In this section Cypress Foot and Ankle expert Dr. Christopher Correa discusses stress fractures. Generally speaking, a fracture is a disruption or “break” of the structural integrity of a bone. In many cases when the term fracture is used the doctor usually is referring to a catastrophic failure where a single bone separates into two or more clear pieces on X-Ray. Typically, when these fractures occur there is a defined injury followed by immediate swelling, loss of function, and extreme pain in a quite dramatic fashion. In the world of foot and ankle these patients usually come into clinic limping, on crutches, or in a wheelchair. In contrast stress fractures are more insidious and often times present as a nagging pain which occurs on the top of the foot or anterior leg. Pain and swelling worsen with activity and relieved with rest/ non weight bearing. In most cases the patient will notice no swelling and minimal pain in the morning however the more walking they do the worse their symptoms become. Overtime these symptoms will tend to worsen and can ultimately progress into full blown fractures with the most severe cases requiring surgery to fix. Because no single traumatic event can be pinpointed in most cases the initial cause of the stress fractures is often unclear and insidious. Let’s take a closer look at what stress fractures really are and how they happen.
A stress fracture, sometimes known as a “hair line fracture” occurs when a crack forms in a bone with the overall structure remaining intact. These are very fine and difficult to pick up on X-Ray often presenting as a normal appearing bone frequently leading to this type of fracture being missed on initial X-Ray. This changes 2 weeks from the onset of symptoms where the signs of boney healing, such as callus formation around the bone, become visible on X-Ray and the diagnosis becomes clearer. While a stress fracture can occur after a trauma, such a dropping a soup can on the top of the foot, they often occur in the absences of any defined event. In most cases stress fractures are caused by low level, repeated strain across a bone that leads to eventual fatigue of the bone and failure. The reason for this is because long bones (tibia, metatarsal, any bones that is longer on one axis than all others) are not rigid and bend. This bending adding resilience to the bone making it resistant to repeated stress. As a comparison the harder and stiffer bone is the more brittle it is causing an increase in fracturing and shattering, much like a pane glass window. This is sometimes seen in a rare condition known as osteopetrosis where the cortex of a bone because thickened and hardened making the bone stiffer. A simple analogue to this is bending a paperclip, you can bend it maybe 4-5 times before the material fails and the paperclip breaks.
Symptoms of Stress Fractures
Symptoms of stress fractures are pain and swelling aggravated by activity and relieved by rest. Often times the foot is not swollen at all 1st thing in the morning and worsen throughout the day. As mentioned earlier most patients cannot identify a single event that caused the injury, but they often fall into one of two scenarios. Either the patient participates in a level of activity that is far above and beyond their normal activity level or they are participating in some activity wearing shoe gear that is inappropriate for the activity. An example of the former would be a person who is relatively sedentary that runs a 10K out of the blue one day “just to prove that he/she can”. An example of the latter would be a well-seasoned athlete running the same 10K on concrete in flip flops or barefoot. Who is at risk for stress fractures? People most risk at stress fractures are
1. People who are older and have decreased bone mineral density.
2. People who are low on Vitamin D.
3. People who are relatively sedentary and attempt to increase their activity greatly for one reason or another.
4. Excessive activity in old/ broken/ inadequate equipment. Treatment for stress fractures includes immobilization in a walking boot, non-weight bearing, Lab work including vitamin D level and in rare occasions bone stimulators or surgery if the bone fails to respond to conservative care.
How can you prevent Stress Fractures?
1. Vitamin D supplementation. This is a simple preventative tip and it is present in many of the cases of stress fractures in younger people. Vitamin D is important in bone health by allowing the bone to absorb calcium and phosphorous. Without vitamin D these materials slowly leech away from the bone weakening the overall structure. Activation of vitamin D in the human body requires exposure to sunlight and with the increase in indoor work complicated by a lack of outdoor activities and increased social isolation due to Covid-19 podiatrists have seen an exponential rise in vitamin D deficiency and stress fractures. For most people this can be countered by taking a one-a-day multivitamin.
2. Train – Many people young and old develop stress fractures after engaging in an activity level above and beyond what their normal daily activity is. This can be counter by:
A. a daily exercise routine with someone as simple as walking or
B. a targeted, gradually increasing exercise routine gear towards preparing your for a specific even such as running a marathon.
If you believe you are suffering from a stress fracture make an appointment with the experts at Select Foot and Ankle Specialists today and take the first step towards recovery!