Stress fractures are tiny cracks in the bone which are normally caused by overuse. Whereas conventional fractures tend to be the result of a single traumatic injury and often result in a complete break in the bone, stress fractures may occur over a period of time due to repeated stresses on the bone. A stress fracture may be an incomplete break of the bone (a crack). This type of fracture does not normally move out of position (become displaced).
Stress fracture of the foot and ankle occur most often in sports that involve running or jumping, or in people who have weak bones due to a condition such as osteoporosis. The foot and ankle are the parts of the body most commonly affected by stress fractures because we use them all of the time when we move around.
Causes of stress fractures
There are two primary causes of stress fractures:
- Repetitive movements resulting in overuse of the foot and ankle. We often see this type of fracture in people who participate in high impact sports such as football, running and tennis.
- People with a condition that causes their bones to become weak (such as osteoporosis) may develop stress fractures from even low-impact activities such as walking. This is because the bones lack sufficient strength to withstand even normal impact forces.
Symptoms of stress fractures
The symptom most commonly associated with stress fractures is pain particularly in the site of the break or crack. The pain will normally intensify when you do high impact activities and lessen when you rest. If you suspect you may have a stress fracture it is vital to stop doing anything that causes pain, as continuing to use a cracked or fractured bone could worsen the fracture and lead to continuous or increasing pain. The affected area may also be swollen and tender to touch.
Who is at risk?
You may be particularly at risk of stress fractures of the foot and ankle if you participate in certain types of sport that involve running and jumping. The risk of injury rises if you rapidly increase the amount of exercise you are doing – for example if you go from running twice a week to running every day. If you are training for an event or you want to up the amount of exercise you are doing, it is best to increase gradually to avoid the risk of stress fractures.
You may also be at risk if you have a condition that causes bone weakness. This type of stress fracture is often referred to as an insufficiency fracture as the bone has insufficient density or strength to withstand normal forces. Certain types of foot deformities, such as bunions, can also cause stress fractures as they change the foot’s load bearing capacity. In the case of bunions, the big toe may be pushed out of alignment so it cannot carry weight as it would normally do, putting increased pressure on other toes. Wearing shoes that do not support the foot properly or that put pressure on the toes can also increase the risk of stress fractures.
Diagnosis of stress fractures
You will normally be given a physical examination and an X-ray to diagnose a suspected stress fracture. However, not all stress fractures can be detected with an X-ray as the bone can regrow over the damaged area. This may show up as calcification. In some cases, you may need a bone scan or MRI to ascertain a stress fracture. Any bone of the foot, ankle or lower leg can be affected but the most common stress fractures occur in the heel bone, metatarsals which connect the toes to the midfoot, the navicular which is near to the ankle and the bones of the ankle joint.
Treatment of stress fractures
The treatment for many types of stress fracture is to rest and wear protective footwear to allow the bone to heal by itself. You will normally need to avoid any kind of high impact activity for around six weeks. The PRICE method (protect, rest, ice, compression, elevation) can help to relieve pain and swelling and you can also take painkillers.
You may need to perform PRICE for six to eight weeks before symptoms start to settle. It is essential during this time, to seek the advice from an orthopaedic specialist who will assess and correct risk factors that may be of benefit to minimise the risk of recurrence.
In some cases, your orthopaedic surgeon may recommend wearing a re-enforced boot or shoe to support your foot or ankle while it heals. Most fractures heal within four to six weeks but some bones take longer than others.
It is important that any return to activity is gradual and you should begin with low impact activities such as swimming or cycling. Wearing comfortable, supportive shoes without a raised heel can support your recovery. Surgery is normally only considered for stress fractures if other, non-surgical approaches have proved ineffectual.
Prevention of stress fractures
There are several steps you can take to reduce your risk of developing stress fractures of the foot and ankle:
- Increase your exercise regime gradually – around 10% a week as a guide – rather than making any sudden changes or switching your sporting activity.
- Alternate between different sporting activities – such as jogging, swimming or cycling – to avoid putting too much pressure on any single part of your body.
- Wear the right footwear for the sport you are doing. Avoid high heels or shoes that are old and stiff.
- Avoid smoking as nicotine inhibits bone healing.
- Ensure you have sufficient calcium and daily Vitamin D to support bone health.
If you suspect you may have sustained a stress fracture it is important to get a proper diagnosis particularly if the pain has continued for more than a few days or has not subsided even with rest.
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