Preventing a Stress Fracture

As spring arrives and the London Marathon is in a few months, at Physio Remedies we are starting to see more running injuries. We know that most running injuries are caused by overuse, and it is always advisable to follow a training plan that builds volume slowly. As Emily, our triathlon coach said in a recent blog, ‘always follow the 10% rule’. However, it is estimated that one in five runners will sustain a stress fracture.

Stress fractures can be tough to diagnose and tough to manage. It is generally believed that stress fractures are mainly down to the high impact forces of hard surfaces. However, a study of 320 athletes showed that only a fifth of stress fractures could be related to an increase in running mileage and/or the transition to training on a hard surface.

The truth is that many stress fractures are down to biomechanical imbalances - something our physios are highly experienced in spotting and treating. So here, we share our top tips on what you can do to help prevent a stress fracture.

What is a Stress Fracture?

A stress fracture is a hairline crack in a bone caused by repeated stresses which are individually insufficient to fracture it. A bone stress fracture is preceded by bone stress or bone bruising which although can be seen on MRI, cannot be picked up on xrays, and may not show any external evidence of injury other than pain on activity. The most common stress fractures (especially for runners) are in the lower leg tibia (23.6%). However they can also occur in the foot - mainly the navicular and metatarsals, as well as in the hips, femur and pelvis.

Sometimes a stress fracture in the tibia is mistaken for ‘shin splints’, as both are caused by cumulative trauma, and present with similar symptoms. They occur when the tissues become overloaded and cannot absorb the shock of repeated impact.

Symptoms of a stress fracture are typically:

• Bone pain that worsens with weight-bearing or repetitive use, particularly impact

• Sudden pain during or after exercise

• Localised swelling that is getting worse – this is seen on superficial bones such as in the shin and forefoot, but difficult to ascertain in the femur for example

• Localised tenderness

• Persistent pain at rest or at night

• Pain increases with activity unlike tendinopathy which tends to decrease with activity

It is always important to seek medical advice and a diagnosis - especially if pain continues after three weeks of self-management - that involves rest, ice and compression. Continuing the aggravating activity will make things worse.

Preventing a Stress Fracture

Sudden increases in mileage or volume can lead to a stress fracture. Increases in frequency and intensity can also contribute to bone stress injuries.

If you are running or even walking at high mileage, or have made a change to your volume or intensity, you should also pay attention to your nutrition and recovery. That includes enough sleep and managing stress levels. For the body to absorb important minerals for bone strength, it is also advised to ensure that you have enough Vitamin D.

Warming up properly before exercise is another key preventive measure. However, stress fractures are usually the result of overlooked imbalances in strength and/or flexibility. By strengthening certain key muscles, you may help to prevent stress fractures.

Physio for stress fracture prevention

Our specialist physiotherapists can assess you for any biomechanical issues and areas of weakness. They can also provide an individualised exercise plan to improve your strength and flexibility, and make sure that your running technique is as good as it can be.

Some areas they may assess include;

General strength and core stability - if the proximal body (core and glute muscles) is weak there may be additional load and stress on the distal structures. It is important to include a strength and conditioning program into your training program, rather than just running. Our physios can assess for any strength deficits and design a program to help you improve this.

Calf tightness - tightness in the calf causes a premature lifting of the heel while running, which transfers a significant amount of force into the forefoot. It is recommended that you carry out regular calf stretches after running.

One study found that individuals with tight calves were 4.6 times more likely to sustain a metatarsal stress fracture.

Toe muscle weakness - any weak area of the metatarsal can be put under repeated stress. By strengthening weak digital flexors you can help minimise the risk of metatarsal stress fractures. They can also check your footwear for signs of weakness (high heels can be a cause).

Running gait - a stress fracture can be a result of poor running mechanics.

Improving your stride mechanics alongside strength and flexibility exercise, will not only reduce risk of injury, but can improve your running performance.

Treatment for a Stress Fracture

If you have symptoms of a stress fracture and need a diagnosis, or if you need to treat and prevent future stress fractures, we can help you. Book a consultation with our expert foot and ankle team here at Physio Remedies - we can always refer you for scans for a definitive diagnosis to help determine the correct treatment plan. An MRI is the gold standard for diagnosing a bone stress injury.

We can help you with footwear modifications, orthotic treatment and training advice. We can also help with your rehabilitation, including non-impact/cross training exercises using our fantastic facilities at the Lansdowne to help you safely return to activity.