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Stress Fracture

One of the most common injuries in any sports is a stress fractures.

They are tiny cracks (micro-fractures) in bones, and they happen because of repeated force or micro-trauma that is a greater rate than the rate of the bone healing. Ie the individual may be exercising too hard or too long.

That being said, the most common stress fractures happen in runners (such as foot or shin splints), but stress fractures can happen in other sports or occupations too, such as

• military or uniformed officers prolonged marching / running
• gymnasts or cricket bowlers with lumbar spine stress fractures

Some individuals who have weakened bones due to osteoporosis or osteopenia can also get stress fractures from everyday use, such as shin splints or even spinal compression fractures.

Stress Fractures occur in these 2 scenarios

1. Repeated, excessive force through NORMAL bone
2. Repeated, excessive force through ABNORMAL bone, e.g. osteoporosis or osteopenia

More often than not, stress fractures typically happen in the weightbearing bones of the lower leg (tibia more than fibula) and the foot.

And it happens more in certain types of training, sports or activities, such as marathoners but moreso in "hard runners / sprinters", such as track and field.

Often patients who are starting out a new exercise program can also be at risk to developing shin splints too.

first of all, What Causes a Stress Fracture?

Stress fractures are always overuse injuries (other than being more at risk due to bone weakening by certain conditions).

It happens when the muscles are tired or fatigued and are not able to absorb forces and shocks. Over time, what happens is that the forces that supposed to be loaded by the muscles are eventually taken by the bone.

That slowly cracks the bone, and that's what is called stress fractures.

Stress fractures are either caused by

1. increasing the intensity or amount of exercise or activity too rapidly
2. training or working out on a new surface or terrain (such as a runner switching from grass running to concrete running)
3. using improper equipment (such as using shoes that are either too hard or too soft)
4. increased physical stress (such as increasing game, play or exercise duration)

Where do Stress Fractures happen?

Most stress fractures happen in the weight-bearing bones of the lower leg (shin or tibia) and the foot. 

Common stress fracture sites are:

1. Metatarsal (Foot)
2. Navicular (Mid-Foot)
3. Tibia (Shin)
4. The neck of the femur (Hip)
5. Pars intraarticularis (Lower Back – Spondylolysis or Spondylolisthesis)

What Activities are susceptible to Stress Fracture?

Other than the usual suspects such as overtraining, switching terrains, or poor equipment, the other stuff that causes or aggravates stress fractures are the nature of the game or activity itself.

Basically, sports or activities that has 

1. repetitive running / sprinting
2. repetitive landing

are more vulnerable to stress fracture.

Studies are showing that athletes and individuals that participate in

1. tennis
2. track and field
3. squash
4. gymnastics
5. basketball
6. dance

are more at risk of developing stress fractures. In these sports, its the repetitive stress of the foot striking and pivoting on the ground that is the primary cause. 

Without enough rest between training, workouts and competitions, athletes have higher chance of developing stress fractures.

question: Are Women More Susceptible to Stress Fractures than men?

Stress fractures and sports do not discriminate - it affects anyone of all ages who play and participate in repetitive sporting activities, such as running.

That being said, studies do show that female athletes seem to experience more stress fractures than their male colleagues or counterparts, but the reason point towards this event called “the female athlete triad”:

Presence of

1. eating disorders (bulimia or anorexia),
2. amenorrhea (infrequent menstrual cycle), and
3. osteoporosis (reduced bone density).

As a female's bone mass decreases, be it due to age or overtraining or undernourishing, the chances of her developing a stress fracture goes up - hence the need for a sports dietitian.

What are the two common Symptoms of a Stress Fracture?

1. Pain with activity is the most common complaint with a stress fracture.
2. No pain / Pain improves with rest.

Whenever any patient presents with these two symptoms, there's a very high chance that they have stress fracture.

How to diagnose Stress Fractures

1. The most common tell-tale sign is the above symptoms: pain with activity, no pain with rest. That will be the first hint and yellow flag for us.
   
   
2. You may need to undergo xray, but the problem with xray in stress fractures is that sometimes the stress fracture may not be obvious or seen in xrays for the first couple of weeks after the pain starts.
   
   
3. MRI (magnetic resonance imaging) is the most clear and specific test available today.
   
   
4. Bone scan can show up "hot spots" which can indicate stress fractures or even tumours.

How are Stress Fractures Treated?

The first and foremost important treatment...is really rest.

Patients and individuals need to rest from the main activity that caused the stress fracture in the first place. You can participate in activities that dont cause any pain during the 8 week period (it takes around 6 to 8 weeks for most stress fractures to heal).

So while you are resting from the exercise, training or sport, it's good for you to go for a screener to screen factors.

Better still if you can take a team injury management approach, consisting of:

1. Sports Physician to address bone density, hormonal issues, calcium, Vitamin D etc
2. Physiotherapist for whole lower limb and core muscle and joint function
3. Orthopedic Surgeon for any injections or surgical intervention if required.
4. Sports Dietitian to ensure proper and adequate sports nutrition.
5. Podiatrist for foot biomechanics assessment

How to Prevent Stress Fractures

1. Incremental growth goals. Whenever you start a new sports or activity, or if you're already in one, start small and gradually build up distance, intensity or load on a weekly basis. Use the 5-10% rule.
2. Rest between exercise or competition days. You can walk, light workout but let your body rest.
3. Cross train. Alternate activities that improves the same fitness goals. For example, instead of running daily, you can run one day, cycle another, swim another, lift weights another, then start over.
4. Eat proper and healthy. Incorporate the micros and macros, and hydrate daily.
5. Go for a musculoskeletal screening by our sports physiotherapist before you start a new training program or season. Go for prehab training too, to condition and prepare your bones, muscles, joints and body for the trainings.
6. If there's pain, do not push through the pain. Unless its light cramping muscle. If it doesnt improve, seek professional medical opinion and consultation.
7. Use proper equipment. If an equipment is old or worn out, replace it. If it's too soft or hard, replace it.
8. Important: the better you take care of yourself, preventing injuries, preventing any injuries from getting worse, or getting treated earlier, the faster you can return to sports at top performance