Stress Fractures

Many of us are familiar with the severe pain that arises from a regular fracture that occurs when we break a bone. These fractures often happen suddenly, like when falling off a playground or being in a motor vehicle accident, and typically require a 4-8 week casting period while the bones set and heal. Stress fractures, however, are a very different type of fracture.

Stress fractures develop when a bone is repetitively overloaded, meaning that the force applied to the bone from regular activity like exercise or walking exceeds the limit that the bone can safely handle, so tiny, hairline cracks start to form.

In the early stages of a stress fracture, there may be a dull ache or niggle, which gradually increases in severity if the stress fracture remains untreated and so continues to worsen over the following weeks or months. This makes stress fractures difficult to pinpoint and diagnose in the early stages, with many people unable to identify the moment or event that their pain started. Instead, patients describe to us an ache starting at the affected fracture site one day out of nowhere, and that the pain is worsened when they try to stand, walk or exercise.

The pain of a stress fracture is typically localised to the area of the bone where the fracture has occurred and may radiate up or down the bone. Stress fractures often occur in the lower limbs because of the impact forces and stress on these bones during physical activity and everyday life. Common sites of stress fractures in the feet and legs include the shin bone (tibia), the long bones of the feet (metatarsals) and the heel bone (calcaneus).

When a bone is repetitively placed under excess pressure and stress over a long period of time, a stress fracture can develop in that area. This may be from:

• Going too hard, too fast in physical activity and overloading areas like the shin bone
• Wearing poor of unsupportive footwear, which places extra strain on certain bones in the feet or legs
• Training on hard surfaces like concrete, meaning the bones are absorbing more forces
• A sudden increase in intensity or duration of high-impact physical activity
• A poor gait pattern or a poor training technique
• Poor foot posture and foot problems like bunions and joint deformities
• Decreased bone strength or density, including from conditions like osteoporosis
• Muscle weakness and imbalances that may alter foot posture and function

The way you recover from a stress fracture does greatly depend on how severe the fracture is, its location, and the symptoms you’re experiencing. If you have nothing more than a dull ache or niggle and choose to manage your stress fracture at home, you can try:

• Stopping any high-impact activities that may have led to the development of the stress fracture
• Avoiding bare feet that may place excess pressure on bones and keep your feet supported with good footwear at all times
• If your foot is red or swollen, you can apply ice to the area for no more than 20 minutes at a time, while keeping your foot elevated.
• Using non-steroidal anti-inflammatories (NSAIDs), where suitable, to help you get some temporary relief from your painful symptoms.

Remember that your actions will play a big role in the outcome of your stress fracture. If you continue to overload the damaged bone, the stress fracture may progress. Keeping the bone offloaded will support its healing and repair.

The dreaded black line

One stress fracture scenario that we observe, particularly in athletes, is where a stress fracture of the shin bone(tibia) that is left untreated progresses to a complete or near-complete fracture in a horizontal line across the bone. This usually occurs halfway down between the knee and ankle. The gap created in the shin bone shows up black on an x-ray, hence the black line. It is ‘dreaded’ because it is more complicated to treat than a standard stress fracture and requires more effort than just giving the bone time to rest and heal while removing the source of the stress. In almost all cases, treatment will involve either removing all pressure from the leg using a moon boot or similar device, or surgically placing a rod through the bone to keep it connected, with the option of using a bone graft to stimulate healing. These ‘hard and fast’ treatment measures are needed as it is difficult for the body to create new bone to fill the gap naturally. 

The dreaded black line often occurs from running and jumping sports, including gymnastics. While the onset of the pain is muted and is often presumed to be shin splints or a mild injury, seeking medical attention is delayed in the hopes that it will heal on its own, during which time the damage can worsen and progress. 

Here at Matt Raden Podiatry, our trusted and experienced podiatrists take stress fractures very seriously, and act promptly to give you the best prognosis. In order to treat stress fractures effectively, we need to identify and address the cause - the repeated stress and pressure to the damaged bone. We’ll work with you to help the fracture heal effectively while helping prevent it from recurring in the future. This may mean: 

• Using good, supportive and cushioning footwear to help reduce the forces and impact on the feet and legs
• Adjusting high-impact activities that are overloading your bones and contributing to fracture development, to those that are low-impact (yet still very powerful)
• Using custom foot orthotics to help with any biomechanical or postural issues that may be contributing to your fracture. This is also one of the ways that we help prevent another stress fracture in the future
• Physical therapy if any muscle weakness or tightness may be contributing to your injury
• A moon boot or air walker if the fracture is severe and needs significant offloading 

A big part of what we do is also education-based. Specifically, helping to teach you about the role that your bone density may be playing in your stress fractures. Exercise, calcium and vitamin D from sunlight form a key part of maintaining a healthy bone density, but some people are prone to weaker bones due to their genetic makeup or medical conditions.