Stress fracture

  • A stress fracture is a reaction to load which if severe may lead to a small bone break or crack in a bone.

  • Stress fractures often arise in the lower limbs due to their weight bearing capacity, including the foot, shin as well as the lumbar spine.

Causes

  • Stress fractures generally occur as a result of excessive force and overload through abnormal loading.

  • This is more common through sports that involve high impact loading- such as running, gymnastics and basketball. Conversely, sports that include high repetitive loading such cricket and volleyball can stress certain structures such as the lumbar spine.

  • When the body has been excessively loaded, the muscles can no longer take the required force, and therefore transfer of the load goes into the bones.


  • Alternatively, some instances other than overload can cause stress fractures, including:

  • Unaccustomed loading through unfamiliar surfaces that can be more ‘unforgiving’- such as concrete and hard surfaces.

  • Changes in shoe type (either too flexible or too rigid)

  • Rapid weight loss, low bone density, nutritional implications.

  • Stress fractures are more likely to occur when abnormal bone is loaded in instances such as osteoporosis, osteopenia etc.

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Signs & Symptoms

When it comes to a stress fracture injury, pain is often progressive:


  • o  Early stages: pain after activity

  • o  Middle stages: pain with activity and walking

  • o  Later stages: pain with all of the above + rest

The pain behaviour may start initially as more of a dull ache, which then will turn into more persistent pain if not managed.


  • As stress fractures worsen- the pain may become more focal.

  • In some areas, swelling may begin to form as a result of the inflammatory process taking place in the area.

  • If it affects your lower limbs, in particularly feet, it may be difficult to walk and weight-bear through the affected area.

  • Loss of range of motion and movement

  • Pain with prolonged periods of sitting and/or standing.

Differential Diagnosis

  • Soft tissue injury (often chronic/longer term)

  • Infection

  • Nerve related injury (ie neuromona)

  • Arthritic changes

  • Bone tumour

How to Manage

  • The primary management for stress fractures involve relative rest and ‘de-loading’ from aggravating factors. Your physiotherapist will discuss this in depth with you and formulate an in-depth management plan. This will enable the inflammatory component of the injury settle down and bone healing to commence.

  • In some instances moonboots/crutches can be required to offload the affected area.

  • Rehabilitation of the area- from the objective assessment, your physiotherapist may have identified areas that may have played a contributing factor to the onset of the stress fracture. This can include muscle weakness, motor control deficits, range of motion issues etc.

References

PROmotion Assessment and Outcomes Measures

A thorough subjective and objective assessment will be undertaken. And may detail;

  • Aggravating and relieving factors

  • What your recent exercise/activity regime has included (to gain an understanding of loading).

  • Recent changes/other factors (weight loss/nutrition/sleep quality/training surfaces/footwear etc.)

  • Dependent on the area and proposed severity of the stress fracture, imaging can be a valuable tool to confirm or rule out stress fractures given the long term management required if confirmed. Your physiotherapist will recommend what type of imaging may be required as this can vary.