Stress Fracture

Definition

A stress [2] fracture is a tiny crack in the bone [3] that is not caused by a blow to the bone [3], but is typically caused by repeated stress [2] or overuse. Most stress [2] fractures occur in the lower leg and foot [4], but they can also occur in the hip and other areas. Most stress [2] fractures can heal spontaneously. However, some may progress to complete fractures, or may require surgery.

Stress Fractures of the Tibia and Fibula

Nucleus factsheet image

Causes

A stress [2] fracture develops from continued physical stress [2] on the bone [3] rather than from a single [5] blow to the bone [3]. It can be caused by:

Increasing the amount or intensity of an activity too quickly (most common)
Switching to a different playing or running surface
Wearing improper or old shoes

Stress fractures can be made worse by continued physical stress [2]. Smoking can also make stress [2] fractures worse because it interferes with bone [3] healing.

Risk Factors

A risk factor is something that increases your chance of getting a disease or condition. Risk factors for a stress [2] fracture include:

Sex: female
Certain sports, especially involving jumping or running:
- Tennis
- Track, especially distance running
- Gymnastics
- Dance
- Basketball
Amenorrhea [6] : not menstruating (women only)
Reduced bone [3] thickness or density
Poor muscle [3] strength or flexibility
Overweight or underweight
Poor physical condition

Symptoms

Symptoms include:

Localized pain [7] on the bone [3]
Pain when pressure is applied directly over the fracture and the area immediately around it
Pain when putting stress [2] on the affected leg
Swelling and warmth at the site of the injury

Diagnosis

The doctor will ask about your symptoms and medical [8] history, and examine the injured area for localized pain [7] and swelling.

Tests may include:

X-ray [9] —a test that uses radiation to take pictures of structures inside the body, especially bone [3]. Stress fractures are microscopic and usually not detectable on an x-ray until at least two weeks after symptoms begin.
MRI scan [10] —a test that uses magnetic and radio waves to show swelling and inflammation inside the bone [3]
Bone scan [11] —a test that uses a short-lived radioactive substance to show a stress [2] fracture

Treatment

Treatment includes:

Medications

Nonsteroidal anti-inflammatory drugs (NSAIDs) can relieve pain [7], but controversy exists surrounding their use for stress [2] fractures. It is possible that NSAIDs adversely affect stress [2] fracture healing.

Rest

Rest is the most important thing you can do for a stress [2] fracture. This includes avoiding the activity that caused the fracture and any other activities that cause pain [7]. Rest time required is typically at least 6-8 weeks.

Crutches or a Cane

You may need crutches or a walking cane to keep pressure off the leg, but most people do not.

Activity

Talk with your doctor about when you can restart activity and how to progress with the amount and type of activity.

A common progression is as follows: Begin with non-weight-bearing activities, such as swimming or bicycling. Next, you can do weight-bearing, nonimpact exercise [12], such as a stair machine. Gradually, you will be able to add low-impact activity, starting with walking. Once you can do fast-paced walking with no pain [7], you can start higher impact activity, such as light jogging. This gradual progression continues until you have reached your preinjury level of activity. Do not return to full activity until you no longer feel tenderness of the bone [3].

Prevention

To reduce your chance of getting a stress [2] fracture:

Wear proper footwear.
Run on a softer surface, such as grass, dirt, or certain outdoor tracks.
Gradually increase the amount and intensity of an activity.
Do not overdo any activity.
Eat a healthful diet, including foods rich in calcium [13] and vitamin D [14] .
Avoid smoking.

RESOURCES:

American Academy of Orthopaedic Surgeons
http://www.aaos.org [15]

American Orthopaedic Society for Sports Medicine
http://www.aossm.org [16]

American Podiatric Medical Association
http://www.apma.org [17]

CANADIAN RESOURCES:

Canadian Orthopaedic Association
http://www.coa-aco.org/ [18]

Canadian Orthopaedic Foundation
http://www.canorth.org/ [19]

References:

American Academy of Orthopaedic Surgeons website. Available at: http://www.aaos.org [15] . Accessed October 12, 2005.

Marx RG, Saint-Phard D, Callahan LR, Chu J, Hannafin JA. Stress fracture sites related to underlying bone [3] health [20] in athletic females. Clin J Sport Med . 2001;11:73-76.

Mayo Foundation for Medical Education and Research website. Available at: http://www.mayo.edu/ [21] . Accessed October 12, 2005.

Sanderlin BW, Raspa RF. Common stress [2] fractures. Am Fam Physician . 2003;68(8).

Wheeler P. Batt ME. Do non-steroidal anti-inflammatory drugs adversely affect stress [2] fracture healing? A short review. British Journal of Sports Medicine. 2005;39:65-69.

Women, Sport, & Performance . Human Kinetics; 1991.

Last reviewed November 2007 by John C. Keel, MD [22]

Please be aware that this information is provided to supplement the care provided by your physician. It is neither intended nor implied to be a substitute for professional medical [8] advice. CALL YOUR HEALTHCARE PROVIDER IMMEDIATELY IF YOU THINK YOU MAY HAVE A MEDICAL EMERGENCY. Always seek the advice of your physician or other qualified health [20] provider prior to starting any new treatment or with any questions you may have regarding a medical [8] condition.