Stress Fractures

Stress fractures are microscopic cracks in the bones that bear weight, such as the hip, leg, and foot. They are caused by increased loading and overuse, such as repeated jumping or running long distances. They are common among military recruits, athletes, and runners. Stress fractures can also develop with normal activity levels when the bone is weaker due to osteoporosis (low bone density). Sudden increases in the amount or type of activity done, such as starting to train for a marathon, can result in a stress fracture. Pain from a stress fracture can occur several weeks after onset of activity and typically begins with pain after activity and progresses to pain during activity and, in severe cases, can cause pain at rest.

Stress fractures can occur due to abrupt increases in activity or training. Several factors can contribute to the development of stress fractures, including:

• Being a white female
• Being post-menopausa
• History of a prior stress fracture
• Family or personal history of osteoporosis or osteopenia (low bone density).
• Metabolic abnormalities such as thyroid dysfunction, vitamin D or calcium deficiency, smoking, or certain medication use such as steroids can impact bone health.

The symptoms can vary depending on the fracture’s location, the injury’s severity, and the individual’s activity level. Common symptoms include:

1. Pain worsens with weight-bearing activity (waking, running, or jumping) and often improves with rest. As the stress fracture worsens, the pain may become constant, persisting even at rest.
2. Limping, difficulty participating in activity or sports.

It’s important to note that stress fracture symptoms can mimic those of other conditions, such as tendonitis. Therefore, an accurate diagnosis is crucial for appropriate management and treatment. If a stress fracture is suspected, reducing or stopping the activities that cause pain and seeking evaluation as soon as possible is recommended to prevent further injury and ensure proper healing.

Diagnosing stress fractures involves a combination of clinical evaluation and imaging tests.

Your UCSF Women’s Sports Medicine Center physician will review your medical history and symptoms and ask detailed questions about your activity level, training program, and other risk factors that could be associated with a stress fracture. They will then perform a comprehensive examination evaluating your gait, checking for strength and tenderness, and, importantly, ruling out other diagnoses.

X-rays are important to evaluate the joint. However, stress fractures often do not appear on X-rays, as a stress fracture involves microscopic changes to the bone. If a stress fracture is suspected but is not visible on an X-ray, further tests may be recommended, such as:

• Magnetic Resonance Imaging (MRI): MRI is the best way to diagnose stress fractures. It can visualize lower-grade stress injuries (bone stress reactions) and differentiate them from stress fractures.
• Computed Tomography (CT) Scan: A CT scan can show stress fractures in greater detail than regular X-rays, particularly in complex bones.

Stress fractures are divided into high-risk and low-risk fractures. Treatment depends upon the specific stress fracture. Generally, low-risk stress fractures can be treated non-operatively. Still, they can take weeks to heal with rest, activity modification, and a short period of immobilization or offloading of the bone. With rehabilitation, athletes can gradually return to their pre-injury activity level. In high-risk stress fractures, surgery may be recommended to stabilize the bone and prevent it from going into a complete fracture.

Other aspects of your health essential to treating stress fractures include assessing your bone density, nutrition, and loading patterns. If you have a personal or family history of low bone density or a diagnosed stress fracture, a DEXA scan will help assess your bone density. Following DEXA scans over time is important to understand how bone density changes with treatment. Our comprehensive treatment plan includes a detailed evaluation by our dietician to optimize your nutrition and an individualized physical therapy program aimed at helping you safely return to impact activities.