Last week I received a text message from a friend asking me to help with his foot problem. He began to describe his symptoms; pain on the top of the foot and behind his toes, swelling, tenderness with pressure, and pain worsening while weight bearing. He continued to tell me that he was at Disneyland last week with his family, and he walked more than 10 miles a day while wearing sandals the entire trip. I told him that he likely had a stress fracture. While stress fractures are not the most difficult diagnosis to make, they can be nagging, painful injuries that persist for a long period of time and interfere with your everyday activities.
So, What is a Stress Fracture?
A stress fracture is a tiny crack in a bone that occurs when it is subject to repeated stress over time, rather than the result of a single injury. Over time, low level impact from even every day activities can cause a bone to develop these painful injuries. We often describe stress fractures as “overuse injuries.” This can mean overuse from increased intensity of a physical activity, such as overtraining in athletes preparing for an event or competition. It can also mean overuse from increased repetition or volume of a normal activity, such as walking, as in my friend’s case. Stress fractures most commonly occur in the bones of the feet, ankles, and lower legs due to the weight bearing nature of these bones. Anyone can develop a stress fracture under the right conditions, but they most commonly occur in athletes who are overtraining or people who undergo a sudden increase in activity level.
How does a Stress Fracture Develop?
Our bones are constantly remodeling and repairing themselves, just like any other tissue in the body. When bone is subject to conditions where it is stressed and fatigued beyond its ability to remodel itself, a stress fracture can develop. Weight bearing activities and exercise are essential for maintaining normal bone density and aiding in bony remodeling. These activities stimulate the bone cells to resorb old bone and build new bone. To illustrate, while in space, astronauts lose bone density due to the lack of stimulus from normal weight bearing. Here on earth, problems occur when the bone’s capacity to heal itself is outstripped by bone damage caused from overstressing, leading to its eventual weakening and subsequently, a stress fracture.
What are the Symptoms of a Stress Fracture?
Deep aching pain which can either be focal or difficult to pinpoint
A constant dull pain that improves when resting but returns when weight bearing
Tenderness to touch or pressure
Pain that worsens gradually over time
Pain that appears shortly after adding a new activity or change in routine
How Do We Diagnose a Stress Fracture?
The first thing to know about diagnosing a stress fracture is that it is imperative you give your doctor a thorough history. Details pertaining to recent changes in activity, exercise routines, shoe gear, jobs and/or job requirements, and even changes in terrain that you’ve been on recently are important. Something I see quite often in my own practice is patients developing stress fractures after vacations where they were doing a lot of barefoot walking on soft, sandy beaches or hiking on uneven terrain. After obtaining a history, your physician will perform a physical exam to localize the pain to the affected bone. Some physicians will place a tuning fork directly over the bone, as the vibration can reproduce the painful symptoms without having to apply much pressure. X-rays should always be ordered to rule out a more serious injury, such as a displaced fracture. We often do not see stress fractures on initial x-ray exams because the cracks in the bone are so small. It can take 2 or 3 weeks for a stress fracture to appear on x-rays, so repeat images should be taken at your follow-up appointment. An MRI can also be ordered which will show swelling in the bone and can help visualize the fracture line. However, this is not routinely done as it is unlikely to change your treatment plan.
How Do We Treat a Stress Fracture?
Immobilization in a boot or cast.
Rest! It can take 4-8 weeks (or longer) for a stress fracture to heal with treatment
Gradual transition out of the boot or cast into supportive shoes after healing
Incremental return to normal physical activity
How Can a Stress Fracture be Avoided?
Gradually increase the intensity of exercise and activity
Wear proper supportive shoe gear
Use shoe inserts or orthotics to promote better biomechanics and reduce abnormal stress on bones
Proper nutrition is crucial for bone health! Adequate amounts of Vitamin D and calcium are necessary for healthy bone turnover.
If you think you have a stress fracture, give us a call at Foot and Ankle Associates of North Texas! We can get your feet back into the game!