What are Stress Fractures?
Stress fractures are different from a typical fracture and generally occur in a physically active person.
- Regular fractures: Typically involve one specific injury to the bone normally from a direct blow
- Stress fractures: Occur over a longer period of time as a result of repetitive application of stresses that weaken the outer surface of the bone.
What Causes Stress Fracture
Stress fractures are a result of repetitive application of stresses that is lower than the stress required to fracture the bone.
Over a period of time this stress results in injury to the cortex of the bone this is called a stress fracture.
Risk factors for Foot and Ankle Stress fractures
|Extrinsic risk factors||Intrinsic risk factors|
|– Running surface (1,17)||– Female (7, 23)|
|– Type of exercise (1, 10, 17)||– Smoking (23)|
|– Inadequate recovery period (22)||– Older age (20)|
|– Footwear (1)||– Family history (17)|
|– Altered foot mechanics (1)|
|– Previous Stress fractures (3, 7, 14)|
|– Poor nutrition (25)|
Where do Stress Fractures in the Foot Occur
Diagnosis of Stress Fractures
Diagnosis is generally made with specific signs and symptoms – when the pain occurs and the location.
X-ray can be beneficial if the stress fracture has been there for a prolonged period.
At the Ankle, Foot and Orthotic Centre we are able to provide additional information about the presence of a stress fracture with ultrasound imaging. A stress fracture will usually appear as a disruption of the normal linear pattern of the cortex of the bone.
Treatment of Stress Fractures
Initial treatment of a stress fracture involves trying to reduce the stress to the bone.
This can be eliminating the activity that is causing the stress – running or high impact activity.
Immobilisation in a CAM walker with a supportive insoles may also be necessary to allow the bone to heal
Typically stress fractures as with most bony injuries can take 6 to 8 weeks to resolve duration of healing will depend on how long the stress fracture has been present
Complications of Stress fractures
A complication of stress fracture is non union of the fracture (not healing)
There are certain high risk stress fractures that occur in the foot and ankle this is a link to an article that discusses high and low risk stress fractures in the foot and ankle
Call The Foot and Ankle Centre for further advice on professional management and treatment options.
1. Romani, W. A., Gieck, J. H., Perrin, D. H., Saliba, E. N., & Kahler, D. M. (2002). Mechanisms and Management of Stress Fractures in Physically Active Persons. Journal of Athletic Training, 37(3), 306–314.
2. Bennell, K. L. M., Crossley, K. A. Y., Jayarajan, J., Walton, E., Warden, S., Kiss, Z. S., & Wrigley, T. I. M. (2004). Ground Reaction Forces and Bone Parameters in Females with Tibial Stress Fracture. Medicine & Science in Sports & Exercise, 36(3), 397-404.
3. Bennell, K. L. M., Malcolm, S. A., Thomas, S. A., Wark, J. D., & Brukner, P. D. (1996). The Incidence and Distribution of Stress Fractures in Competitive Track and Field Athletes. The American Journal of Sports Medicine, 24(2), 211-217.
4. Bennell, K. L. M., Malcolm, S. A., Wark, J. D., & Brukner, P. D. (1996). Models for the pathogenesis of stress fractures in athletes. British Journal of Sports Medicine, 30(3), 200-204.
5. Brukner, P. D., Bradshaw, C., Khan, K. M., White, S., & Crossley, K. (1996). Stress Fractures: a review of 180 cases. Clinical Journal of Sports Medicine, 6(2), 85-89.
6. Burne, S. G., Mahoney, C. M., Forster, B. B., Koehle, M. S., Taunton, J. E., & Khan, K. M. (2005). Tarsal navicular stress injury: long-term outcome and clinicoradiological correlation using both computed tomography and magnetic resonance imaging. American Journal of Sports Medicine, 33(12), 1875-1881.
7. Field, A. E., Gordon, C. M., Pierce, L. M., Ramappa, A., & Kocher, M. S. (2011). Prospective study of physical activity and risk of developing a stress fracture among preadolescent and adolescent girls. Archives of Pediatrics & Adolescent Medicine, 165(8), 723-728.
8. Fowler, J. R., Gaughan, J. P., Boden, B. P., Pavlov, H., & Torg, J. S. (2011). The Non-Surgical and Surgical Treatment of Tarsal Navicular Stress Fractures. Sports Medicine, 41(8), 613-619.
9. Gross, C. E., & Nunley, J. A. (2014). Medial-sided Stress Fractures: Medial Malleolus and Navicular Stress Fractures. Operative Techniques in Sports Medicine, 22(4), 296-304.
10. Harrast, M. A., & Colonno, D. (2010). Stress fractures in runners. Clinics in Sports Medicine, 29(3), 399-416. Jones, M. H., & Amendola, A. S. (2006). Navicular stress fractures. Clinics in Sports Medicine, 25(1), 151-158.
11. Kelly, P. J., & Bronk, J. T. (1990). Venous Pressure and Bone Formation. Microvascular Research, 39(3), 364-375.
12. Khan, K. M., Brukner, P. D., Kearney, C., Fuller, P. J., Bradshaw, C. G., & Kiss, Z. S. (1994). Tarsal navicular stress fracture in athletes. Sports Medicine, 17(1), 65-76.
13. Khan, K. M., Fuller, P. J., Brukner, P. D., Kearney, C., & Burry, H. C. (1992). Outcome of conservative and surgical management of navicular stress fracture in athletes: eighty-six cases proven with computerized tomography. The American Journal of Sports Medicine, 20(6), 657-666.
14. Lappe, J. M., Stegman, M. R., & Recker, R. R. (2001). The Impact of Lifestyle Factors on Stress Fractures in Female Army Recruits. Osteoporosis International, 12(1), 35-42.
15. Mann, J. A., & Pedowitz, D. I. (2009). Evaluation and treatment of navicular stress fractures, including nonunions, revision surgery, and persistent pain after treatment. Foot and Ankle Clinics, 14(2), 187-204.
16. McCormick, J. J., Bray, C. C., Davis, W. H., Cohen, B. E., Jones, C. P., 3rd, & Anderson, R. B. (2011). Clinical and computed tomography evaluation of surgical outcomes in tarsal navicular stress fractures. American Journal of Sports Medicine, 39(8), 1741-1748.
17. Milgrom, C., Finestone, A., Segev, S., Olin, C., Arndt, T., & Ekenman, I. (2003). Are overground or treadmill runners more likely to sustain tibial stress fracture? British Journal of Sports Medicine, 37(2), 160-163.
18. Oddy, M. J., & Davies, M. B. (2009). Stress Fractures of the Navicular. Operative Techniques in Sports Medicine, 17(2), 115-118.
19. Otter, M. W., Qin, Y. X., Rubin, C. T., & McLeod, K. J. (1999). Does bone perfusion/reperfusion initiate bone remodeling and the stress fracture syndrome? Medical Hypotheses, 53(5), 363-368.
20. Pegrum, J., Crisp, T., & Padhiar, N. (2012). Diagnosis and management of bone stress injuries of the lower limb in athletes. BMJ, 344, e2511.
21. Potter, N. J., Brukner, P. D., Makdissi, M., Crossley, K., Kiss, Z. S., & Bradshaw, C. (2006). Navicular stress fractures: outcomes of surgical and conservative management. British Journal of Sports Medicine, 40(8), 692-695.
22. Ross, R. A., & Allsopp, A. (2002). Stress Fractures in Royal Marines Recruits. Military Medicine, 167(7), 560-565.
23. Shaffer, R. A., Rauh, M. J., Brodine, S. K., Trone, D. W., & Macera, C. A. (2006). Predictors of stress fracture susceptibility in young female recruits. American Journal of Sports Medicine, 34(1), 108-115.
24. Taunton, J. E., Ryan, M. B., Clement, D. B., McKenzie, D. C., Lloyd-Smith, D. R., & Zumbo, B. D. (2002). A retrospective case-control analysis of 2002 running injuries. British Journal of Sports Medicine, 36(2), 95-101.
25. Tenforde, A. S., Sayres, L. C., Sainani, K. L., & Fredericson, M. (2010). Evaluating the relationship of calcium and vitamin D in the prevention of stress fracture injuries in the young athlete: a review of the literature. PM & R: the journal of injury, function and rehabilitation, 2(10), 945-949.
26. Torg, J. S., Moyer, J., Gaughan, J. P., & Boden, B. P. (2010). Management of tarsal navicular stress fractures: conservative versus surgical treatment: a meta-analysis. American Journal of Sports Medicine, 38(5), 1048-1053.
27. Torg, J. S., Pavlov, H., Cooley, L. H., Bryant, M. H., Arnoczky, S. P., Bergfeld, J., & Hunter, L. Y. (1982). Stress fractures of the tarsal navicular. A retrospective review of twenty-one cases. The Journal of Bone and Joint Surgery, 64(5), 700-712.
28. Warden, S. J., Burr, D. B., & Brukner, P. D. (2006). Stress Fractures: Pathophysiology, Epidemiology, and Risk Factors. Current Osteoporosis Reports, 4(3), 103-109. Wohl, G. R., Towler, D. A., & Silva, M. J. (2009). Stress fracture healing: fatigue loading of the rat ulna induces upregulation in expression of osteogenic and angiogenic genes that mimic the intramembranous portion of fracture repair. Bone, 44(2), 320-330.