Stress fractures: risk factors and symptoms

By Cristiano Antonino On Feb 18, 2022

Stress fractures: repeated sporting activities or particular biomechanical conditions subject our skeleton to functional overload stress, which the muscles are not always able to absorb

This leads to a particular type of fracture, known as a ‘stress fracture’

Marathon runners, dancers and gymnasts, jumpers and basketball players, as well as canoeists are among the sportsmen and women most at risk of stress fractures.

The same applies to those who wear reinforced footwear for long marches, such as soldiers.

This risk also exists for those who do not practise sport and lead sedentary lives, but who, due to genetic conformation or the results of trauma, are affected by alterations in the structure of the lower limbs, even if these are not obvious, which can nevertheless lead to functional overload.

What can be done to prevent them, recognise them and intervene early with appropriate treatment?

Stress fractures

Stress fractures are not (at least in the early stages) a true and complete interruption of the continuity of a bone segment (as happens in an acute trauma), but a sort of “fissuring”, due to repeated micro-fractures that the bone tries to repair, not always effectively; if the physiological limits are exceeded, it is as if the mechanism goes haywire.

If unrecognised, they can also give rise to real fractures, with the possible formation of the reparative bone callus, a sort of ‘sleeve’ that joins and welds the damaged parts of the bone.

Sometimes, if not recognised in the initial phases, also because the painful symptoms are more tolerable than those caused by a real fracture, stress fractures are only diagnosed as an “outcome”, that is, when the bone callus itself is noted on the X-ray, testifying to the fact that it has been repaired.

Traditionally, the most severely affected parts are the bones of the lower limbs and feet.

Possible risk factors for a stress fractures include:

running for many kilometres;
jumping repeatedly on hard surfaces, especially if there are morphological changes in the foot or lower limbs;
suddenly intensifying one’s physical activity routine;
dancing on your toes, as is typical of dancers (professional or not), so the location of stress fractures is typically at the metatarsal level or in some cases also at the tibia (leg).

Stress fractures: when to see a doctor?

Usually the alarm bell is a persistent bone pain, which the patient can point to in a well-located place, in the absence of a direct major trauma and very often related to physical activity.

If in the first phases of onset, with rest from physical activity the pain seems to regress, in the more advanced phases, the symptomatology persists and is present even at rest.

Sport and prevention of stress fractures

It is important to consider all possible risk factors, usually related to the bone structure and the type of repetitive activity (sport, but not only), to which the skeletal segment is subjected.

For this reason, it is essential to exercise sensibly, possibly choosing the discipline best suited to one’s physical constitution.

Muscle strengthening and increased physical activity should also be done gradually.

It is just as important to wear suitable footwear, equip oneself with sports equipment appropriate to one’s abilities, and try to alternate high-impact forms of physical activity with others that are less so.

Although in many cases of sports-related stress fractures the risk factor ‘osteoporosis’ is not considered in the first instance, it should certainly be taken into account for certain categories of patients ‘at risk’, including postmenopausal women, but also individuals suffering from endocrine-metabolic disorders that may alter the good state of health of the bone, weakening it.

Prevention is very important, as is early recognition of this type of injury, since early treatment shortens healing time, reduces discomfort for the patient, and allows a quicker return to sport.

Since stress fracture is generally not recognisable with common X-rays in its early stages (which are in any case symptomatic for the patient), in case of strong diagnostic suspicion it is advisable to prescribe an MRI examination, which offers a twofold advantage: it does not expose the patient to ionising radiation, and it allows the recognition of bone alterations from the earliest stages, before a structural alteration of the bone also forms.

What to do when stress fractures are diagnosed

With the exception of some types of fractures (e.g. femoral neck fracture, but not only), which may require surgery (i.e. stabilisation with metal synthesis means), the treatment of stress fractures is in most cases conservative.

First of all, rest is essential and, if a segment of the lower limb is affected, obviously weight bearing, using crutches.

Healing and full recovery usually takes an average of 4 to 6 weeks.

The variability is mainly due to the fact that not all stress fractures are diagnosed at the same stage, sometimes when they are already healing.

However, it is possible to accelerate the repair process by applying so-called ‘biophysical regenerative therapies’, which include magnetotherapy and shock waves.

Although different in nature, both are physical stimulations capable of inducing beneficial effects at a cellular level.

In particular, the shock wave is a mechanical stimulus that has no harmful effects on living tissue, but accelerates the metabolic activity of bone cells, as well as the production of growth factors and the growth of new small blood vessels.

Already used for a few decades to treat pseudo-arthrosis and delays in bone consolidation, Shock Waves may also be the best treatment for stress fractures in many cases, since, in addition to stimulating bone repair, they can normalise the correct remodelling of bone tissue, literally ‘stressed’ by altered biomechanical conditions.

It is a non-invasive therapy, almost free of side effects, practised on an outpatient basis, and well tolerated by the patient, if performed with appropriate instrumentation and expertise on the part of the operator.

In this regard, it is essential that the treatment is performed under ultrasound control (or at least after ultrasound “centring”), so that the treatment is “focused” exactly at the point of the bone segment affected by the stress fracture.

Prevention, early diagnosis, and timely therapeutic treatment (for which Shock Waves and any other biophysical stimuli are a valid therapeutic resource), represent the winning strategy to cope with bone “stress” and ensure a rapid return to daily activities and sport.

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