Stress fractures are a common overuse injury in athletes and the sporting population. They are defined as a partial or complete bone fracture that results from repeated application of a stress lower than the stress required in order to fracture the bone in a single loading.

They are frequently seen in runners, sports where there is a lot of running, such as football and rugby, dancers and in military recruits.

Stress fractures can occur anywhere in the body but the weight-bearing bones of the lower leg and foot are particularly common areas for stress fractures. This is due to the repetitive forces they must absorb during activities like walking, running, and jumping. Other common areas for stress fractures and stress reactions include the lower back (pars stress fracture or spondylolysis), pelvis (neck of femur, sacral and pubic ramus stress fractures) and ribs in rowers.

Causes

The most common reason people get stress fractures is a sudden increase in physical activity. This can be due to an increase in the frequency, volume or intensity of activity. Sometimes there are coexisting problems affecting bone health such as osteoporosis, vitamin D deficiency or an inadequate calorie intake. This may be due to a condition known as relative energy deficiency in sport (RED-S). Research shows that female athletes are more prone to stress fractures. This may be related to RED-S or the female athlete triad. RED-S can affect both female and male athletes. Strength and conditioning deficits, training errors, and biomechanical factors can also contribute to stress fractures.

Common symptoms

• Pain during exercise which reduces when resting
• Pain that occurs and intensifies during daily activities such as walking
• Tenderness to touch at the site of the fracture

Diagnosis

If you suspect you have a stress fracture, early diagnosis is key. Your OrthTeam consultant will take a history to find out more about your symptoms and to identify any relevant risk factors for the injury. They will examine you and will usually refer you for an MRI to help confirm the diagnosis. They may also do blood tests to check your vitamin D and calcium levels, refer you for a DEXA scan to check your bone mineral density and where relevant, other tests to check for relative energy deficiency in sport (RED-S).

Treatment

Treatment will depend on the location of the stress fracture and its severity. The majority of stress fractures are treated non-surgically. Your consultant will advise rest from provocative activity. Usually this will be for at least six to eight weeks. If the fracture is in your leg or foot, it may be recommended to use crutches to keep weight off until the pain subsides. Stress fractures in the foot, ankle and lower leg may require you to use a removable boot for six weeks or more. Other management considerations include education around progression of training loads, vitamin D supplementation, advice regarding calcium intake in the diet, sports nutrition input to optimise calorie intake to match calorie expenditure, strength and conditioning to help absorb impact loads, to prevent further stress fractures and to optimise bone mineral density.

You will usually be referred to a physiotherapist to help oversee a gradual return to sporting activity once the fracture has healed and to advise on appropriate strength and conditioning to reduce the risk of recurrence. For fractures around the foot, you may be referred for podiatry input for consideration of orthotic prescription. Sometimes additional medical treatment with drugs such as teriparatide are used to help strengthen the bones or to assist with fracture healing, but only in special circumstances. In certain high risk sites including the navicular and the fifth metatarsal bones in the foot and with the neck of femur, surgery may be needed.

Book an appointment with Dr John Rogers or Dr Jim Kerss by calling 0161 447 6888.