Have you been having pain in one of your feet that just won’t go away? Have you been increasing your running distance and frequency, only to find this pain progressively worsening? Is this pain interfering with your training or racing? The answer maybe deeper than you think.
A stress fracture is a “crack” in the bone, and it’s a relatively common condition in the foot of an athlete who does a lot of running and jumping.
Fractures can be categorized in many ways, but it is important to differentiate between an acute fracture and a stress fracture.
An acute fracture is caused by a sudden trauma, that can be either from a direct force (like falling out of a tree and landing on your leg), or an indirect force (like falling from the same tree, but this time getting your leg caught between two branches and twisting the bone). Unlike an acute fracture, a stress fracture is not the result of one specific trauma or force. Instead, a stress fracture is the result from repeatedly loading or stressing a bone. Our bones are constantly being remodeled. This normal process of our cells breaking down old bone and building up new bone is called remodeling and it is a cycle that goes on throughout our lives. If you increase the amount of “loading” or stress on the bones, it results in microtrauma, and speeds up, or accelerates the remodeling process. During this phase, there is usually no pain or symptoms, and X-rays will not show any significant changes. If this “overloading” of the bone continues, you will begin to have pain during your training session or run. As this mirotrauma accumulates, you may notice pain starting earlier and earlier into your run. If you continue to train, you may progress into the stress-reaction phase. This phase is characterized by progressively worsening pain. You may now have pain immediately upon running, and the pain may remain even after you stop. The pain you used to have only at the end your run is now present when you are just walking. At this stage you may also have night pain. (1). Although a MRI or bone scan may be positive at this phase, most likely an X-ray will be negative (no signs of fracture). As microtrauma continues to weaken the bone, it will eventually lead to a completed fracture. It is usually not until this phase, that an X-ray will show positive for a stress fracture.
Stress fractures of the foot are almost always related to a sudden increase in amount or intensity of an activity. “Doing too much, too soon, too often, and with too little rest.” (2). Other factors that contribute to stress fractures of the foot are exercising on a hard surface, shoes that have poor support and shock absorption and structural problems of the foot. “Menstrual and eating disorders can also cause reduced bone mineral density and increase the risk of stress fractures.” (2)
Some common sites in the foot for stress fractures are the navicular bone (found on the inside of your arch) the metatarsals (known as “March fractures”) and the sesamoid bones (beneath the head of the first metatarsal and the base of the fifth).
Treatment of a stress fracture will most importantly mean decreasing the load on the bone, preferably making it non-weight bearing. This usually means crutches, possibly casted for 4-8 weeks. The amount of time depends on where the fracture is located. The areas that have the poorest blood supply will take longer to heal. In certain cases, surgery will be indicated to stabilize the fracture site. Alternative exercises may be indicated during this time. Activities such as swimming, stationary cycling and strength training may be prescribed. Resuming activity and training must be done gradually and cautiously. All activity must remain pain free. A physical therapist will be able to treat and guide you through this important phase of recovery. It is also beneficial to evaluate the foot structurally (do you need orthotics?), assess footwear (get good shoes), modify your training program (more rest, cross training, slower progression, vary running surface, limit miles…etc). After your initial rehab, you may want to work with a personal trainer who has education and experience working with runners.
Stress fractures of the foot usually heal well if they are properly and early diagnosed and treatment protocol is followed. Addressing the above concerns will help to prevent another stress fracture.
Bibliography
1. Magee, D.: Orthopedic Physical Assessment (3rd Edition). W.B.
Saunders Company. Philadelphia. 1997.
2. Bahr, R. & Maehlum, S.: Clinical Guide to Sports Injuries. Gazette bok.
Oslo. 2004.
