Dr Sullivan Explains: Stress Fractures, how they occur, the types and the treatment.

Player X has a stress fracture or Player Y is out of practice because of persistent pain.  This type of thing is heard frequently throughout training camp, preseason and the regular season.  I thought I would explain the concept of a stress fracture before we talked about specific types of stress fractures that occur.

A stress fracture is an overuse injury. It occurs when muscles become fatigued and are unable to absorb added shock that occurs from the repetitive activity of practice and game. Eventually, the fatigued muscle transfers the overload of stress to the bone causing a tiny crack called a stress fracture. Generally stress fractures occur at sites where the muscle has been pulled away from the bone to which it is attached.

When I explain this to patients, I use the example of gluing something and inadvertently gluing your fingers together.  When you pull your fingers apart breaking the bond of the glue, you create the same type of stressors that a stress fracture does when the muscle is ripped away from the bone.  While the glue example only hurts for a second or two, a stress fracture can result in pain for 6-8 weeks while the muscle heals itself and reattaches the damaged fibers to the bone.

The simple tearing away of the muscle is a class 1 stress fracture.  With proper treatment, which is basically rest and limited stress to the area, the severity of the injury does not progress.  However, continuing to play through the pain can result in an actual microfracture of the bone itself.  Needless to say, this is a more bothersome injury.

Most stress fractures occur in the weight bearing bones of the lower leg and the foot. However, location is more associated with type of activity and certain injuries are more often associated with specific activities.

Particular locations of stress fractures are commonly associated with particular activities.  Metatarsal, Navicular, Pars Articularis, Fibular and Tibial fractures are commonly seen in football players.  Baseball players who experience Ulnar Collateral ligament injury (Tommy John) often also experience Olecranon stress fractures.  A grade 1 Lisfranc injury in the foot is associated with a stress fracture of the 1st and or 2nd metatarsal.

Pars Articularis is a stress fracture in the articulation area between the vertebrae in the spine. This could be what Derek Wolfe was suffering from, or in addition to another condition/injury.

Stress fractures are the one time a woman doesn’t want to be superior to a man.  Stress fractures in female athletes are 3 times more common in females than in males.  There are a number of theories why this is true, but the most common thought is that a lack of adequate calcium in diet can lead to an increased incidence of stress fractures. The female athlete triad: eating disorders (bulimia or anorexia), amenorrhea (infrequent menstrual cycle), and osteoporosis is a condition that has been associated with the increased rate of stress fractures in female athletes.

The most common symptom associated with stress fractures is pain exacerbated by activity and relieved with rest.  Stress fractures are difficult to diagnose because plain film x-rays are usually negative when pain first occurs.  Often times adequate treatment is delayed because appropriate diagnosis is delayed days, even weeks because the only symptom is persistent pain and sometimes mild to moderate swelling at the pain site.  Persistent pain should lead to repeat x-rays which may or may not show bone remodeling (healing), if persistent pain does not diagnose problem. MRI or nuclear bone scans maybe used to show specific localized areas of injury that may not appear on typical x-rays.

Once the diagnosis of a stress fracture is made, then comes treatment.  The most important treatment is rest. Individuals need to rest from the activity that caused the stress fracture, and engage in a pain-free activity during the six to eight weeks it takes most stress fractures to heal.  If the activity that caused the stress fracture is resumed too quickly,  harder-to-heal stress fractures can develop. Re-injury also could lead to chronic problems where the stress fracture might never heal properly, this is called persistent nonunion.

How are stress fractures prevented? Common sense is #1 – If it hurts don’t do that thing that makes it hurt.  Fans often get upset when an athlete on their favorite team is held out of a game or practice because of pain.  They think the athlete is being a wuss or is “soft” and out of condition.  This is not true.  Pain is the body’s way of telling you something is wrong.  Ignoring pain is just asking for a worse injury to occur.

Here are some tips developed by the American Academy of Orthopaedic Surgeons to help prevent stress fractures:

  • When participating in any new sports activity, set incremental goals. For example, do not immediately set out to run five miles a day; instead, gradually build up your mileage on a weekly basis.  In football players this goal is met thru the gradual build up of activity during OTA’s.  It helps explain why athletes start out with strength and conditioning before getting to on the field activities.
  • Cross-training — alternating activities that accomplish the same fitness goals — can help to prevent injuries like stress fractures. Instead of running every day to meet cardiovascular goals, run on even days and bike on odd days. Add some strength training and flexibility exercises to the mix for the most benefit.
  • Maintain a healthy diet. Make sure you incorporate calcium and Vitamin D-rich foods in your meals. Most people assume this means drinking more milk, but calcium is found in several foods you may not be ware of these include Kale, broccoli, figs, sardines, salmon,and black beans
  • Use the proper equipment.
  • Do not wear old or worn running shoes.
  • If pain or swelling occurs, immediately stop the activity and rest for a few days. If continued pain persists, seek medical evaluation.
  • It is important to remember that if you recognize the symptoms early and treat them appropriately, you can return to sports at your normal playing level.

By now everyone who reads these articles know how much I like car analogies.   A simple example of a stress fracture in a car is driving with a broken shock.  While usually the car will still roll and get you from point A to point B, it may not be the smoothest of rides.  Ignoring the busted shock long term can lead to premature tire wear, brake wear and tear and other more serious damage to the cars suspension.  The same is true in athletes.  Ignoring persistent pain can result in longer periods of nonparticipation and in some cases has resulted in premature ends to athletes competitive careers.

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