Dr Laura McDonald-Wedding
Normally when you think of a standard fracture, it is caused by trauma – a big hit, landing, knock, fall to the site. You wear a cast for a few weeks and then it’s healed and you get going again.
Stress fractures are a little different!
Bone is a living thing with constant turnover of cells. In stress fractures the bone turnover and breakdown outweighs the bone building. This imbalance leads to, firstly, a stress reaction and then, eventually a crack and fracture line in the bone.
These stress fractures can happen anywhere in the body, but we commonly see them in the foot, lower leg, thigh and back. If you do a throwing sport or gymnastics / circus (with lots of handstands), then we also see it in the upper limbs. Additionally, in rowers, we see it in the ribs.
Stress reactions and fractures can mimic other pathologies and problems – for instance, plantar fascia in the foot, achilles tendinopathy in the lower leg, hip joint pathology in the thigh, facet joint or disc problems in the back. Some clues can be if the pain gets gradually worse with exercise, or if jumping / hopping or large forces through the area worsen the pain. A classic description of a foot metatarsal stress fracture is sharper pain that gets worse as you run or aches into the next day. The takeaway is that you need a clinician to do a careful history and examination and to be on the lookout for it – so that it’s not missed.
If your doctor suspects a stress reaction / fracture, then often an MRI + / – CT scan will be needed to help both diagnose the exact location and determine the severity. These two pieces of information are critical, as they can change the management drastically. For instance, with location, some sites are higher risk for not healing compared to others (and therefore, need longer offloading time). Likewise, a stress fracture (crack in the bone) will need a longer period to heal than a stress reaction (no crack). This type of management plan and guidance is where a Sport & Exercise Physician can be very helpful. Similarly, there are many new adjunct treatments available to help us heal stress reactions and fractures – ensure to ask your Sport & Exercise Physician about these to help you get going sooner!
Once diagnosed and an acute management plan is in place, the other key role of a Sport & Exercise Physician, is to help determine what has caused the bone turnover imbalance. This is arguably the most important part of the consult. If we can identify the cause of the imbalance, we can help prevent it occurring again. For instance, increased loading through training / technique errors or biomechanical imbalances can increase bone breakdown. On the other hand, diet, hormonal and endocrinological issues can reduce bone formation. By interrogating each of these factors, we can tailor our management specifically to you. This means both long-term prevention as well as improving overall health and wellbeing in the process.
In summary:
– Stress reactions and fractures are common, particularly in the legs but also in the trunk and upper limb depending on the physical activity you do
– They are caused by bone turnover imbalance – but in order to prevent a recurrence you need to work out what has caused this in you
– Be suspicious for a stress reaction / fracture if you’re symptoms don’t settle with initial treatment and are getting worse the more you use the area
– There are many new adjunctive treatments available to help heal stress reactions /fractures – always ask your Sport & Exercise Physician about them
