The Breaking point: when stress gets too much
This article: From Peak Performance "May 2017".Describes the signs, symptoms and common causes of stress fractures in runners and shows how runners can minimise the risk of stress fracture and provides rehab advice for those who are recovering from a stress fracture injury Trevor Langford looks how runners can identify the early signs of stress fracture, manage and injury once it has occurred and most importantly, reduce the risk of stress fracture before injury occurs! Stress fractures are a commonly diagnosed injury in physiotherapy clinics, with studies suggesting that stress fracture accounts for 16% of all running related injuries. Research has also ascertained that 80-90% of stress fractures occur in the lower limbs and that stress fractures are becoming more common with increased exercise participation, and occurring at an earlier age too. The purpose of this article is to help you identify the early signs and symptoms of a stress fracture and effectively manage this type of injury. This shouldn’t replace the diagnosis of a physiotherapist or a doctor of course; rather it is designed to help guide you in the right direction. Signs and symptoms A stress fracture can occur when bone cell depletion outpaces the laying down of new bone cells, which results in a weakened bone structure. This can happen when someone begins a new activity, but can also arise in experienced athletes too, when the load is dramatically increased. It is essential to be aware of what to look for if you suspect stress fracture. A stress fracture of the lower leg typically presents with swelling, redness, heat and pain, which is aggravated by running or loading, and which eases with rest or reduced load. Tenderness at the bone site is present on palpation (pressing). A ‘hop test’ is often included in a clinical assessment to determine the intensity of pain and how much load if any the patient is able to withstand. In this test, you stand on one foot (of the leg that hurts) and hop. As a very rough (but unscientific) guide, if you can hop on it, it is probably not a stress fracture (if it is a stress fracture, the pain will not be tolerable). However, a hop test would not be carried out on someone who had severe pain on walking and ascending/descending stairs. Common causes Box one highlights a variety of the factors that are known to be associated with stress fracture. Athletes, and sometimes coaches alike, often take the approach to ‘push through pain’ – either because curtailing training may be perceived as a sign of weakness or because they are unaware of the implications surrounding it. Muscle fatigue is to be expected following a heavy training session, and this should be managed using recovery strategies. However, pain affecting a bone should be very carefully monitored. Ignoring the onset of a niggle (perhaps because a big event is on the horizon), can be a common reason why a stress fracture is sustained. If a niggle does present, it’s essential to manage it appropriately using ice and soft tissue release around the involved bone - but most importantly by modification of bone loading. Barefoot running or minimalist footwear.
A stress fracture of the lower leg typically presents with swelling, redness, heat and pain, which is aggravated by running or loading, and which eases with rest or reduced load
- Irregular menstrual cycle in females and use of a contraceptive pill.
- Age – Older athletes being at greater risk.
- Race – White athletes are more at risk than black athletes.
- Anatomy – high foot arches increase risk compared to lower foot arches.
- Gait – Poor running gait increases stress fracture risk.
- Bone – Reduced bone mineral density (BMD) and reduced bone width.
- Aerobic fitness – slower runners at greater risk of stress fractures due to increased foot contact.
- Nutrition – deficits in certain nutrients can predispose to stress fractures.
- Sedentary lifestyle – those living an inactive lifestyle prior to starting running.
- Previous injuries – Those suffering previous stress fractures are at greater risk of subsequent fracture.
Extrinsic factors •
- Type of sport – Runners are particularly susceptible to stress fractures.
- Physical load – Those who cover higher mileage are more likely to be diagnosed with a stress fracture.
- Footwear – Age/mileage of training shoes (older/high-mileage shoes increase risk).
- Training / playing surface – Hard surfaces increase risk.