A stress fracture is a tiny break in a weight-bearing bone, caused by repetitive force often from overuse. Stress fractures in the feet are feared by runners and other athletes as they make it impossible to run without pain, unlike other injuries such as tendon or joint pain. A decent period of time of full rest is highly likely.
Where an impact fracture is generally caused by a fall or a trauma, stress fractures have a gradual onset and therefore are often not foreseen. A stress response is when the bone is overloaded but has not fractured and is the early stage of a stress fracture.
Stress fractures can occur anywhere in the body where there is overuse including the hips and lower back, but they are commonly found in the lower areas due to weight-bearing activities. The tibia (shin bone) is the most common bone susceptible to stress fractures, and they are also often found in the foot.
The foot contains many small bones, with those running from the middle part of the foot to the toes called the Metatarsals – stress fractures often occur in the second and third metatarsals, and also in the heel.
What Causes Stress Fractures?
Bones have a certain capacity for load, and they fracture when there is an increase in the impact loading, by running, walking or jumping at a load that the bones cannot tolerate. If there is an imbalance between the capacity and the impact load over a period of time, a bone stress injury will occur. There can be very little pain initially so you may not be aware of any imbalance.
A simple example is military recruits who frequently develop bone stress injuries in the early part of their training. The impact load of the significant training they undertake several times a day, every day, is often too much for a new, unconditioned recruit.
Incorrect technique while training can also cause a stress fracture, as can changing the type of surface you exercise on (such as from grass to concrete), running on a slope, or wearing improper footwear.
Bones in older athletes may have a lower bone density or even osteoporosis which weakens the bone making them more susceptible to injury. Also, other existing foot conditions such as tendonitis or bunions, or muscle weakness can also be contributing factors.
Symptoms of a Stress Fracture
There will be pain, swelling or aching at the site of the stress fracture, and tenderness when touched on the bone. Pain may appear during an activity and then resolve with rest, or it may not go away at all after ceasing an activity.
Pain can arise while at rest or during normal daily activities and you may notice that you can’t hop or even shift your weight to the affected foot.
If a stress fracture is not treated early, then the pain can be pretty severe. Seek assistance from a medical practitioner or sports physio if you experience foot pain and an MRI, CT or bone scan can determine whether a bone stress injury exists as well as the severity of the injury. Note that an x-ray is not ideal to diagnose a stress fracture as the breaks are so fine, they are difficult to see.
Treatment for Stress Fractures in the Foot
There is not a lot you can do for a stress fracture apart from complete rest as it is necessary to allow time for the bone to mend. While taping, massage and dry needling may help other foot injuries, they do not accelerate bone healing.
Expect that you will need to commit to at least 6 weeks of rest, particularly avoiding the activity that led to the fracture in the first place. Crutches or a moon boot may be recommended during this time. Anti-inflammatory medication may be prescribed to get some relief from pain and swelling.
Your doctor may refer you for further tests to investigate your bone mineral density, vitamin D level, bloods, menstruation and hormones, to see whether there is another contributing factor to your bone injury.
It is really important to take care of your stress fracture as if it doesn’t heal properly it may lead to arthritis or even require surgery. Don’t ignore any pain in your feet and you are more likely to make a full recovery.
Returning to Normal Activity
It is important not to attempt to return to running or your usual impact loading activity until advised it is safe to do so by your doctor. Once you are pain free when you are walking and hopping, you can begin to return to your normal activity – but do it gradually!
A qualified sports physiotherapist can work with your doctor and assist you with a tailored training plan to keep you safe and pain free while slowly increasing the intensity and duration of your activities.
Remember that the injury occurred due to an imbalance in your impact loading and recovery so keep that in mind during future activity. Give your bones a chance to rest during exercise and have days of no exercise for a few weeks.
Bone injuries can occur when muscles fatigue as they are unable to absorb as much force and therefore the bones are impacted harder. Strength training, particularly in the calf and foot, will keep your muscles working well and protect your bones. Heavy strength training with 4-8 reps is ideal for optimal bone density levels.
Adequate Vitamin D and Calcium are crucial for healthy, strong bones. A GP, sports doctor or nutritionist can check your levels and provide expert advice. Sleep is also needed as that is when your body and bones recover.
Melbourne Sports Physiotherapy can help with any questions you have about foot pain. They are experienced in all foot and ankle injuries and can refer you for further investigations or scans if necessary. Call to make an appointment or book online.