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Injury/Pain

The Complete Guide to Stress Fractures

Overview

A stress fracture is a tiny crack in a weight-bearing bone. It can develop in any part of the body, but the American Academy of Orthopaedic Surgeons says that more than 50 percent of all stress fractures occur in the lower leg or feet.

sergiok / flickr

If you're starting an exercise program or moving to an unfamiliar and physically demanding sport or physical activity, you’re at risk for doing too much too soon, a situation that can lead to a stress fracture. Often difficult to diagnose, stress fractures may also be associated with hormonal imbalances, nutritional deficiencies, and bone disorders.

How Stress Fractures Happen

A stress fracture is an overuse injury that begins when supporting muscles become fatigued and can't absorb the continuing stress of running, training, or competition. Eventually, the stress is transferred to bones, which develop small cracks.

The list of possible causes is long and includes factors such as abruptly increasing training frequency, intensity, or duration, poor conditioning, incorrect technique, lack of flexibility, and muscle-tendon imbalance. Poor shoe construction or excessive wear could place too much stress on muscle groups or bones. Anatomical problems such as flat feet, bowed legs, or knock knees might also eventually lead to a stress fracture. The injury simply depends on which bones are the subject of repetitive forces.

Here are some sport-specific examples of how a stress fracture might happen:

  • A tennis player switches from a soft to a hard surface
  • A runner uses shoes that are worn or less flexible
  • A basketball player gets increased playing time

Stress Fractures by the Numbers

15.6
Percentage of stress fractures that account for all sports injuries

39
Percentage of female athletes with irregular menstruation that develop stress fractures

50
Percentage of all stress fractures that occur in the lower legs or feet

Who’s At Risk for Stress Fractures

Track and field athletes are particularly susceptible, but basketball players, gymnasts, military personnel, and dancers are also in a high-risk group.

Female athletes with abnormal or absent periods might have weakened bones, which puts them at risk, as do flat feet, high arches, bow legs, or knock knees in other athletes.

In addition to athletes who place stress on lower body muscles and bones, those who throw and those who play racquet sports can sustain fractures of the upper and lower arm. Adolescent throwers can place too much stress on bones in the shoulder and upper back area. Cyclists, weight lifters, soccer players, and even fencers are not immune.

Symptoms

  • Pain at the site or tenderness to touch
  • Pain that is noticeable during exercise, but that decreases or disappears with rest
  • Increasingly noticeable pain during workouts, perhaps earlier in a workout
  • Pain even when not exercising

Initial Treatment

  • Apply ice packs for 15-20 minutes at a time, 3-4 times a day.
  • Rest. Avoid the activity that may have caused the injury.
  • Acetaminophen may relieve pain, but there is limited evidence showing that pain relievers such as aspirin, ibuprofen, and naproxen can interfere with bone healing.
  • Immobilization may be necessary, but only if your doctor recommends it.

Comeback Strategy

It could take anywhere from a month to three months for a stress fracture to heal. Give it time. Coming back too soon will just create more problems than you had with the initial injury.

In the meantime:

  • Cross-train with activities that do not place stress on the affected bone, such as swimming or cycling.
  • Increase training intensity gradually over a period of weeks, introducing hills, interval training, jumping exercises, and high-impact activities only after a period of graduated training
  • Begin training on surfaces that absorb shock, then progress to synthetic, grass, sand, or uneven surfaces

Prehab

Incorporate these injury prevention exercises into your routine.

1. Toe Spread

  • Spread your toes apart to activate the muscles.
  • Perform as many reps as you can until fatigued—up to three minutes, twice a day.

2. Toe Pick-Ups

  • Using only your toes, pick up marbles of scrunch up a towel that is lying on the floor.
  • Perform until fatigued, twice a day.

3. Tennis Ball Roll-Out

  • Sitting, place a tennis ball, golf ball or baseball under the arch of your foot.
  • Apply light pressure as you roll the ball along the bottom of your foot.
  • You may find some tender spots; work those spots as you can tolerate it.
  • Perform for 3-5 minutes, twice daily.

How to Avoid the Injury

  • Wear lightweight, activity-specific athletic shoes.
  • Replace running shoes every 300-500 miles.
  • Periodically vary your training surface.

Movement Prep

Incorporate these dynamic exercises into your warm-up, or movement prep, routine. Go about 10 yards for the hand walks and do 10 reps per leg for the other stretches.

Together, these movements stretch the muscles along the back part of your leg, improve balance, and help stabilize your hips. By controlling your hip and femur (upper thigh bone) more effectively, you'll be better able to control your lower leg from the top down—and less likely to sustain lower body injuries.

  1. Handwalks
  2. Inverted Calf Stretch
  3. Inverted Hamstring Stretch

Jim Brown, Ph.D. has written 14 books on health, medicine, and sports. His articles have appeared in the Washington Post, New York Post, Sports Illustrated for Women and Better Homes & Gardens. He also writes for the Duke School of Medicine, UCLA School of Medicine, Cleveland Clinic and Steadman-Hawkins Research Foundation.


Tags: Soreness, Injury, Rehabilitation, Shin Pain, Knee, Pain, Calves, Prehab, Lower Body, Foot, Rest, Ankle, Injury Prevention

References

  1. Sue Falsone PT, MS, SCS, ATC, CSCS
, director of performance physical therapy at Athletes' Performance
  2. American Orthopaedic Society for Sports Medicine
  3. American Academy of Orthopaedic Surgeons
  4. American College of Sports Medicine

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