Foot Stress Fractures: Causes, Symptoms, Treatment and Prevention
A stress fracture is a small/tiny crack in the surface of the bone or a severe bruising of the bone known as a stress reaction , it can occur in the foot, leg or hip. The weight bearing foot and lower leg bones are most susceptible to stress fractures due to the repetitive forces they are absorbing. Being Podiatrists we mainly see fractures in the metatarsal bones of the foot, navicular bone and more rarely in the calcaneus or tibia. However they can occur through any bone of the foot or lower limb. Stress fractures occur when there has been a change either internally to the body or externally to the body, an overload or a repetitive movement placed upon the foot and leg bones . A stress fracture or stress reaction are most common in runners, dancers and repetitive and impact sports such as Soccer, AFL, Basketball.
Causes/ risk factors for stress fractures of the foot:
As stress fracture/ stress reactions are generally caused by a sudden increase in activity and loading caused by repetitive force is placed through the foot and ankle during daily activities. Our bones are constantly changing and responding to the loading that is placed through them, which allows for an increase in calcium deposited at the site. However in order for a stress fracture to occur the repetitive load is greater than the ability of the bone to repair itself and a bone stress reaction starts. If we ignore the signs and symptoms small cracks within the surface of the bone can begin, leading to a stress fracture.
Certain bone conditions such as osteoporosis, osteopenia, long term steroid use and being low in Vitamin D can cause you to be more susceptible to a stress fracture or stress reaction even when performing everyday activities.
Female Athlete triad is a main cause of stress fractures and as the name suggests affects women. This is usually caused by extremes in eating habits(eating disorders), hormonal changes and over-exercising which lead to a decrease in bone mass and can be a main contributor to a stress fracture.
Sudden changes in activities can lead to stress fractures and normally occur when trying a new style of exercise whether it be running, HIIT or playing sport. Increasing activity intensity can be speed or duration, and lastly, changing workout surfaces some examples are outdoor running to treadmill running or vice versa, or flat surface to hills, inside court to outdoor courts.
When there is a change to your biomechanics whether it be deliberate or unknown compensation caused by the smallest of things e.g a blister, corn, callous or whether it be due to a bunion or tendon/muscle injury, the foot and lower limb is being impacted and can increase ground force reactions. This may lead to a stress reaction or stress fracture.
Change in Surface
The change in training or playing surfaces can impact on which bones are being loaded and even lead to overloading leading to an increased risk of a stress fracture.
Ensuring you have the correct footwear is as important to preventing stress reactions/ stress fractures to the foot and lower limb. If you are not using the correct footwear running shoes- for court sports it can lead to overloading of metatarsals, fibula, navicular and other bones within the foot. It is equally important to ensure that your footwear is also not worn out or too flimsy for the activity you are doing, as the shoe may have lost cushioning and stability contributing to overloading.
So you think you may have a stress fracture or stress reaction these are the signs and symptoms to look for:
- Pain usually develops gradually and becomes worse when weight bearing or during activity, described as a deep dull pain or sharp localised pain.
- Swelling of the site of a suspected injury – generally localised to the area- top of the foot for metatarsal stress fractures, side of foot for navicular stress fractures or ankle for tibia stress fractures.
- Bruising over site of injury.
- Tenderness on palpation of the site.
- Noticing changes in the way that you walk or run due to avoiding putting pressure in the area.
If you are suspecting a metatarsal stress fracture or a stress reaction or a stress fracture of any type it is imperative to immediately reduce High intensity loading, ceasing of walking, running and jumping, HIIT or sport being played. Ice the affected area, elevate and seek professional advice (podiatrist or doctor) as soon as possible to prevent further pain and worsening of the injury.
Until your appointment with your podiatrist or doctor follow the advice below.
- Rest- avoid activities that increase your loading through your foot (walking, running, jumping) and if you can’t avoid it ensure you are wearing a supportive shoe runner over a ballet flat or thong.
- Ice- apply ice immediately to reduce swelling and then as needed for periods of 20 minutes throughout the day.
- You may take anti-inflammatory (Nurofen) to help with swelling or a Paracetamol to help with pain within the first 24hr if needed.
- Elevate- keep your leg/foot elevated if possible.
Upon presentation to your appointment with your podiatrist they will begin by taking a thorough subjective assessment- this will include asking you questions in regards to your current physical activity levels, nutrition,medical history including medications, changes in training surfaces, changed in training loads and footwear history as well as where you pain is located and how you would describe the pain.
The podiatrist will then ask you to remove both shoes if assess the foot or ankle and start by palpation the non affected limb to get a baseline of pain levels and feeling of the bone regularity further to this they will be comparing side by side looking for swelling, bruising or any other signs of inflammation. Next they will begin to palpate the affected foot/ankle where there may be a stress fracture- they are looking for a pinpoint positioning or bone irregularity with the site of question. Depending on the findings the podiatrist may recommend further imaging to confirm diagnosis.
The podiatrist may request imaging to be done and this can be an x-ray, however, it is not uncommon for an x-ray to come back completely clear as the stress fracture is generally too small to be seen on plain fil x-ray and can take up to 6 weeks to show. Other imaging modalities are generally preferred and this may include ultrasound, bone scan, bone density, CT or MRI this is due to the specificity of the imaging picking up the stress fracture. Most times the podtairst will be able to diagnose a stress fracture without any imaging being required.
Majority of the time, stress fractures of the metatarsals can heal without surgical intervention. Treatment of stress fractures normally includes a Cam-walker commonly known as a moon boot for a period of 4-6 weeks depending on the severity of the stress fracture.
Other options depending on the mode of action may include orthotics or a carbon fibre plate or a rocker bottom shoe, of which are normally facilitated into a long term treatment plan to avoid recurrence.
Other treatment that will be suggested is refraining from high impact activities for a minimum of 6 weeks before slowly reintroducing load.
Surgery is rarely indicated or recommended for metatarsal stress fractures as majority tend to heal properly however may be considered for more complicated or non healing stress fractures such as navicular stress fracture or if they fail to respond to nonsurgical approach.
Most common stress fractures of the foot or ankle take about 4-6 weeks to heal however some sites such as the 5th metatarsal and navicular can take up to 12 weeks to heal.
It is important that when starting to re-introduce loading exercise this is facilitated slowly and you consult your podiatrist on a strength and conditioning program for your intrinsic foot muscle and lower limb muscles, to ensure less stress in put through the bones of the lower limb and may include footwear changes, flat style of shoes and more low impact activity initially.
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