What are they?

When we talk about a stress fracture, we mean a small crack or bone edema in a bone, usually caused by overuse and repetitive activity.

It happens when the muscles become so fatigued that they can no longer absorb additional shock. Gradually, the weakened muscles transfer the overload to the bone, resulting in a small crack. This crack is called a stress fracture.

What causes it?

A stress fracture often results from a sudden increase in the intensity, duration, or frequency of an activity. This is commonly seen in new athletes who start a sport but also in experienced ones who, for example, after a rest period between competition seasons, do not resume training gradually but start with the same duration/intensity they had before the break. The likelihood of a stress fracture also increases in athletes who, apart from the sudden increase in activity, do not give their body enough time for recovery and ignore any discomfort that may appear.

Various other factors—such as training technique and nutrition—may increase the risk of a stress fracture.

Examples include:

Incorrect technique
Anything that alters the mechanics by which the foot absorbs impact forces when hitting the ground increases the risk of a stress fracture. Thus, tendinitis, a callus, a blister, or a wound can affect the loading pattern during walking or sports, resulting in overload on a certain bone.

Wrong equipment
The use of worn-out shoes or footwear inappropriate for the specific sport or athlete (depending on the loading pattern) can lead to a stress fracture.

Change of surface
A recent change in the exercise surface—such as when a tennis player switches court type from grass to clay or a runner changes running surface (e.g., from treadmill to asphalt)—can cause a stress fracture if not done gradually.

Bone insufficiency
Stress fractures can also occur in individuals with reduced bone density, as in osteoporosis or long-term use of certain medications, even during normal daily activity.

Are stress fractures more common in women than men?

Medical studies have shown that female athletes are more frequently affected by stress fractures. This is likely due to a condition known as the “female athlete triad,” which includes: eating disorders (bulimia or anorexia), amenorrhea (absence of menstruation), and osteoporosis.

However, eating disorders are not only a problem for female athletes; an increasing number of male athletes also seem to present similar issues.

Where and when do they occur?

Most stress fractures occur in the lower limbs. The tibia is the most commonly affected bone, followed by the fibula, tarsal bones, metatarsals, femur, and the pubic ramus of the pelvis. Practically, they can occur in any bone subjected to continuous repetitive loading.

Studies have shown that most stress fractures happen in athletes involved in track and field, tennis, and gymnastics. In all these sports, repeated loading of the lower limbs can cause injury. Insufficient rest between training sessions or competitions predisposes the athlete to such fractures.

Symptoms and diagnosis

Pain during activity that progressively worsens is the most common symptom and usually decreases with rest. Local tenderness, swelling, or bruising may also occur. It is important for the orthopedic doctor to take a detailed history of the athlete and be aware of various risk factors.

X-rays are often negative in the first few weeks and advanced imaging such as CT scan, bone scintigraphy, or MRI may be required to confirm the diagnosis.

Treatment

First aid
The athlete should seek advice from a specialized orthopedic doctor if they suspect a stress fracture. Ignoring it may have serious consequences: a small crack or bone edema can develop into a complete fracture.

Initially, until the orthopedic consultation, the following are recommended:

• Rest
• Ice therapy
• Compression and
• Elevation of the limb

Definitive treatment
The goal of treatment is pain relief and fracture healing, which usually takes 6-8 weeks.

Treatment depends on the location and severity of the fracture. Most are managed conservatively.

The most important factor in treatment is rest. The athlete must avoid activities that caused the injury.

Usually, the athlete can engage in activities that do not load the affected limb, in order to maintain good physical condition until healing occurs. In some cases, the use of crutches for non-weight bearing walking, special braces, or casts may be necessary.

Rarely, some fractures require surgical treatment and stabilization with internal fixation.

It is important for the athlete-patient to follow the orthopedic doctor’s rehabilitation instructions carefully to return to their sport as quickly and safely as possible. Returning to activity too early may cause the fracture to worsen or delay healing, potentially leading to chronic problems.

Prevention

Prevention is the most important factor.

Some tips:

• When starting a new sport, gradually increase the quantity and intensity of training.
• Proper warm-up.
• Cross-training with different sports to maintain overall fitness.
• Good nutrition with adequate calcium and vitamin D intake.
• Use appropriate equipment and footwear.
• Rest for a few days if pain and/or swelling occur.
• Seek timely advice from a specialized orthopedic doctor if pain persists.