Stress Fractures
Introduction
Stress fractures are small cracks in the spongy part of a bone that are caused by overuse or repetitive activity. This can happen in a person with normal bone quality that has increased their activity, or it can happen in a person that is doing normal activity but have weakened bone, for example from osteoporosis. Occasionally improper footwear, very high arches or very flat feet will cause stress fractures because the abnormal foot posture or position is causing abnormal stress.
The most common bones in the foot to develop stress fractures are the metatarsals but stress fractures are also seen in the heel bone (calcaneus), fibula (outer ankle bone), talus (bone in the ankle joint) and navicular (a bone on the top of the foot).
Anatomy
There are 28 bones in the human foot, although some people have more than that if they develop accessory bones (which range from 2-20% of the population). As you can imagine, the bony structure of the foot takes on significant weight during normal activities. In fact, it has been said that the feet take on 4 times the body weight while walking and up to 10 times the body weight while running.
When the bones of the foot or ankle take on too much weight, they cannot hold up to all the force and they respond by swelling and becoming painful. Eventually, if the excessive weight or force is not lessened, the bone will develop a crack in the spongy part of the bone –this is called a stress fracture. Stress fractures can lead to full fractures if left untreated.
Symptoms
Patients usually describe a gradual onset of pain in the foot, ankle or heel. The pain typically improves somewhat with rest but gets significantly worse with activity.
- Pain which improves with rest
- Pain which worsens with activity
- Swelling on the top of the foot, ankle or heel
- Tenderness to touch at the site of fracture
- Rarely bruising
Stress fractures typically occur after a change in activity such as starting an exercise program, or change in footwear. They can also happen if you do too much too soon when starting an exercise program or even after a period of non-weight-bearing (such as after surgery).
Diagnosis
A diagnosis of stress fracture can be made by history and clinical examination. X-rays do not detect stress fractures in the early stages but can show evidence of stress fracture after 3-4 weeks. Early diagnosis oftentimes requires advanced imaging such as a bone scan or an MRI
Treatment
If you experience symptoms of a stress fracture initial treatment includes:
- Rest. Spending less time on the foot will help alleviate pain.
- Ice can help decrease pain and swelling.
- Compression will help prevent additional swelling.
- Elevation. As much as possible, maintain the foot elevated to decrease swelling.
- Anti-inflammatory Medications. If possible, take anti-inflammatory medications to alleviate pain and reduce swelling.
Dr. DeMill may also recommend the following treatments if the above items fail to improve your symptoms:
- Activity modifications. Stress fractures usually take about 6-8 weeks to heal so you should cut down on activities that bring you pain and avoid impact activities such as walking, running or jumping.
- Protective Footwear: Using a supportive stiff-soled shoe or an orthotic. A custom orthotic can be fitted for your shoes to give more support to the arches and properly balance your feet.
- Immobilization. In some cases, it may be necessary to use a brace, a boot, a walking cast or to completely avoid weight-bearing. Some stress fractures take longer to heal and sometimes requires strict non-weight-bearing in a cast.
- Bone Stimulator. Occasionally a machine called a bone stimulator is prescribed to help facilitate healing of a stress fracture. These are typically electromagnetic or ultrasound technology.
Surgery
In some patients, stress fracture may not adequately heal by the above treatments and surgery may be considered. This usually requires that plates or screws be placed to stabilize the bones and aid in the healing process. As the stress fracture heals and stabilizes, pain and swelling subside. X-rays or a CT scan may be used to confirm healing of the fracture.
When Dr. DeMill is reassured that the fracture is healing, he will allow gradual return to weight-bearing and footwear. Eventually and the healing process continues he will allow you to get back to regular footwear and a gradual return to regular activities. Dr. DeMill may recommend new shoes, a specific type of shoe and orthotics to help prevent stress fractures in the future.
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