Lower Extremity Stress Fractures/
Why does it occur?
Stress fractures of the foot and lower extremity are typically caused by overuse or a sudden increase in activity to a normal bone. Insufficiency fractures are fractures that occur from normal stresses to an abnormal bone. Often, fractures to the lower extremity can be caused by a combination of stress fractures and insufficiency fractures.
One of the most common presentations for stress fractures is the novice runner who decides to start improperly training for a marathon. Impact to the bone with activities such as running or jumping causes micro-trauma. If a patient does not allow enough recovery time, an imbalance occurs in the bony remodeling process which can lead to a stress reaction. If the activity and trauma continues, this stress reaction can cause a break in the bone called a stress fracture.
Insufficiency fractures can also occur without overuse or activity increase in patients with osteoporosis or other conditions that contribute to bone weakening (Vitamin D deficiency, bone tumor, etc…). Other risk factors are women with eating disorders, or who train to the point of losing their normal menstrual cycles.
The rise of increased amount of sports and sports specialization in America has increased the incidence of overuse problems such as Stress Fractures. Unfortunately, many coaches and parents have advocated significantly increasing the amount of practice throughout the year. While this potentially does improve an athlete’s skills, it does so at the expense of causing increased overuse injuries. We clearly understand that there are significant pressures of potential college aspirations, perhaps parental pushing of the child, and just a child’s want to get better at a sport. However, this imbalance of over training an adolescent child to the point of injury remains as one of the biggest problems we face in sports medicine.
Stress reactions and fractures should be taken seriously. An untreated stress fracture can go on to require surgery and therefore following treatment protocols is extremely important.
Patients normally present with pain that increases with weightbearing or activity. Most patients have no history of trauma, yet commonly report some form of overuse or activity increase.
An x-ray is usually ordered to assess the bone for any obvious fracture lines. Early on, however, stress fractures may not be seen on x-ray. By the time a stress fracture is visible on x-ray, the stress fracture is already severe. In these cases, an MRI may be ordered given MRI’s are highly sensitive for stress fractures and stress reactions.
The most important aspect of treatment is activity modification. The offending activity must be stopped. Patients with stress fractures are often our most active patients and do not want to stop the offending activities. While we value and understand the importance of exercise and sports, a stress fracture must be taken seriously. If a stress reaction or fracture is not treated properly, surgery may be indicated.
Depending on the severity and duration of the pain, Dr. Steven Lee may advise non-weightbearing with crutches for patients who experience pain with walking. Dr. Lee may furthermore recommend that the patient wear a CAM boot if the stress fracture is located in the foot/ankle region. Patients are usually instructed to remain non-weight bearing until they no longer experience pain with walking. A gradual return to weight bearing is then usually instituted.
Dr. Lee may order blood work or recommend that you see a specialist for further evaluation and management of underlying bony pathology such as osteoporosis, bone tumor, or Vitamin D deficiency if suspected.
Surgery is usually indicated in patients that fail to heal or develop a visible fracture line that displays any evidence of displacement or non-union. Surgery is also usually advised to address bone tumors in order to remove the tumor and fortify the bone.
It is very important to note that the majority of stress fractures can be managed non-operatively if the patient is willing to adhere to strict activity modifications.
*It is important to note that all of the information above is not specific to anyone and is subject to change based on many different factors including but not limited to individual patient, diagnosis, and treatment specific variables. It is provided as an educational service and is not intended to serve as medical advice. Anyone seeking specific orthopedic advice or assistance should consult Dr. Steven Lee or an orthopedic specialist of your choice.
*Dr. Steven Lee is a board certified orthopedic surgeon and is double fellowship trained in the areas of Hand and Upper Extremity Surgery, and Sports Medicine. He has offices in New York City, Scarsdale, and Westbury Long Island.