Physical Therapy for Bone Stress Fractures
Feeling Stressed about Stress Fractures?
Muscle Strain or Stress Fracture?
If you are reading this article there is a good chance you have been diagnosed with a stress fracture/bone stress injury (BSI) or are wondering if your symptoms might indicate one. When we hear the word fracture most of us think about a traditional bone break in which a large force applied suddenly to a bone causes it to break. These types of fractures typically result from an accident like a fall or a car crash. Bone stress injuries, however, are quite different in terms of the risk factors, mechanism of injury and treatment approach. Let’s begin by devling a bit further into the anatomy and physiology of a bone stress injury and what symptoms might indicate you have a stress fracture.
INTRO TO BONE STRESS INJURIES
The term bone stress injury is often used when discussing stress fractures. A fracture as it is known in the traditional sense only occurs in later stages of a bone stress injury. Unlike a typical fracture which is usually the result of a sudden, large force, BSIs occur in response to repetitive submaximal loading without sufficient recovery time. This repetitive stress exceeds the bone’s elastic resistance causing structural fatigue and eventually what we know as a stress fracture. There are typically two scenarios that result in a bone stress injury. The first is abnormal stress upon a normal bony structure and the second is normal stress on an abnormal bony structure. In either case, a bone stress injury may occur.
BSIs are most often seen in weight bearing bones. Athletes and military recruits are two of the populations most susceptible to BSIs because of the high volume and repetitive nature of their activities. Running and gymnastics are two sports with higher rates of BSI among athletes. BSIs can be stratified into high and low risk categories based on the likelihood that the fracture will progress to a displaced fracture or non-union fracture and require surgery:
High Risk Stress Fracture Sites
Calcaneus (heel bone)
Fifth metatarsal
Sesamoid bones
Talus
Anterior tibia
Medial malleolus (inside ankle bone)
Neck of the femur
Head of the femur
Patella (knee cap)
Pars articularis of the lumbar spine
Tarsal navicular
Low Risk Stress Fracture Sites
Pubic ramus (lower part of pelvis)
Sacrum
Ribs
Humerus
Posteromedial tibia
Fibula
2nd-4th metatarsal shafts
HOW ARE BONE STRESS INJURIES DIAGNOSED?
If you or your healthcare provider suspects you have a BSI it is important to get imaging to determine the grade or severity of the BSI as this will determine the appropriate treatment plan. While X-rays are usually an excellent choice to diagnose a frank bone fracture, X-rays will typically remain normal in appearance the first few weeks after symptom onset with a BSI. MRI on the other hand is the most sensitive imaging modality and can detect even low grade injuries early. BSIs are staged based on their appearance on MRI (T1 and T2 are different MRI imaging techniques):
Grade 1: Periosteal edema only (periosteum is the outer surface of the bone)
Grade 2: Bone marrow edema (only on T2 weighted sequences)
Grade 3: Bone marrow edema (on T1 and T2 weighted sequences)
Grade 4: (4a) Multiple discrete areas of intracortical signal changes; (4b) Linear areas of intracortical signal change correlating with a frank stress fracture
If a reaction is seen in the outer part of the bone on x-ray it usually correlates with a grade 3 BSI while a fracture line correlates with a grade 4 BSI.
WHAT ARE SYMPTOMS OF A BONE STRESS INJURY
While the symptoms of a BSI may vary slightly based on location, they tend to follow a specific pattern. Typically BSI begins with a complaint of insidious onset of pain that is worse with activity and lessens with rest. If activity continues and the BSI progresses, pain may be felt even at rest. If the area of injury can be palpated by hand, tenderness with palpation of the bone may be experienced over that area. Soft tissue swelling may also be present over the area in the earlier stages. With a stress fracture involving the hip or pelvis, pain may be experienced in the groin and worsened when the leg is rotated inward.
“Shin splints” also known as medial tibial stress syndrome is an indicator of an early stress reaction and if it progresses can be hard to distinguish from a stress fracture.
A “hop test” is commonly used as a tool to identify a BSI, especially in the tibia, as hopping repeatedly on one leg will cause pain caused by BSI but not if it is shin splints. Similarly a “fulcrum test” can be used to identify a femoral shaft stress fracture. Because it may be difficult for you to differentiate a BSI from a soft tissue injury, it is important to seek the advice of a qualified healthcare provider.
WHAT ARE THE RISK FACTORS FOR DEVELOPING A BONE STRESS INJURY?
Risk factors for a BSI include both intrinsic and extrinsic elements that may interact differently within each person during different times in their lives and training. Identifying which risk factors are modifiable versus unmodifiable provides a target to minimize the risk of re-injury in the future. Here are some of the significant risk factors for BSI:
Intrinsic risk factors
Female sex
Older age
Skeletal structure variations
History of prior bone injury
Inadequate muscle strength, flexibility and endurance
Low energy availability (underfueling)
Menstrual cycle dysfunction
Low BMI
Low bone mineral density
Disordered eating
Low Vitamin D
Low calcium stores
Extrinsic risk factors
Inadequate recovery between training sessions
Inadequate sleep duration and quality
Inadequate post-exercise nutrition
Increasing training loads too quickly
Changing training terrain suddenly
HOW CAN PHYSICAL THERAPY HELP?
Physical therapists play an important role in the prevention and recovery from a bone stress injury. Treatment of a BSI depends on its stage and the site of injury. Typically modified weight bearing is prescribed to promote remodeling and rebuilding of the affected area followed by a gradual return to activity once deemed safe by your physician and based on repeat imaging and a reduction in symptoms. While you likely have to take some time off from the sport that contributed to the BSI in the first place, physical therapy should be a part of your recovery from the beginning. Here are some ways that physical therapists address BSI:
Screen for risk factors of BSI and provide counseling, or a referral to another professional for counseling, on how to minimize and modify these risk factors
Prescribe an exercise program for uninjured areas of the body to minimize loss of strength and fitness during recovery time
Create a progressive treatment plan for the injured body part to help it return to full strength and flexibility in preparation for return to sport and activity
Guide you through a return to sport program which includes careful monitoring of symptom response
Address other contributing biomechanical and performance factors that can reduce your risk for re-injury or other injuries in the future
If you are currently recovering from a stress fracture, now is the time to start physical therapy. If you are injured and unsure if you have a stress fracture, our physical therapists can perform an examination to help determine if a referral to an orthopedic or sports medicine physician is needed and then help support you through the recovery process. We are excited to support you in your recovery and return to the sports you love while helping you reduce the likelihood of re-injury in the future.
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First we evaluate, then we heal, then we strengthen our clients so they can reach their goals, feel better, and live happier lives. We do so by utilizing a range of core techniques and specialized treatments to reduce pain, improve mobility, enhance physical strength and deal with the underlying issues, not just the pain itself.
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