Stress Fractures of the Foot and Ankle

A stress fracture is a tiny crack in a bone, or bad bruising in a bone. Most stress fractures originate from excessive use and repeated activity, and are common in runners and athletes who participate in running sports, like soccer and basketball. Dr. Weaver of Audrain Orthopaedics is here to make sure that you're informed about stress fractures and how to handle them.

Stress fractures usually occur when individuals change their activities — such as trying a new workout, abruptly boosting the intensity of their workouts, or changing the workout surface (jogging on a treadmill machine vs. exercising outdoors). Additionally, if osteoporosis or other disease has damaged the bones, just performing everyday activities might create a stress fracture.

joint inflammation orthopedic care Sports Medicine mexico columbia missouriThe weight-bearing bones of the foot and lower leg are particularly at risk of stress fractures as a result of the repetitive forces they need to absorb through activities like walking, running, and jumping.

Staying away from high impact activities for an adequate period of time is vital to recovering from a stress fracture in the foot or ankle. Going back to activity prematurely can not only delay the healing process but also raise the risk for a total fracture. Should a complete fracture take place, it's going to take much longer to recover and return to activities.

Description

Stress fractures take place most often in the second and third metatarsals in the foot, which are usually thinner (and often longer) than the adjacent first metatarsal. This is the area of greatest impact on your foot as you push off whenever you walk or run.

Stress fractures are also common in the calcaneus (heel); fibula (the outer bone of the lower leg and ankle); talus (a tiny bone inside the ankle joint); and the navicular (a bone at the top of the midfoot).

Lots of stress fractures are overuse injuries. They occur over time when repetitive forces lead to microscopic harm to the bone. The repetitious force that creates a stress fracture is not great enough to cause an acute fracture — like a broken ankle due to a fall. Excessive use stress fractures manifest when an athletic movement is repeated so often, weight bearing bones and supporting muscles don't have enough time to heal between exercise sessions.

Bone is in a continual state of turnover—a process called remodeling. New bone develops and replaces older bone. If an athlete's activity is too great, the breakdown of older bone happens rapidly — it outpaces the body's capability to repair and replace it. Consequently, the bone weakens and becomes vulnerable to stress fractures.

Cause

The most typical cause of stress fractures is an abrupt escalation in physical activity. This increase can be in the frequency of activity—such as exercising more days every week. It can also be in the duration or intensity of activity—such like running longer distances.

Even for the nonathlete, an unexpected boost in activity can cause a stress fracture. For example, if you walk occasionally on a day-to-day basis but wind up walking excessively (or on uneven surfaces) while on a vacation, you may experience a stress fracture. A new type of shoes can reduce your foot's ability to absorb repetitive forces and result in a stress fracture.

Several other factors — from your training routine to your diet plan — increases your risk for a stress fracture.

Bone Insufficiency

Issues that lessen bone strength and density, like osteoporosis, and some long-term medications can make you more likely to experience a stress fracture-even when you're performing typical everyday tasks. For example, stress fractures are more prevalent in the winter season, whenever Vitamin D is lower within the body.

Studies demonstrate that female athletes are more prone to stress fractures than male athletes. This could be due, in part, to decreased bone density from a condition that physicians refer to as the "female athlete triad." When a girl or young woman goes to extremes in dieting or exercise, three interconnected health problems may develop: eating disorders, menstrual dysfunction, and early osteoporosis. As a female athlete's bone mass decreases, her probability for getting a stress fracture increase.

Poor Conditioning

Doing too much too soon is a common cause of stress fracture. This can be the case with people who are just starting an exercise program-but it takes place in seasoned athletes, as well. For example, runners who train less over the winter months might be anxious to pick up right where they left off to the end of the previous season. Rather than starting off slowly, they resume running at their preceding mileage. This situation in which athletes not only boost activity levels, but push through any discomfort and don't give their bodies the opportunity to recover, can result in stress fractures.

Improper Technique

Anything that changes the mechanics of how your foot absorbs impact as it strikes the ground may raise your risk for a stress fracture. For instance, if you have a blister, bunion, or tendonitis, it could affect how you put weight on your foot when you walk or run, and may require an area of bone to handle more weight and pressure than normal.

Change in Surface

A change in training or playing surface, for example a tennis player going from a grass court to a hard court, or a runner moving from a treadmill to an outdoor track, can add to the risk for stress fracture.

Improper Equipment

Donning worn or flimsy shoes that have lost their shock-absorbing capability may bring about stress fractures.

Symptoms

The most typical symptom of a stress fracture in the foot or ankle is pain. The pain normally develops slowly and exacerbates during weight-bearing activity. Other symptoms may include:

•   Pain that reduces during rest

•   Pain that occurs and intensifies during normal, daily activities

•   Swelling on the top of the foot or on the exterior of the ankle

•   Tenderness to touch at the site of the fracture

•   Potential bruising

First Aid

Speak with your doctor at the earliest opportunity if you feel you have a stress fracture in your foot or ankle. Disregarding the pain may have significant consequences. The bone may break entirely.

Until your appointment with the doctor, stick to the RICE protocol. RICE stands for rest, ice, compression, and elevation.

•   Rest. Stay away from activities that put weight on your foot. If you have to bear weight for any reason, you should always be wearing a really supportive shoe. A thick-soled cork sandal is better than a thin slipper.

•   Ice. Use ice immediately after the injury to keep your swelling down. Use cold packs for 20 minutes at a time, a couple of times per day. Don't apply ice directly on your skin.

•   Compression. To avoid additional swelling, lightly wrap the area in a soft bandage.

•   Elevation. As much as possible, rest with your foot raised up above your heart.

Additionally, nonsteroidal anti-inflammatory drugs, or NSAIDs, like ibuprofen or naproxen may help alleviate pain and minimize swelling.

Doctor Examination

Physical Examination

Your doctor will discuss your medical history and overall health. He or she will ask about your work, your activities, your diet, and what medicines you're taking. It is crucial that your physician knows your risk factors for stress fracture. If you have had a stress fracture before, your doctor may order a full medical work-up with laboratory tests to take a look for nutritional deficiencies such as low calcium or Vitamin D.

After talking about your symptoms and health history, your doctor will examine your foot and ankle. Throughout the examination, he or she will seek out areas of tenderness and apply light pressure directly to the injured bone. Often, the key to diagnosing a stress fracture is the patient's report of pain in response to this strain. Pain from a stress fracture is normally limited to the area directly over the injured bone and isn't generalized over the entire foot.

Imaging Tests

Your doctor may order imaging tests to help confirm the diagnosis.

X-rays. X-rays offer images of dense structures, such as bone. Since a stress fracture begins as a tiny crack, it's often hard to see on a first x-ray. The fracture may not be visible until several weeks later whenever it has actually started to heal. After a couple of weeks, a kind of healing bone called callus may appear around the fracture site. In many cases, this is the point at which the fracture line actually becomes visible in the bone.

Other imaging studies. If your physician suspects a stress fracture but can't see it on an x-ray, they might suggest a bone scan or a magnetic resonance imaging (MRI) scan. Although a bone scan is less specific than an MRI in showing the location of the stress fracture, both of these types of studies are more sensitive than x-rays and can detect stress fractures earlier.

Treatment

The goal of treatment is to relieve pain and allow the fracture to heal so that you are able to go back to your activities. Following a physician's treatment plan will help you go back to activities quicker and prevent additional harm to the bone.

Treatment varies depending on the location of the stress fracture and its severity. The majority of stress fractures are treated nonsurgically.

Nonsurgical Treatment

In addition to the RICE protocol and anti-inflammatory medication, your physician may suggest that you use crutches to keep weight off your foot until the pain subsides. Other ideas for nonsurgical treatment may include:

Modified activities. It typically takes from 6 to 8 weeks for a stress fracture to heal. During that time, switch to activities that place less stress on your foot and leg. Swimming and cycling are good alternative activities. Nevertheless, you shouldn't resume any type of physical activity that involves your injured foot or ankle-even if it is low impact-without your doctor's recommendation.

Protective footwear. To minimize strain on your foot and leg, your physician may recommend wearing protective footwear. This may be a stiff-soled shoe, a wooden-soled sandal, or a detachable short-leg fracture brace shoe.

Casting. Stress fractures in the fifth metatarsal bone (on the external side of the foot) or in the navicular or talus bones take longer to heal. Your physician may apply a cast to your foot to help keep your bones in a stationary position and to remove the stress on your involved leg.

Surgical Treatment

Some stress fractures call for surgery to heal effectively. In most cases, this involves supporting the bones by inserting a type of fastener. This is called internal fixation. Pins, screws, and/or plates are oftentimes used to hold the small bones of the foot and ankle together throughout the healing process.

Recovery

In many instances, it takes from six to eight weeks for a stress fracture to heal. More serious stress fractures can take longer. Although it may be hard to be sidelined with an injury, going back to activity too quickly can put you in danger of larger, harder-to-heal stress fractures and an even longer down time. Reinjury could lead to chronic problems and the stress fracture might not heal correctly.

Once your pain has subsided, your physician may confirm that the stress fracture has healed by taking x-rays. A computed tomography (CT) scan can also be useful in determining healing, particularly in bones where the fracture line was initially difficult to see.

Once the stress fracture has healed and you're pain free, your doctor will allow a gradual return to activity. During the initial phase of rehabilitation, your physician may recommend alternating days of activity with days of rest. This gives your bone the time to grow and withstand the new demands being put on it. As your level of fitness improves, slowly increase the frequency, duration, and intensity of your exercise.

Prevention

The following guidelines can help you avoid stress fractures in the future:

•   Eat a healthy diet. A well-balanced diet rich in calcium and Vitamin D can help build bone strength.

•   Use proper equipment. Old or worn running shoes might lose their ability to absorb shock and can lead to injury. In general, athletic shoes need to have a softer insole, and a stiffer outer sole.

•   Start new activity slowly. Progressively increase your time, speed, and distance. In many instances, a ten percent increase every week is ideal.

•   Cross train. Vary your activities to help avoid overstressing one area of your body. For example, alternate a high-impact sport like running with lower-impact sports such as swimming or biking.

•   Add strength training to your regular workout. One of the better ways to prevent early muscle fatigue and the loss of bone density that comes with aging is to integrate strength training. Strength-training exercises utilize resistance methods such as free weights, resistance bands, or your own body weight to develop muscles and strength.

•   End your activity if pain or swelling comes back. Rest for a couple of days. If the pain persists, visit your doctor.

If you have any more questions regarding stress fractures of the foot or ankle and live in or around Mexico, Columbia, Jefferson City, or Moberly, Missouri, contact Audrain Orthopaedics today and arrange an appointment.

You did everything in your power to make sure I got back on my feet…Literally!

L.K. age 32