those with osteoporosis, Paget’s disease and osteomalacia, the bone may suffer from pre-existing poor healing or structure.

Who does it Happen to?

  • Stress fractures account for 10-20% of all sport injuries
  • 30% in running sports

Places where it occurs?
Over 90% of stress fractures are in the lower limb. Research indicates the tibia (shin bone) is the most common area, this is followed by navicular, metatarsals, fibula. Other areas also include the calcaneus (heel bone), femur (leg bone), sesamoids (bones under big toe) and pelvis. While uncommon in the upper body, stress fractures may occur in the humerus (arm bone), scapula (shoulder blade), clavicle (collar bone), ribs and vertebral spine, particularly in throwing sports.

Risk Factors

Intrinsic (Factors that can’t be modified)

  • Sex: Female athletes are at a 2-3x risk, increasing with disrupted menstrual cycle (amenorrhea), low bone mineral density, low BMI, eating disorders, osteoporosis and late menarche (>15 years old).
  • Bone Geometry: Leg length discrepancy, abnormal bone length and shape.
  • Limb alignment: Increased knee/hip valgus, external rotation, rearfoot eversion, forefoot pronation, pes planus (flat foot), rigid cavus (excessively high arch)
  • Age: Higher incidence in <20 years and >40 years old. Post-menopausal in females.
  • Previous history: 5x increased risk of reoccurrence

Extrinsic (Factors that we can change)

  • Extrinsic (Factors that we can change)
  • Type of activity/exercise (eg basketball, running, army training, gymnastics)
  • New shoe wear
  • other factors include biomechanics (poor running style), hard surfaces (starting road or treadmill running) and body weight.

Less commonly but still important to note:

  • Recent surgery (screw fixation, joint replacement)
  • Certain therapies (radiation, corticosteroid),
  • Systemic body conditions (osteoporosis, Rhematoid arthritis, Paget’s disease)
  • Lifestyle choices; smoking, caffeine intake, dairy intake (one serving less than average), high alcohol consumption
  • Body composition; below average calf size, bone mineral density and BMI.

How do they Present – What to look out for!?

  • A sudden increase in pain, along with activity and less recovery than norm
  • Physical activity tends to aggravate and worsen the symptoms, resting reduces the discomfort
  • Specific/focused pain that is tender to touch
  • Sometimes can refer pain up/down the length of the bone

The best way to diagnose stress fractures
Up to 85% of stress fractures are undetected on initial scans (1st week), up to 50% on 2nd/3rd week on follow up. From when symptoms start (ie when it starts hurting), a visible fracture (break) may not show up on scans till the 3rd week.

  • MRI is considered the gold standard and fractures often show up first here.
  • Computerized Tomography (CT scans) are slightly more effective than X-rays. However the high dose of radiation in CT scans, often outweighs its benefit compared to X-ray, especially in children and teens.
  • A bone scan or ultrasonography may also be used

Managing the fracture
In our experience, headaches caused by neck issues respond extremely well to manual therapy, almost providing immediate relief. Even if physio initially aggravates your headache, at the very least, it allows us to determine that the headache is coming from the neck.

  • Complete rest or de-loading fracture site (for example: wearing a boot, using crutches or wearing a sling)
  • A tailored progressive exercise program
  • Addressing biomechanics, limb alignment issues, lifestyle choices and adjusting exercise habits and training programs.
  • Foot orthoses may be prescribed
  • Modalities such as shockwave therapy have some research evidence, in assist with healing process.
  • Dietary supplementation

Timeline/prognosis

  • Approximately 6 weeks of protective management is necessary, followed by around 6 weeks of progressive increase in activity.
  • High risk areas such as 5th metatarsal, femoral neck and anterior tibia, have a risk of not healing together and surgery may be considered.
  • Low risk zones such as fibula, femoral shaft (middle) and calcaneus, heal with standard conservative treatment, less time is required to return to activities.