Stress fracture – what to do with a stress fracture?

Stress fracture – what to do with a stress fracture?

A stress fracture is caused by overloading the bone and is noticeable through pain in the affected body region. This is particularly common with athletes who take on too much when training. Here, you can find out how a stress fracture develops, where it can occur and how it is treated. We also tell you what you can do to avoid a stress fracture and how you can speed up the healing process. 

What is a stress fracture?

In contrast to a classic bone fracture, the so-called stress fracture (also known as a stress fracture  ) is not caused by a single traumatic event (e.g. a fall) but by many so-called micro-traumas. That is, the fracture develops slowly due to recurring local overload.

Fatigue fractures occur more often due to overloading, especially in athletes. A well-known example is the so-called march fracture of the metatarsal bone. This metatarsal fracture mainly occurs in people who have to walk, dance or, as the name suggests, march a lot.

This injury was first described in 1855, and days of marching often caused soldiers to break their metatarsals. These fractures coined the term march fracture, which is still used today.


How does a fatigue fracture occur?

A stress fracture occurs due to sustained mechanical stress on a bone. The body reacts to stress by remodelling the bone to withstand the new requirement. This is a natural process that occurs in the body every day. 

This stress response can be viewed as a precursor to fatigue fracture. The body’s protective mechanisms are insufficient if the stress is too high. The bone can no longer cope with the load, and a fatigue fracture occurs. 

Risk factors and causes of a stress fracture

In addition to long-term stress on the bone, existing malpositions, for example, of the foot or the spine, represent further risk factors for developing a stress fracture. 

Overall, women are more likely to suffer from stress fractures. 1 These are often young women, for example, dancers, who are putting too much strain on their bones due to a strict diet and physical overload at the same time. 

On the other hand, post-menopausal women are prone to osteoporosis due to hormonal changes. In osteoporosis, bone density decreases, which can more easily lead to a stress fracture. 


What is an insufficiency fracture?

The so-called insufficiency fracture can be seen as a form of fatigue fracture. Fatigue fractures, in the classic sense, are caused, as described, by excessive stress on the bone. Here, the bone itself is healthy. 

Insufficiency fractures, on the other hand, occur under a load that would be tolerated by healthy bone. The X-ray image cannot be distinguished from that of a classic fatigue fracture, but the cause of the fracture is different. The bone is weaker than usual, and for this reason, it cannot withstand the load.

Factors that can lead to insufficient bone are:

  • an inadequate diet
  • a lack of vitamin D
  • an imbalanced hormonal balance
  • osteoporosis

Symptoms: How do you recognize a stress fracture?

The symptoms of a stress fracture can gradually appear since the preliminary stages of the fracture often already exist. This can manifest in slight pain in the affected body region after training.

However, a previous load often goes undetected, and the first pains appear suddenly, for example, after a particularly hard workout. Most people describe a dull ache in the affected area that worsens with exertion.

The pain can radiate to neighbouring areas of the body. Those affected often report pain in the knee after a fracture of the fibula. Local swelling and redness are usually also visible.

Many sufferers initially take their symptoms of pain, swelling and redness for simply overloading or overstretching of the ankle or the affected area. Very similar symptoms also appear in the case of periosteum inflammation.

How is the diagnosis made?

If the pain persists for over a week, you should always consult your family doctor or an orthopaedist. In most cases, a trained doctor can already diagnose based on the symptoms described and a detailed discussion about the types of sports practised. 

An X-ray then confirms the diagnosis of a stress fracture. However, this is only possible about three to four weeks after the fracture occurs since the fracture still needs to be visible in the X-ray image. This is because the lines along which these breaks run are excellent. These fracture lines only become visible through the body’s natural decalcification and degradation processes before they heal again.

An MRICT or bone scintigraphy can provide faster evidence of a stress fracture. However, these methods are significantly more complex and expensive than X-rays. CT is also associated with high radiation exposure. In the past, therefore, these methods were used almost exclusively by competitive athletes who depended on a quick diagnosis. In the meantime, MRI has become increasingly common as a standard imaging method, so those affected often receive a diagnosis more quickly these days. 

If pain occurs again after a stress fracture has been identified, or if the pain is so severe that it is difficult to bear, a doctor should be contacted promptly in any case. 


Where can a fatigue fracture occur? 

A stress fracture can occur in any bone. The localization depends primarily on the respective load. Most stress fractures occur in the lower half of the body:

  • The fibula  (tibia) is the most commonly affected bone at 49 per cent. 
  • Then follow the seven tarsal bones (tarsus) with 25 per cent, for example, the so-called cuboid bone (Os cuboideum). 
  • The march fracture of the metatarsal bones  (metatarsal area) is also prevalent at 9 per cent. 
  • Stress fractures occur more frequently on the heel or heel bone  (calcaneus). The sports that trigger it are mainly running sports such as hiking, jogging, dancing and athletics. 
  • In sports such as cycling or golf, a stress fracture can sometimes also affect the ribs
  • Gymnasts, in particular, can suffer a stress fracture of the carpal bones due to the heavy strain that this sport puts on the hand.

Overall, it is estimated that approximately 1.9 per cent 2 of athletes experience a stress fracture each year. 

How is a stress fracture treated? 

Therapy for a stress fracture is usually limited to conservative healing methods. This means that, apart from taking painkillers and relieving the affected bone, those affected mainly have to take it easy until they have completely healed

For those affected, this means refraining from the sport that presumably led to the fracture. Physical activities that similarly stress the body should also be avoided. Prolonged sick leave may be required for sufferers who work physically to allow for full recovery. 

Gentle sports such as swimming or aqua gymnastics can be taken up during healing. Exactly when this is possible depends on the fracture type and should preferably be discussed with the doctor treating you. A gentle load should be possible after about two weeks. 

In addition, other conservative treatment options can be used. These include: 

  • stabilizing rails
  • plaster casts
  • insoles for shoes
  • orthopaedic tapes (for example, you can tape the foot with a metatarsal fracture) 
  • Walking aids for relief (“crutches”)

Stress fracture: when do you have to operate?

Surgical treatment is necessary for a stress fracture of the thigh or hip, especially at the femoral neck. Fractures in the hip area can be displaced and grow together again. If these are not treated surgically, the pelvis can be misaligned. 

Rarely do more complex stress fractures occur, which can lead to a malposition of the foot, for example, without an operation . Surgical correction is also necessary here. 

In most cases, however, surgery is not necessary.


How long does a stress fracture last? 

A stress fracture can take several weeks to months to heal completely. A common misconception of many sufferers is that the fracture is healed as soon as the pain is gone. However, there is often still a tiny fracture at this point. Those affected should, therefore, only slowly resume their training a few weeks after being free of pain. 

In uncomplicated cases, a return to work is possible six to eight weeks after a stress fracture. However, the training should be started slowly and built up continuously. It sometimes takes half a year for the rehabilitation to be complete.

How can you prevent a stress fracture? 

Ermüdungsbrüche können vor allem durch ein angemessenes Training vermieden werden. Insbesondere ungeübte Sportler sollten ihr Training langsam steigern und ihrem Körper nicht zu viel auf einmal zumuten.

Bei bekannten Fußfehlstellungen sollten orthopädische Einlagen während des Trainings getragen werden.

Especially in the winter months, you can consider taking food supplements with vitamin D tablets. Vitamin D is crucially involved in bone formation and is only produced by the human body when exposed to sufficient sunlight. In the cold season, this is not guaranteed, and a supplement is often recommended. A study has also found that high-dose vitamin D therapy can improve healing after a stress fracture.3,4

Calcium is also involved in bone formation, and there should be enough calcium in the diet (e.g., milk products and nuts ) to avoid a stress fracture or to support healing.

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