As life shows signs of returning to normality, so too will our sporting routines. For some, this may be an opportunity to start a new exercise regime to improve both physical and mental wellbeing. Regardless of the underlying reason, a sudden return to a high volume of impact exercise, seen commonly saw during each of the enforced lockdowns, has resulted in an increased presentation of stress fractures. Mr Tim Sinnett, expert Foot and Ankle Consultant, discusses this common presentation.
A stress fracture occurs when a bone is placed under higher than normal load (or “Stress”) at regular or prolonged periods. The classic textbook description is that of a ‘March fracture’: a stress fracture described in soldiers who were suddenly forced to march or run significant distances at regular intervals during their training or when on missions.
I saw a similar picture of events as many turned to daily exercise during the last three lockdowns. A patient would typically describe developing a low level pain in their foot or ankle after starting or returning to a new exercise regime. This could sometimes be followed by a sudden worsening of the pain which prevented further exercise.
Stress fractures, especially of the foot and ankle, can be difficult to diagnose unless you are seen by an experienced practitioner in their field .
Examination findings often suggest a soft tissue injury rather than a bone injury and early X-rays are often normal. An MRI scan is an excellent way of demonstrating a stress response (the pre-cursor to a stress fracture) or indeed an established fracture not visible on X-ray. The images below demonstrate stress fractures as seen on MRI.
Figure 1 shows a stress fracture to the fibula (outside of the ankle) and in Figure 2 we can see a calcaneal stress fracture.
Figure 1: A T2 weighted sagittal MRI view of the ankle demonstrating bony oedema and fracture of the fibula
Figure 2: A T2 weighted sagittal MRI view of the calcaneum demonstrating a fracture line.
The history from the patient in both cases was consistent with a stress fracture. For medical professionals, a great review on the problem of heel pain can be found here.
New runners or runners who have recently significantly increased their weekly mileage, are particularly prone to stress fractures of the metatarsals. With the advent of HIIT and Cross-fit, I have also seen an increase in calcaneal stress fractures which I have attributed to the significant loading exercises that are often part of the routines performed.
The vast majority of patients sustaining stress fractures do not require surgical intervention, but early and accurate diagnosis will prevent a lengthy rehabilitation. Often, supportive measures in the form of walking boots or splints and a graduated physiotherapy led rehabilitation is all that is required.
If a stress fracture occurs outside of a change in exercise regime then specific investigations should be made into underlying causation. Bone health is the primary focus and will require blood tests and a review of diet, medications and lifestyle. For women, an underlying sex hormone abnormality should also be considered.
If you or your patients are experiencing a low level discomfort that is not improving with simple first aid or adapting an exercise regime, then consider the possibility of a stress fracture and refer on to a Foot and Ankle specialist.