What Is a Stress Fracture?

A stress fracture is a bone fracture that develops from repeated overload. It doesn't happen suddenly, but develops gradually. When a bone is repeatedly loaded over a longer period without sufficient recovery, old bone tissue is broken down before new bone tissue has grown back strong enough. During this phase, the bone becomes more vulnerable, and small cracks (microfractures) can develop. If this loading continues, a stress fracture can result, without any traumatic event (such as a fall) having occurred (1).

Stress fractures can be divided into two types:

• Fatigue fractures occur in healthy bone that is overloaded through repeated stress (for example, during sport)
• Insufficiency fractures affect bone that is already weakened, for instance due to osteoporosis or other conditions (2)

This article focuses mainly on fatigue fractures, as seen in physically active individuals.

Who Is Affected?

Fatigue fractures mainly occur in young, physically active people who place high demands on their bodies. Women are affected more often than men. About one in five sports injuries is a stress fracture. In most cases, they affect the lower extremity (4).

Why Do Stress Fractures Occur?

Stress fractures often have multiple causes. They do not result from too much or too intense training alone, but from an interplay of various contributing factors. Further risk factors that can promote a stress reaction in the bone include:

• Low BMI and low vitamin D levels (5)
• Weakening of bone due to an energy deficit in the body, as seen in what is known as REDs (Relative Energy Deficiency in Sport) (see article on REDs) (6)
• Anatomical and biomechanical characteristics (e.g. foot deformities) (7)
• Sleep disorders
• Medications (corticosteroids, NSAIDs)
• Genetics (8)

Diagnosis

Diagnosing a stress fracture requires a careful medical history and clinical examination by your doctor. The gold standard for diagnosis is imaging via MRI (3). Based on the MRI findings, four severity grades are distinguished, with grades 1 to 3 classified as a stress reaction and grade 4 as a stress fracture. Depending on the location, a further distinction is made between low risk and high risk stress fractures (8). This is relevant for the course of treatment.

What Do We Do in Physiotherapy?

Treatment is always tailored individually to the type and location of the injury as well as the severity. In a thorough medical history discussion, we talk together about lifestyle and risk factors. Based on this, we create a personal therapy program that supports healing, prevents relapses, and enables a safe return to activity. Treatment typically begins with a phase of reduced loading, so the bone has enough time to regenerate. This rest period varies depending on severity. This is followed by a gradual increase in loading, during which we analyze and correct any faulty loading patterns. If needed, we work in an interdisciplinary way with other specialties (such as nutritional medicine, KPNI, or psychology) to optimize factors like nutrition, sleep, and stress management, thereby supporting healthy bone healing. Only once you are pain free does the structured return to sport begin, working toward your individual goals.

Feel free to reach out to our practice with any questions.

Text: Tatiana Ryll

‍_Quellen

_{(1) Vera, A. M., & Patel, K. A. (2021). Stress fractures of the foot and ankle. Operative Techniques in Sports Medicine, 29(3), 150852. https://doi.org/}

_{10.1016/j.otsm.2021.150852}

_{(2) Hackenbroch C, Weber M, Thierfelder K M. Stressfrakturen und andere stressinduzierte Verletzungen. Radiologie up2date 2021; 21(03): 247 - 267.}

_{doi:10.1055/a-1382-7166}

_{(3) Wright AA, Hegedus EJ, Lenchik L, Kuhn KJ, Santiago L, Smoliga JM. Diagnosticaccuracy of various imaging modalities for suspected lower}

_{extremity stress fractures. Am J Sports Med. 2016;44:255–263.}

_{(4) A. Abbott, M. L. Bird, E. Wild, S. M. Brown, G. Stewart, und M. K. Mulcahey, „Part I: epidemiology and risk factors for stress fractures in female}

_{athletes“, Phys. Sportsmed., Bd. 48, Nr. 1, S. 17–24, Feb. 2020, doi: 10.1080/00913847.2019.1632158.}

_{(5) Zalneraitis BH, Huuki E, Benavides LC, Benavides JM. Relation of Vitamin D Level, BMI, and Location of Lower Extremity Stress Fractures in Military}

_{Trainees. Mil Med. 2023 Jul 22;188(7-8):e1970-e1974. doi: 10.1093/milmed/usac258. PMID: 36004444.}

_{(6) Haskell, A., & Coughlin, M. J. (2023). Coughlin and Mann’s surgery of the foot and ankle (10th ed., 2 vols.). Elsevier.}

_{(7)Beck BR, Rudolph K, Matheson GO, Bergman AG, Norling TL. Risk factors for tibial stress injuries: a case-control study. Clin J Sport Med. 2015}

_{May;25(3):230-6. doi: 10.1097/JSM.0000000000000126. PMID: 24977954.}

_{(8) Hoenig T, Ackerman KE, Beck BR, Bouxsein ML, Burr DB, Hollander K, Popp KL, Rolvien T, Tenforde AS, Warden SJ. Bone stress injuries. Nat Rev Dis}

_{Primers. 2022 Apr 28;8(1):26. doi: 10.1038/s41572-022-00352-y. PMID: 35484131.}

‍