Stress Fractures of Bone

A stress fracture is a relatively common happening in those who pursue sport and in military personnel who march and train vigorously. Stress fractures are mostly a feature of the lower limb bones but can be present in other areas of the body. The foot metatarsals, the fibula and the tibia show the greatest frequency of this type of injury, with decreasing likelihood further up the leg. The application of repetitive strains to the bone at a level insufficient to cause immediate fracture can do so over time as the activity proceeds.

Increasing levels of pain reported in the part during activities or exercise is the typical pattern of presentation, with a recent upturn in the intensity or frequency of training often reported. Treatment is uncomplicated and involves reducing the levels of activity and in some cases by immobilisation. Most heal without problems but there are some fractures which are much more likely to suffer from non-union and for which surgical intervention may be required. With orthopaedic surgery and formal immobilisation these fractures will eventually heal.

Stress fractures happen when bone is repetitively loaded and this type of fracture is not usually the result of any particular traumatic occurrence. On being stressed with repeated tension or compression loads bone adapts by remodelling its structure and repairing the stress induced damage. If more of the microscopic damage to the bone occurs than can be repaired by the remodelling process then a fracture may occur. Significant increase in the person’s recent physical training is a common theme.

The risk factors include an increase in the frequency of the applied stresses, an increase in the intensity of those stresses or a change in the area to which the stresses are being applied. If the surface area of the bone to which the stress is applied is reduced then the absolute stresses through those bony areas increase, or the load may be absolutely increased. Running and jumping are examples of more high risk activities, as may be changes in performance technique or in the nature of the surface exercised upon.

Many of the mechanical factors are presumed to be the important issues in stress fracture but there may be many others including changes in diet with low calorie intake, reduced bone density or osteoporosis, muscle weakness, being female and perhaps a series of other factors. Female runners have a particularly high incidence of this kind of injury as they may have restricted calorie intake, changes in their menstrual cycle and reduction in density of bone, typical in sports people who have a low bodily weight like a ballet dancer.

A stress fracture typically comes on without much warning and often without severe symptoms, during an activity of repeated limb loading and without trauma. Resting will usually abolish the pain which will re-appear on performance of the weight bearing activity again. Tenderness and swelling may be apparent locally around the fracture site but it may be two to four weeks before a fracture can be discernible on x-ray. Bone scanning may detect fractures much earlier, within 72 hours of the incident, but are less clear as to the exact cause.

Stress fractures are mostly treated with conservative methods, the most effective and the most straightforward being to limit the aggravating functional activity responsible for a period of four to six weeks. If weight bearing causes significant pain then it can be restricted by using elbow crutches with a rigid walking boot, brace or below knee plaster cast. Studies have been done on wearing corrective orthoses in shoes and there is some evidence they can reduce the incidence of stress fractures, with some potential benefits from shock absorbing insoles

Most commonly these fractures heal well and without complications but there can be problems with non-union in some particular areas. The base areas of the second and the fifth foot metatarsals are areas which can suffer from poor healing and which should be followed up for more prolonged immobilisation or surgical intervention if they do not heal.

Jonathan Blood Smyth, editor of the Physiotherapy Site, writes articles about Physiotherapists, physiotherapy, physiotherapists in London, back pain, orthopaedic conditions, neck pain and injury management. Jonathan is a superintendant physiotherapist at an NHS hospital in the South-West of the UK

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