Causes and Key Treatment Options for Stress Fractures
Stress fractures are breaks in bones caused by repeated force on a bone and can range from very mild to quite severe (1). Stress fractures are difficult to self-diagnose because the symptoms (pain and swelling) are similar to other types of injuries. The following article will describe the features and causes of stress fractures in the lower leg and will discuss common treatments, therapies, and recovery.
A stress fracture is a break in a bone that is caused by either a) repeatedly overloading the bone, as often occurs with runners, or b) normal action taking place on weakened bone, as can occur with the elderly. Stress fractures are characterized by small, often hairline breaks in the bone (2).
Stress fractures range in severity from mild to severe. At its most mild, a stress fracture feels like a dull pain at the point of injury. As the fracture develops, or in the case of a more severe initial fracture, the pain can become severe enough to prevent you from performing simple activities like walking or even standing without support. You may also notice swelling at the site of the fracture.
Although stress fractures generally occur due to repeated force on a bone, several other factors can be involved. Common causes include:
Bone insufficiency: Medical conditions such as osteoporosis and certain medications, such as heparin and warfarin, can lower bone density, making your bones more susceptible to becoming overloaded by even minor stresses, resulting in a stress fracture (3).
Insufficient conditioning: Stress fractures can be caused simply by pushing yourself too hard at a physical activity before proper muscle conditioning has taken place. This can happen to athletes across all experience levels (4).
Poor technique: Having good technique while performing physical activities is an important key to avoiding many injuries, including stress fractures. Poor technique can be due to lack of training or because of circumstances that cause a differentiation from normal technique. For example, blisters or a bunion can lead you to favor one leg over another.
Improper equipment: Using the proper equipment is very important when participating in any physical activity that involves the exertion of force on your bones. This is as simple as having well-fitting shoes that provide enough padding to absorb shock that could potentially lead to a stress fracture (5).
Stress fractures typically start as a dull pain, localized to the site of the injury. In less severe cases, the pain will be present when engaged in physical activity but may decrease or even disappear when performing less strenuous activities, such as walking or standing. However, in more severe cases, when a bigger initial fracture is present, or when a small fracture goes uncared for and progresses into a larger one, the pain can be severe and debilitating.
How do you really know if you have a stress fracture? Unfortunately, oftentimes they can only be diagnosed by a medical professional. If you’re experiencing pain during impact activities, which does not subside or steadily worsens, consult a physician and discuss the possibility of a stress fracture and to rule out another type of injury. Injuries such as bruising of the bone, infections, plantar fasciitis, shin splints, strains and sprains and even some tumors can mimic the symptoms of a stress fracture, so it’s important to see a physician for a clear diagnosis.
Initially, the physician will compile a complete physical history of the patient. He/she will try to determine the incident that led to the stress fracture or identify factors that may have contributed to it. He or she will also look for factors that may rule out the fracture or identify another cause of the
persistent pain. Depending on how much time has passed since pain was first noticed, the initial injury itself may be hard to remember. For that reason, expect the examining physician or to ask lots of questions about how long the pain has been present, what makes it better or worse, and if it has changed over time (6).
If the physician has further questions, they will most likely prescribe an imaging test, which will provide the best evidence of a fracture. An MRI or CT scan tends to be used rather than an x-ray because stress fractures can be very difficult to detect, especially when they are at early stages. An MRI is the most common type of scan ordered to diagnose stress fractures. The physician will view the MRI or CT scan, searching for a small fracture in the bone or disrupted blood flow to the region where pain is occurring.
Stress fractures are not inevitable. They can be avoided by paying attention to things like proper technique, gear, and training schedules, as well as by maintaining a healthy diet and varying your physical activities (7). Perhaps most importantly, pay attention to your body. Take a break from any activity that causes repeated pain. If a few days of rest doesn’t relieve your pain, contact your physician for a more in-depth examination.
Most stress fractures don’t require surgery. Instead, a pain reliever is likely to be prescribed, and the patient will be directed to rest and refrain from putting weight on the fractured limb. Commonly prescribed pain medications include ibuprofen (trade names: Motrin, Advil, Nupirn) or naproxen (trade names: Aleve, Midol, Naprosyn). If the injury is mild and some weight can be put on the limb, the physician may prescribe a walking boot or brace. These stiff, bulky devices allow a person to walk hands-free with only minor disruptions to normal walking gait (8).
For more severe stress fractures, the physician will direct the patient to be non-weight bearing. No weight should be put on the injured limb for the recommended time frame (generally 1 to 3 weeks for a stress fracture), and the prescription tends to consist of a combination of bed rest, an assistive device, and physical therapy (9). When a person is prescribed non-weight bearing, crutches tend to be the first device that comes to mind. Fortunately, there are new advances in non-weight bearing medical technology, which allow non-weight bearing activity with additional mobility. Because it is so important to follow the non-weight bearing prescription, it is necessary to figure out which device will work best for you. The various options are explained below.
• Crutches — Although crutches are a well-known mobility aid for those who are non-weight bearing, they have several limitations. First, they require both hands, which can pose a challenge when completing even simple tasks, such as getting to and from the car with groceries or carrying books between classes. Having both hands occupied can also pose balance issues. Furthermore, crutches rest under your armpits, which can cause irritable rubbing on the skin covering your ribcage and under your arms. Finally, crutches do not allow for leg elevation, which many physicians will recommend for optimal recovery.
• Knee scooters — Knee scooters or knee walkers are one alternative to crutches. While these devices allow greater ease of motion and require less upper body strength than crutches, they still restrict your daily activities. They cannot be used on stairs, in small spaces, on slopes, or over uneven terrain. Lastly, like crutches, they require the use of both arms.
• iWALK2.0 Crutch Alternative — The iWALK2.0 is a revolutionary device that overcomes the issues posed by the other devices. It enables movement over all types of surfaces and through small spaces. It is hands-free, and the lower half of the affected leg is held in an elevated position. This last point is critical, as most physicians believe that rest is the single best therapy for allowing stress fractures to heal. Returning to weight-bearing activities before the bone is fully healed is one of the most common ways to delay healing or cause re-injury.
Most stress fractures do not require surgery, but there are some exceptions. if the bone fails to heal with non-surgical treatment, surgery will be required and will typically involve either using screws to secure the bone or grafting new bone into the space that the fracture has left open (10).
In the event of surgery, it is critical to adhere to the physician’s advice on rehabilitation. Failure to do so can result in incorrect healing, which consists of failure of the bone to heal or the bone healing out of alignment. Be sure to pay attention to the level of pain you are experiencing or if any swelling occurs at the site of the injury. Both should subside with proper recovery and rehabilitation procedures.
Recovery from surgery can be a lengthy process and is generally split between rest and physical therapy. During the rest phase, a physician will likely suggest refraining from any activity that puts stress on the site of the injury. Depending on the specific injury and its severity, the physician may prescribe a non-weight bearing regimen for several weeks. During this time, the physician will most likely suggest one of the devices detailed in the “What it Means to be Non-Weight Bearing” section above. The rest period often lasts for one to three weeks, depending on the severity of your injury.
After the rest period, physical therapy will likely be the next step to recovery. The goal of physical therapy is to return the patient back to their former level of activity. A physical therapist will be involved in the patients’ recovery for several months in order to guide progress and help avoid activities that are likely to lead to re-injury.
Physical therapy for a stress fracture will consist largely of muscle strengthening and conditioning. Stronger muscles help lessen the force of impact on your bones and joints by absorbing shock and assisting in balance. The physical therapy regimen will consist of a variety of activities, so as not to put too much stress on any one part of the body, particularly the part that suffered the stress fracture. The exact details of the physical therapy regimen will be tailored to each individual.
Throughout recovery, the physician will ask you many questions regarding the injury, and in turn, it is important to ask questions that will help you track individual progress. Ask about different treatment options, signs of complications, and expected recovery times. Communicate with the physician about differing physical needs during recovery. For instance, if physically active and crutches are prescribed, ask the physician if there are other options allowing greater freedom of movement while resting the injured limb, such as knee scooters or the iWALK2.0. A long and uneventful recovery is rewarded by a return to healthy physical activity.
Despite being painful and inconvenient, stress fractures are frequently mild injuries that can be treated non-surgically. Generally, a combination of pain medication, rest and a non-weight bearing device enabling movement without putting weight on the injured limb are all that is needed to reach full recovery. Remember, if prescribed a non-weight bearing period, it is very important to choose the medical device that will work best for your lifestyle. Initial medical treatment should be followed by physical therapy, to enable timely recovery and avoidance of future stress fractures.
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