Stress Fractures: How physiotherapy can help

Stress fractures are overuse injuries. They occur when muscles become fatigued. Fatigued muscles are unable to absorb the load and impact from running. Therefore, a stress fracture is caused when the bones takes on the load. Stress fractures can also be caused by conditions that weaken the bone such as osteoporosis. Therefore the two types of stress fracture are:

• Excessive force through a normal bone

• Excessive force through an abnormal bone

Female athletes are more susceptible to developing stress fractures due to a condition referred to as the 'female athlete triad':

• Eating disorders (bulimia or anorexia),

• Amenorrhea (infrequent menstrual cycle)

• Osteoporosis (reduced bone density)

Stress fractures most commonly occur through the metatarsals, navicular, tibia and neck of femur. Depending on the demands of your sport, sometimes lumbar stress fractures can occur in e.g. cricketers and gymnasts.

The main reasons a stress fracture occurs are:

• A rapid increase in the amount and intensity of training

• A change in training surface e.g. switching from grass to hard court in tennis

• Inadequate support or worn out trainers

• Poor muscle conditioning

The main symptoms of a stress fracture are a localised, burning pain that comes on with activity and eases with rest, tenderness on palpation and sometimes increased tightness of muscles around the fracture site.

X-rays are normally the first step in diagnosing an x-ray. If the stress fracture does not show up on x-ray, a bone scan or MRI may be required.

Rest and protected mobilisation of a moonboot for 4-8 weeks is the best way for you to heal your stress fracture. During this time, and following this, physiotherapy treatment can commence.

When trying to determine the cause of a stress fracture, a detailed subjective and objective assessment with your physiotherapist is required. This helps to determine whether it was training load or surface that caused the injury, or whether poor biomechanics, muscle tightness, or joint stiffness may have contributed to the injury. Looking at calcium intake in diet is also important. Keeping a meal diary can be useful in determining if there is insufficient calcium in the individual's diet.

Physiotherapy treatment such as soft tissue release and dry needling of tight structures may be recommended. In order to improve shock absorption and biomechanics when running/playing sport. Joint mobilisations of stiffer joints may also be appropriate to prevent overload of the joint near which the stress fracture occurred.

Strengthening Exercises

Strengthening exercises aimed at improving stability, in particular around the pelvis, knee and foot may be prescribed by your physio. This may entail working on single leg squatting techniques, functional exercises related to running technique and strengthening of the intrinsic muscles to the foot. Progressive muscle strengthening will also help the patient return safely to their normal activities after the fracture has healed, and may be key to preventing recurrence. Strong, well-conditioned muscles help to dissipate forces that otherwise would be transmitted to bones and joints along the kinetic chain. During this time, gentle low load exercise such as swimming, cycling and using a cross trainer may be suitable.

Once the fracture has healed a gradual return to sport is recommended. Functional progression from walking to running to sport-specific skills permits the athlete to regain fitness and confidence prior to the resumption of training and competition. As a general rule training volume should not increase by more than 10% from one week to the next. It has also been recommended that every 3 - 4 weeks there is a drop in training by about 10 - 20%.

If you are concerned that you may have developed a stress fracture, contact us here for an assessment with one of our experienced physiotherapists. Alternatively, if you feel your running technique needs improvement, physiotherapist David Richards can carry out a running assessment and give you tips and exercises to improve your running biomechanics and efficiency.