Stress Fractures of the Foot
Why do stress fractures of the foot occur?
Stress fracture of the feet are minor cracks or bruising over the bone/s of the ankle or foot. Such cracks and bruising are usually a result of repetitive injuries and overuse/abuse of ankle and foot bones and are reported more frequently in athletes.
Stress fractures comprise approximately 15% of all sports related injuries(1) and affect up to 20% of all military recruits due to training-related activities. In most cases, stress fractures heal spontaneously with conservative treatment such as rest and over the counter pain medications without requiring any other medical treatment. However, putting too much pressure over a healing stress fracture can lead to delayed healing or even a complete fracture.
What are some classical symptoms of a stress fracture of the foot?
Even though the intensity and severity of symptoms may vary, the characteristic symptoms of stress fracture of ankle and foot include:
- Severe pain, which is usually sudden in onset but may be gradual in some cases. The pain generally worsens with activity and gets better with rest.
- Swelling can be evident at the site of stress fracture, mostly in the ankles
- Appearance of bruising or visible changes of the overlying skin.
- Tenderness on touch.
Causes of stress fracture of ankle and foot
Stress fractures are caused by:
- Physical activity: A sudden but poorly compensated increase in the physical activity (such as a sudden increase in training) is the most common cause of stress fractures.
- Insufficiency of bone: Certain diseases such as osteoporosis, vitamin D deficiency, and use of certain medications can also lead to stress fractures. It is believed that female athletes are more prone to develop stress fracture as compared to male athletes.
- Poor conditioning: Poor maintenance or incomplete healing of a previous stress fracture or related injury is one of the leading causes of complex stress fractures that may lead to a complete fracture of the bone. This happens most commonly during winter, when conditioning and warm-up are more important.
- Use of improper exercise techniques: The bones of ankle and foot are responsible for bearing and balancing the weight of the entire body, especially during exercise. The musculoskeletal framework of foot also serves as the body’s shock absorber. Therefore, the correct technique is critical when starting a new exercise or workout regimen.
- Road Surface change: A change in the surface area, such as jogging on a hard surface or switching from jogging on grass can increase the risk of stress fractures.
- Improper shoes: Using inadequate gear (such as tight shoes or ill-fitting footwear) can interfere with the capacity of foot to act as a natural shock absorber and can lead to stress fractures.
How to diagnose or identify stress fracture of ankle and foot?
1. Physical examination
A thorough physical examination is one of the basic methods of assessing any fracture. This should start with your healthcare practitioner asking you about your medical history, drug history, activity status, occupation history etc. then a thorough examination of ankle and foot is done looking for visible or concealed signs of fracture as well as associated signs and symptoms such as tenderness and swelling etc.
2. Laboratory tests
Laboratory tests such as the blood levels of vitamin D and calcium are also useful to exclude metabolic factors and minimize the risk of future stress fractures.
3. Imaging tests
Some commonly used imaging tests to diagnose stress fractures include X-rays and magnetic resonance imaging (MRI). Both of these imaging tests are fairly sensitive and helpful in detecting stress fractures.
Treatment of stress fractures of ankle and foot
Treatment of stress fractures is usually conservative and non-surgical.Specific Treatments for Stress fractures include:
- Use of non-steroidal anti-inflammatory medications.
- Use of crutches for optimal weight distribution to ensure early recovery or healing.
- Switching to low-impact activities such as swimming or cycling.
- Use of protective foot wear.
- In highly mobile or high risk patients, use of casting or plaster can help in keeping the bones aligned; without increasing the risk of complications or delayed healing
- Calcium and vitamin D supplements are also helpful in enhancing the speed of recovery.
Rarely in complicated cases surgery may be needed. In these cases Internal fixation can done by plates, screws, and pins to hold the bones in place.
- Complete recovery from stress fracture is usually achieved within 8 weeks. In case of complete fractures the healing time is prolonged to a few months.
- Special care is required to prevent re-injury to ankle or foot in order to avoid serious complications.
- A follow up is CT scan is usually recommended
Prevention of stress fracture
Following are preventive measures that are used for the long-term management of stress fractures:
- Maintenance of healthy diet
- Using correct and appropriate techniques and equipment
- Try to start any new activity slowly and progressively
- Do not over stress the body
- If any swelling appears, stop the activities.
- Regularly change or even alternate your shoes to change the stress patterns on your foot bones.
- Cameron, K. L., Peck, K. Y., Owens, B. D., Svoboda, S. J., Padua, D. A., DiStefano, L. J., … & Marshall, S. W. (2013). Biomechanical risk factors for lower extremity stress fracture. Orthopaedic Journal of Sports Medicine, 1(4 suppl), 2325967113S00019.
- Warden, S. J., Davis, I. S., & Fredericson, M. (2014). Management and prevention of bone stress injuries in long-distance runners. journal of orthopaedic & sports physical therapy, 44(10), 749-765.
Janet D. Pearl, MD, MSc is the Medical Director of The Center for Morton’s Neuroma and Complete Spine and Pain Care, an interventional and integrated Pain Management program located in Framingham, Massachusetts. Previously, Dr. Pearl was the Co-Director of the Pain Management Center at St. Elizabeth’s Medical Center, where she was also the Director of the Fellowship program. She is the former Director of a satellite pain center of the Brigham and Women’s Hospital, Pain Management Center, located at the HealthSouth Braintree Rehabilitation Hospital. Dr. Pearl held academic appointments at Harvard Medical School and Tufts Medical School. She serves on the Health Care Services Board of the Commonwealth of Massachusetts Department of Industrial Accidents since 2000 as one of its physician representatives and is Chair of the Committee on Pain Management.