The most common reason for a bone to sustain a fracture is due to a trauma or mechanism of injury such as a slipping on the stairs or twisting mechanism to the foot and ankle.  However, there is another type of fracture that can occur with no traumatic event, the stress fracture.  A stress fracture that is caused by too much stress being put on a bone. The fracture is a result of repetitive trauma, and it develops gradually over time rather than a one-time incident. It most commonly affects bones of the lower extremity, such as the tibia in the lower leg and the metatarsal bones of the foot, but it can occur in any bone.

There are several factors that can lead to a stress fracture of the lower extremity.  Starting a new exercise program, repetitive high-impact exercise, and increasing in training volume or intensity.  Other factors can also affect the mechanics of the lower extremity and the healing capacity of the bone.  Poor fitting athletic shoes can change the pressures on certain areas of the foot and legs.  Poor nutrition and low vitamin D and calcium will affect bone healing.

A patient will present to a foot and ankle specialist with pain and swelling to the affected area.  The fracture site that is often aggravated with activity.  Initial a person might be able to continue the activity through the pain, but as the fracture worsens, the pain increases, and the person is not able to continue with the activity anymore.  Even walking may become difficult and painful at times.

The specialist will ask about if there have been any recent changes in the type, intensity, duration, or frequency of activity in the month prior to the pain starting. X-rays of the area where the pain is will be obtained to look for any evidence of a healing fracture. Sometimes it can be difficult to see a stress fracture on x-rays, especially if the pain only started within the past 2-3 weeks, or if there has not been any period of rest to allow for healing.  Since x-rays may be negative at first, the specialist may treat the foot or ankle as stress fracture until proven otherwise.  Occasionally a magnetic resonance imaging (MRI), computed tomography (CT) scan, or a bone scan may be ordered to evaluate the painful area further. 

If there is a high-suspicion of a stress fracture or if a stress fracture is identified, a period of immobilization with a walking boot may be necessary, with or without crutches, to help the athlete become pain-free. This period, can range anywhere from two to six-weeks, is generally followed by a very slow return to activity directed by a sports medicine physician. Some stress fractures are considered high-risk, and in those cases, surgery may be recommended.

The goal is injury prevention when starting a new exercise regimen or increasing activity.  Being cognizant of changes in activity is important.  Training schedules can be monitored with a training log and cross-training can be helpful.  When trying to increase activities, gradually increased by no more than 10%-15% per week.  Optimal training surfaces will help with higher impact activities.  A well-balanced diet with proper intake of vitamin D and calcium will help with bone health especially in winter months.

As always, if you are concerned about a possible injury or stress fracture, please see a provider for proper diagnosis and management.

Sean Grambart, D.P.M., FACFAS