How Stressed is Your Stress Fracture?

May 19, 2010
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When a Podiatrist diagnosis a patient with a stress fracture, patients only hear the “fracture” part of the diagnosis. However, the “stress” part of that statement is extremely important and delineates a stress fracture from other types of fracture in its mechanism of injury and prognosis for recovery.

Stress fractures differ from other fractures in that they are not caused by acute trauma, but rather repetitive trauma and stress to the bone. Therefore, patients suffering from a stress fracture can relay no history of injury to the area. They are more commonly seen in athletes and especially runners who are constantly demanding their bodies to perform. Typically, stress fractures start as a small break in the outer (cortex) portion of the bone leading to inflammation within the bone and pain for the patient. If a stress fracture is not detected in its early stages and the patient continues on with normal activity, the size of the break can increase resulting in fracture completely across the bone. Although the most likely location for stress fractures in the foot are the 2nd and 3rd metatarsals (long bones), they can be found in the leg as well, just less frequently.

Signs to look for when you are suspect for a stress fracture include pain that is increased with activity and that may or may not be accompanied by swelling. The pain will be progressive, meaning that with each day it seems to increase, and it will become painful to the point where you will begin to cut back on your athletic and normal daily activity. As mentioned before, you may not remember injuring yourself, as stress fractures don’t present themselves in association with acute trauma, thus symptoms, rather than physical presentation becomes important. If a stress fracture becomes a possibility in the back of your mind, it’s best to withdrawal from activity and seek out your local Podiatrist.

After ruling out other possibilities for the cause of your recent pain, your Podiatrist will take x-rays to evaluate the bones of the foot. This is where the diagnosis for a stress fracture becomes tricky: a stress fractures’ break in the cortex of the bone may not appear on x-ray until 10 to 14 days after the initial break. In the early stages there is not enough bone resorption (washing away of bone in the area of the fracture) to be picked up by plain x-ray. Therefore, despite what the x-ray may or may not show, the Podiatrists index of suspicion for a stress fracture, combined with your clinical symptoms and history, will likely be the basis of your diagnosis. In some cases you may be given a prescription for an MRI or CT scan which can look closer at the bone and be able to pick up a stress fracture from day one, however, this is not always necessary.

The treatment of choice in patients with stress fractures is rest and immobilization, meaning you will likely need to wear a CAM (controlled ankle motion) walker in addition to discontinuing athletic activity. A CAM is a removable boot that should be worn as much as possible, but can be removed at bedtime for comfort. It is used initially because it decreases motion and stress on the foot while allowing patients to walk while wearing it, without the use of crutches. When patients are compliant and wear the CAM as instructed, it is usually sufficient enough to allow healing of the bone. More aggressive forms of immobilization such as casting can be utilized, but are reserved for patients who don’t comply with the initial treatment attempts using a CAM. Keep in mind, the longer you continue normal activity on the stress fracture the higher your risk of breaking the bone completely, which inevitably leads to a longer recovery time. Therefore, it is in your best interest to limit activity and immobilize the foot!

Your clinical symptoms will indicate to your Podiatrist when appropriate healing has taken place and transition back to a sneaker with a slow increase in your activity is safe. However, you should plan on about 4-6 weeks of immobilization, as that is how long it will take for your pain to decrease and for the defect in the bone to fill in with new bone and fibrous tissue. Certainly you can take ibuprofen for pain as needed, as well as apply ice to the area in attempt to keep the swelling down, but rest and immobilization are key!

Unfortunately, there isn’t much you can to do to prevent a stress fracture, but there are things you can do to cut down your risk. If you already have a workout routine and you plan to increase your level of activity or distance running, do so slowly. Changes and increases in activity often bring on a stress fracture, as your body is not adequately prepared. If you don’t have a consistent routine, but want to get moving, start slowly and with short distances, building up to your ultimate goal. In both situations your bones need a chance to adjust to the increased stresses and if given adequate time to do so, you decrease your risk of injury.

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