Stress Fractures – What are they and what can be done?

Stress Fractures 

The year is a quarter of the way through, and I have seen an increase in the number of stress fractures in adolescent children. The population I have been seeing these occur in is 13-17year old male athletes participating in cricket, rugby and rowing. Now I’m not drawing any conclusions other than that is what is presenting to me, but I still think it is worth noting and pointing out. One thing they all have in common is over-training and core/ trunk weakness!

Let’s start with what is a stress fracture? 

A stress fracture is a “small crack in the bone” that can occur from repetitive trauma, namely when the muscles are fatigued and unable to absorb the load, they transfer the impact to the bones, resulting in microfractures. Stress fractures are overuse injuries. Bones do remodel and it is true we do need load/ force to get stronger and adapt but when the damage is greater than the remodelling, we get stress fractures, which without proper management can worsen over time. Most stress fractures occur in weight bearing bones of the body, so the lower back and foot, with over 50% of stress fractures being reported in the lower limb. 

Symptoms 

• One of the most common symptoms reported is pain with activity which eases with rest.
• Localised pain and swelling over the bone. I must note this isn’t always the case sometimes pain can be poorly localised particularly with early onset lower back stress reactions. 
• Pain may be sharp, dull, or intermittent. 
• Night pain may be experienced 
• Pain when weight bearing. 

Risk factors 

• Certain sports – i.e., Cricket (repetitive hyperextension), gymnastics, basketball, rowing 
• Increased activity – most junior sports now limit the amount of activity junior athletes can do, but you can’t stop individuals training. 
• Sex – Women especially those with abnormal menstrual cycles 
• Weakened bones – e.g., Osteoporosis 
• Previous stress fractures – previous injury can increase the risk of future injury 
• Diet – eating disorders have been shown to increase the risk of stress fractures, lack of Vitamin D and calcium have been shown to increase the risk. 

Diagnosis

How do you diagnose a stress fracture? My first advice is to see a physiotherapist or a GP. If a patient/ client presents to myself, I will always include a GP in the management pathway and insist the patient (especially if adolescent) to see a Sports Medicine Doctor. 

In my assessment I will look at: 

History 

• Insidious onset with or without trauma. Sometimes an acute episode can unlock/ uncover the issue that has been gradually building up 
• A history of significant volume of a specific exercise 
• Initially symptoms may only be during exercise, they will gradually affect the patient in daily life if left untreated

Examination 

• Local tenderness over the suspected site, but like I mentioned not always
• May be some soft tissue swelling. Soft tissue tenderness may suggest muscle injury, early onset stress reaction, remember this is overload and the muscles can no longer cope with the load of the activity, hence it is transferred to the bone

Testing

• Clinicians may refer for X-Ray, CT or MRI to confirm a diagnosis 
• Blood tests/ hormone testing 
• Special tests which can include; Quadrant testing, single leg hop test, compressive load testing, the activity which causes pain e.g. hyperextension
• Palpation 

Testing should only be undertaken by trained clinicians and a good general rule is if you suspect – INVESTIGATE!

Treatment 

Treatment is a loaded question and could probably go on for pages and pages, because it depends on the site of the stress fracture, the individual, the sport, the activity, the stage of the injury and much more. But lets be really general!

• Load management – which may include a period of rest 
• Modified weight bearing – like I said depends on the injury 
• NSAIDS and pain relief 
• Core/ Trunk strengthening – more relevant for lower back stress fractures but this can be applied to all lower limb stress fractures and for that matter upper limb as well.
• Technique correction 
• Muscular endurance 
• Muscular strength and coordination 
• Dietary review 
• Athletic coaching 
• Proper footwear
  

It is important to note that this is in general terms speaking about stress fractures, there are of course different definitions which are better used for more specific articles/ journals. 

These include: 

• Stress fractures 
• Fatigue fractures 
• Insufficiency fractures 

This may be a topic for another time! But in this article, it’s let’s keep it simple. 

If you believe you have a stress fracture or are a clinician managing a patient with a stress fracture constant monitoring is required to ensure the stress fracture does not worsen and cause the patient issues further down the track. Stress fractures are one of those injuries that rest is indicated because exercising through the pain isn’t going to fix it and therapist involvement is key.

Slow and steady wins the race!