Treatment and Prevention of Stress Fractures

The Basics of Stress Fractures

If you start having pain and swelling in a specific location that seems to come out of the blue and continues to escalate, you may have a stress fracture. Often, there will be a slow buildup of pain in the isolated area. Stress fractures can happen to any bone in your body, but they are more likely to happen  in your feet or lower legs. The metatarsals are a common location and the area right behind your second toe is a prime location for this injury.

Pain and swelling just behind the second and third toes can also be a sign of capsulitis (inflammation of the soft tissues and ligaments surrounding a joint). This is the warning that your body gives you before it goes into 3-alarm mode. The key difference, though, is the amount of pain experienced. Capsulitis is around a 3-6 (on our pain scale) and a stress fracture is more like an 8-10.

The metatarsal bone is the most frequently injured one, but there are certainly cases where a stress fracture develops in the midfoot or heel. They are not usually seen in the toes, however. This can be attributed to both the mobility and lack of weight-bearing function for your lower digits.

The reason for the prevalence of stress fractures in the metatarsals comes down to the amount of force placed on the area. Even when walking, which is a relatively low-impact activity, you still place at least double your bodyweight on the forefoot. When you walk or run often, you are placing what we call “repetitive load to failure” on at-risk bones. This is the same effect that occurs when you start bending a metal coathanger. At first it is very stiff but weakens with each bend or cycle of stress. If the force is allowed to continue, it will lead to complete failure.

Essentially, stress fractures develop when bones are subjected to forces they aren’t used to, and without being given enough time to recover before additional stress loads are placed upon them. Repeated overuse and application of physical stress can lead to imbalance between the resorption and growth processes your bones naturally go through on a regular basis. Bones adapt at a much slower rate than muscles do, so it is common for a stress fracture to develop after muscles have adapted and peaked in strength from training while bones are trying to play catch-up in strength.

Repetitive forces can actually be a good thing–bones not subjected to a safe amount of force do not remodel correctly and can atrophy. But failing to provide bones with adequate rest increases the likelihood an individual will sustain a stress fracture.

Runner holding ankle on bridge, with backpack

Vitamin D3, Skin Cancer Prevention, and Stress Fractures (Oh My!)

In addition to the force loads, there are other issues that can put bones at heightened risk. A key one is a lack of vitamin D3.

When people think about strong bones, calcium is the nutrient that likely comes to mind first. Calcium is certainly important, but it is vitamin D3 that enables bones to properly absorb the calcium. This is a bit of an issue, since most people are low in this essential vitamin. (In over 20 years of testing, we’ve only found one patient who tested for the proper amount.) There may be other issues at play, but a big one comes down to awareness and education on skin cancer.

Wait, what? Well, your body has the ability to make vitamin D3, but it requires sunlight. Given the awareness and education on melanoma, many people apply sunscreen if they are going to be outside for extended periods. Others simply stay inside more often. This is good for skin cancer prevention, but not for producing vitamin D3.

This would be a bit more of a catch-22 situation (you have increased odds of skin cancer if you’re in the sun, but you need sunlight for that important vitamin), except there’s a third option. You can protect yourself from harmful UV rays and supplement the vitamin D3.

If you are going to supplement—and you absolutely should—don’t bother with the tablets at your local grocery store. Your body doesn’t efficiently absorb the vitamins and those kinds of products are poorly regulated. Instead, consider a liquid capsule or, even better, a product called Replesta.

Early Detection and Treatment is Always Your Friend

Paying attention and catching the issue early can shave time off of the amount of time it takes to heal from this injury. Ultrasound imaging is very effective in diagnosing early stress fractures. Treatment will be more aggressive by the time x-rays demonstrated fracture lines or a mushroom cloud of new bone surrounds the damaged bone, so early detection is really the key and can help you prevent the condition from worsening.

With regard to treatment options, the gold standard is to completely offload any forces on the affected area. This is assisted with a removable boot, allowing you to have a certain degree of mobility. This is of significant importance if you want to keep the healing time to a minimum. Unfortunately, I see patients that do not want to offload the foot and believe a small post-op shoe will protect the area. This will provide almost no benefit and extend the recovery time three to four times longer.

At-home care measures for a stress fracture are centered on rest, ice, and slowly resuming activities over time (and after you’ve been cleared to do so!). Rest allows your body the opportunity to perform natural healing functions, while ice reduces levels of pain and swelling. It is essential to ease back into your physical activities, but only when, once again, we determine it is safe for you to do so. Gradually resuming your activities reduces your risk of injury.

The good news is that there are steps that can be taken to lower your risk of suffering a stress fracture. We’ve already covered the importance of vitamin D3, but other important measures include:

  • Cross-training. Not only does incorporating low-impact activities into your workout regimen lower your risk of injury, it also leads to greater overall levels of fitness.
  • Eating well. Proper nutrition is essential for making sure that your bones are strong. Eat lots of foods that contain calcium and vitamin D3.
  • Making gradual workout changes. Whether you are just starting a workout program or have decided to ramp up your existing routine, do so gradually. It is better to start at a light level and slowly progress instead of trying to do too much and ending up with a stress fracture or other injury.
  • Wearing proper footwear. Shoes should always be activity-appropriate, fit properly, and offer ample cushioning and arch support to assist in the distribution of forces. Custom orthotics can also serve a great benefit in correcting alignment issues that make one more susceptible to overuse injuries.

 “Stix and stones may break your bones”… but repetitive trauma can really harm you. An improperly treated stress fracture may allow the metatarsal to change in position and become slightly elevated when it heals. This allows the adjacent metatarsal to become overloaded and repeat the stress fracture process in the future, creating a dominoes affect.

Stress fractures are fairly common and may not seem like a big deal (since they are tiny cracks), but you don’t want one to turn into a major issue. Instead, contact us if you think you have this injury at the earliest opportunity. To request an appointment, or if you would simply like more information, dial (317) 545-0505 and our staff will be happy to help.