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A Physical Therapy Guide to Lower Extremity Stress Fractures

Introduction

Stress fractures are a common injury among athletes, especially runners. However, anyone can suffer from a stress fracture. In this guide, we will discuss the symptoms, causes, and top conservative treatment options for stress fractures.

Up to 20% of overuse injuries in the lower body are stress fractures.1 A physical therapist will provide guidance for activity modification to and how to gradually get back to previous levels of activity.

Table of Contents

Understanding Stress Fractures

A stress fracture is a small crack in the bone that occurs from repetitive stress or overuse. When the load placed on the bone exceeds its ability to rebuild with repetitive activities like running, marching, and jumping, the bone can develop a stress injury which includes localizes swelling in the bone that can progress to a fracture.

Stress fractures are different from acute fractures (i.e. broken bone from a fall) in that they develop over time from repetitive stress instead of one traumatic event.

The most common location for stress fractures is in the lower extremities since they bear weight with daily activities (up to 95%). Common locations include the shin, foot, and ankle particularly the tibia and second metatarsal (base of the second toe).2 However, they can occur in any bone of the body.

Symptoms of Lower Extremity Stress Fractures

The most common symptom of a stress fracture is pain that worsens with weight bearing. Typically, the pain will start slowly and progress over time if not addressed.

Other symptoms include:

  • Pain during weight-bearing activities, particularly high impact
  • A tender point along the bone fracture that elicits sharp pain
  • A dull ache after activity (although, the pain might subside with rest if less severe)
  • Redness or swelling without bruising
  • Inability to tolerate normal daily activities, sports, work, etc.

Risk Factors for a Stress Fracture

Many risk factors can predispose someone to developing a stress fracture. These include:

  • Osteoporosis (poor bone health)
  • Female gender3, specifically when hormone imbalances occur
  • Older age (over 60 years old)
  • Smoking
  • Obesity or sudden weight gain
  • Participating in high-impact sports
  • A sudden increase in activity level
  • Shoe wear
  • Flat feet4
  • Work or hobbies that require a lot of time standing or walking on hard surfaces (i.e. concrete)
  • Poor nutrition
  • Sleep deprivation
  • Sedentary lifestyle
  • Chronic use of anti-inflammatory drugs (NSAIDs)
  • Relative energy deficiency in sport (RED-S)

Diagnosing a Stress Fracture

Diagnosing a stress fracture is often a matter of ruling out other potential causes of the lower leg, foot, and ankle pain first. Thus, your physical therapist will focus on looking at your history and functional deficits. During an initial exam, you can expect:

  • An in-depth review of medical history, symptoms, and activity levels
  • A physical examination of the painful area to assess tender points and swelling
  • Assessment of risk factors for developing a stress fracture
  • Lower body range of motion
  • Leg length assessment
  • Posture and gait analysis

Imaging studies, such as an x-ray or MRI, may be ordered if a stress fracture is suspected. Imaging will likely need to be repeated several times throughout the treatment process. This is because as high as 80% of stress fractures won't show up on an initial assessment.4

What to Expect from Physical Therapy for Stress Fractures

If you are diagnosed with a stress fracture, your physical therapist will work with you to develop a treatment plan.

The first step in treating any stress fracture is initial rest from activity which overloads the healing bone. Depending on the location and severity of the injury, this may mean complete rest or just modifying your activities.

When your body is ready, your physical therapist can then progress you back to your previous activity levels while carefully monitoring the response to increasing training load. This will likely include a gradual increase in the frequency, duration, and intensity of your activities.

As you return to your normal activities you can expect guidance on how to:

  • Boost your bone health with appropriate weight-bearing activities
  • How and when to progress safely
  • Biomechanical training to reduce unnecessary strain with activity, particularly with running and jumping
  • Assessment and recommendations for footwear and/or orthotics
  • Designing a comprehensive home exercise program with a focus on regaining strength, endurance, range of motion, coordination, and balance of the affected lower extremity
  • Collaborating with your coach/trainer
  • When to consult with a dietician to address any issues with slow healing

Why Do I Need PT for a Stress Fracture?

While you may be able to manage some stress fractures on your own, seeking out the help of a physical therapist has many benefits. They will help you find the right balance between rest and activity. Thus, optimizing your speed to recovery without compromising bone health or risking future injury.

Do I Need Surgery?

Whether you need surgery or not will depend on a couple of different factors. These include:

  • The severity of the fracture
  • The risk of fracture progression
  • Location of the fracture (whether there's adequate blood flow for healing)
  • Activity level and overall health

With severe cases, poorly vascularized areas, and some athletes that want to recover as soon as possible, surgery will likely be recommended for the best outcomes.4

Preventing Stress Fractures

The best way to deal with a stress fracture is to avoid getting one in the first place. Some ways you can do this include:

  • Wearing appropriate shoes for your sport or activity
  • Gradually increasing the frequency, duration, and intensity of your activities
  • Eating a well-balanced diet rich in calcium and vitamin D
  • Maintaining a healthy weight
  • Avoiding smoking and alcohol
  • Incorporating cross-training activities into your routine to allow the body to rest
  • Listening to your body and taking breaks when you're feeling off or sore
  • Maintaining a caloric load sufficient for your activity level

Getting Conservative Treatment for Stress Fractures

Dealing with a stress fracture can be frustrating. However, it's a sign from your body that it's time to slow down and take some rest.

For the best results on your road to recovery, let your physical therapist and symptoms guide you. When you tune in and get expert advice, you will be able to get back to your normal sport and activities as soon as possible.

Get in touch with one of our specialized orthopedic CityPT therapists to optimize your recovery potential.

This guide is intended for informational purposes only. We are not providing legal or medical advice and this guide does not create a provider-patient relationship. Do not rely upon this guide (or any guide) for medical information. Always seek the help of a qualified medical professional who has assessed you and understands your condition.

References


  1. Edwards WB, Taylor D, Rudolphi TJ, Gillette JC, Derrick TR. Effects of running speed on a probabilistic stress fracture model. Clinical Biomechanics. 2010;25:372-377.
  2. Bargfeldt C, Krogsgaard M, Rasmussen SW. Stress fracture in combination with avulsion from the tibia in a marathon runner: a case report. Scandinavian Journal of Medicine and Science in Sports. 2011;21:330-332.
  3. Queen RM, Abbey AN, Chuckpaiwong B, Nunley JN. Plantar Loading Comparisons Between Women With a History of Second Metatarsal Stress Fractures and Normal Controls. The American Journal of Sports Medicine. 2009;37(2):390-395.
  4. Physiopedia. Leg and Foot Stress Fractures. Physiopedia.com. Accessed July 4, 2022. https://www.physio-pedia.com/Leg_and_Foot_Stress_Fractures#cite_ref-Queen_5-0