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A stress fracture is a break that can occur in a bone due to repetitive load over time rather than direct trauma like other fractures. Patients can present at any point on the continuum and the good news is that the earlier it is detected the quicker the recovery.
We often think of bones as inert, but they are living tissue and will react to load just like muscles, tendons and ligaments. When there is too greater rate of bone being broken down compared to that being built up, an imbalance is created which can lead to a stress fracture.
The diagnosis of a stress fracture will mean several months out of impact training and then several more months potentially to work through a graded return to a running programme.
So understanding how they occur can be a useful way to prevent them.
Pain from a stress fracture can present in different ways. Most often it starts as a low level dull ache in the affected area, becoming increasingly severe if the patient ignores the symptoms and continues to exercise and load the injured body part, preventing it from healing.
If there is inflammation of the lining of the bone then it can be very painful to touch and feel swollen compared to the other side. However, the pain can also sometimes radiate outwards from the stressed bone, perceived diffusely in a wider area, which sometimes makes it hard to localise and can make the diagnosis unclear in some cases. Discomfort can persist after activity and pain at night or when at rest is a typical feature.
It can last for several days after an intense period of exercise and as the stress injury becomes more established, can be intrusive even on simple daily activities such as walking to and from work.
A stress fracture can be missed on a simple x-ray, especially if the injury is less than 2 weeks old. MRI scanning is a much more accurate method to pick up a stress fracture; even subtle bone stress can be identified allowing early diagnosis and therefore improving prognosis and recovery times.
The causes can be multifactorial. The extrinsic factors would include training volume and intensity, recovery between sessions, sleep, footwear, training surface etc. Intrinsic factors would relate to the body and how a person moves ie biomechanics. It may be that there are areas of muscle weakness, inflexibility or poorer patterns of movement that contribute to overload.
Treatment & Management
A multi-disciplinary team approach is recommended for the optimal management of stress fractures. A patient would ideally get input from a Sports Doctor, Dietitian and Physiotherapist and may also need Podiatric input as well if their foot posture and biomechanics are thought to contribute.
After initial assessment and diagnosis by the sports doctor, the patient would work with an experienced Physiotherapist to correct any biomechanical contributing factors and improve functional strength gradually, as well as discussing and learning the role of the extrinsic factors.
Article written by Dr James Noake MBChB MBS MRCS MRCP MScSEM FFSEM
Dr Noake is a specialist in sports medicine and holds clinics at The Chelmsford Private Hospital on Wednesdays and Fridays.
Call 01245 253760 or email firstname.lastname@example.org for an appointment.