Stress Fractures

Prevention and Treatment
Strategies for Stress Fractures.

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Stress fractures are small cracks in the bone caused by repetitive stresses or overuse, such as the repetitive impact on the bones of the lower leg and foot during running and jumping activities. This injury commonly occurs in the weight bearing bones of the feet, upper and lower legs, and hip area.

Any athlete may encounter this injury but those with lower bone density due to genetic, metabolic or dietary issues are more susceptible. Women may be more susceptible as well due to irregular or absent menstrual cycles, eating disorders or osteoporosis. Recovery time usually ranges from six to ten weeks.

What is a stress fracture?
When bones are subjected to stresses they adapt, just as muscles do, to become stronger. To increase in strength they must rob calcium from one area to build another. This weakens that area and new, and repetitive, stresses on that weakened area can cause a crack. This fracture is a result of the bone's inability to handle the stress over time.

Weakened bones, due to old injuries or other conditions, are much more susceptible to stress fractures because they are unable to handle the new stresses applied to them. Athletes with compromised bone density must be very careful when increasing their work load.

Increases in intensity, duration or frequency can lead to stress fractures due to the process of repair and rebuilding being interrupted. The bones need adequate rest time to rebuild and restructure. If unable to repair, the bone will weaken and become susceptible to fracture. Treatment must be initiated as soon as possible to prevent further damage and a more severe fracture.

What sports and activities are most vulnerable?
While stress fractures can occur in any sport, they are most common in high impact sports of a repetitive nature. Sports such as basketball, track and field, dance, gymnastics and tennis are all examples of sports with a high frequency of stress fractures.

Athletes in any sport can fall victim to stress fractures if their form, posture or technique is incorrect or conditions change without a chance to adapt. Changing playing surfaces or using worn shoes, with poor support, can increase the risk as well. Increasing training loads too quickly or changing intensity without a period of time to adapt will make athletes more susceptible.

Anatomy of stress fractures
Stress fractures can occur in any bone that is compromised due to weakening when repetitive stresses are applied to it. Some bones are more commonly affected. Those bones that regularly bear weight and therefore receive the most shock from high impact activities are more susceptible.

The tibia (the larger of the two bones in the lower leg, referred to as the shin bone) is the bone involved in the highest percentage of stress fractures. The fibula (the other lower leg bone), the metatarsals (the long bones extending from the heel to the toes), and the femur (the thigh bone) are also commonly involved.

Causes
Stress fractures are caused when repetitive stresses are applied to a weakened bone. This is a chronic injury, which means that it does not happen from a one time event, but over an extended period of time. Improper equipment (worn or improper shoes), muscle imbalances, or improper running and walking gait can all cause stress fractures.

The muscles are designed to act as shock absorbers during impact activities. They take the stress off the skeletal system and the internal organs. When the muscles become fatigued due to a workload that is more than they can handle they will no longer be able to work as shock absorbers. The load is then transferred to the bones. The force is transferred through the bone until it reaches a weak area where it causes a small crack. Over time, that develops into a stress fracture. This process is known as the fatigue theory.

When the human body is subjected to a slight increase in workload it will adapt by getting stronger. The bones, tendons and muscles will all change to handle the increase. If the workload is increased too quickly the body is unable to adapt quick enough and the stress is transferred to the foundation of the body (the skeletal system.) If there is a weakness in any part of the skeletal system this increase in stress will cause it to succumb to the pressure and crack. This process is known as the overload theory.

Symptoms
Symptoms of stress fractures are fairly focused. Pain usually increases with weight bearing activities and diminishes with rest. Pain is most severe at the beginning of the activity then subsides in the middle of the activity and increases in severity near the end. The pain continues as a dull throb after the activity. Swelling and point tenderness around the site of the fracture may also occur. The pain will gradually get worse and may occur earlier in the workout over time. If left untreated the pain may become unbearable.

Prevention
Due to the extended recovery time (6-10 weeks), preventing stress fractures is of major importance. Gradually increasing workloads at a rate of no more than 10% a week and varying the training by using cross training techniques will help to off set the overload and repetition often associated with stress fractures.

Warming up properly and preparing the body for the workout will help to keep the muscles from fatiguing as quickly. This will also prevent injuries to the muscles and tendons, which could lead to further weakening of the bones. Injuries to the muscles, tendons or ligaments that support the skeletal system could lead to excess, and awkward, pressure on the bones.

Flexibility is essential as well. Muscles that are flexible will provide more support and, due to their elasticity, absorb more shock. They are also less susceptible to injury, which could lead to an imbalance or improper gait. Stiff muscles will also lead to incorrect running and landing patterns that could lead to extra stress.

Stretching is one of the most under-utilized techniques for improving athletic performance, preventing sports injury and properly rehabilitating sprain and strain injury. Don't make the mistake of thinking that something as simple as stretching won't be effective.

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Using proper conditioning strategies before starting a new activity or beginning competition will also help. Strengthening the muscles (especially those in the legs) will keep them from fatiguing too early and allow them to effectively absorb the shock of the activity. Strength training will also help to strengthen the bones. Stronger muscles will support the body and help maintain proper form during running and jumping activities.

Nutrition is another important preventative measure for stress fractures. Increased nutritional intake of calcium and vitamin D will assist in bone growth and regeneration, which is vital to preventing stress fractures.

Treatment
Rest is the first step in treating a stress fracture. Stopping the activity that has caused the injury and resting the injured area is essential. Ice and elevation are also important in short term treatment. Over the counter non-steroidal anti-inflammatory medicines will help as well.

For minor stress fractures simply resting and avoiding the offending activity until pain is eliminated may take care of it. However, if the pain returns after re-starting the activity it may be necessary to see a medical professional.

Another helpful method for improved recovery is the use of ultrasound and heat. Ultrasound, or TENS (Transcutaneous Electrical Nerve Stimulation) simply uses a light electrical pulse to stimulate the affected area. While heat, in the form of a ray lamp or hot water bottle, is very effective in stimulating the damaged tissues.

Some stress fractures require immobilization or reduction of weight bearing stress. An air cast, immobilizing boot, or even crutches may be required.

It is important to keep active during the rest period with no-impact activities such as swimming, biking or weight training. This will make the return to activity less painful.

When it is time to return to activity, usually 4-8 weeks after the injury, it is important to work back gradually and identify the error that originally caused the injury and avoid the same mistakes.

If you enjoyed this issue of The Stretching & Sports Injury Report, please feel free to forward it to others, make it available for download from your site or post it on forums for others to read. Please make sure the following paragraph and URL are included.

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Article by Brad Walker. Brad is a leading stretching and
sports injury consultant with nearly 20 years experience
in the health and fitness industry. For more articles on
stretching, flexibility and sports injury, please visit
The Stretching Institute.
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