Stress fracture

Stress fracture, also called fatigue fracture, is a bone injury resulting from repeated stress on a bone rather than a single intense traumatic force.

Introduction

It usually occurs in areas subjected to repetitive loading, such as the bones of the foot, ankle, tibia, femur, or pelvis. Stress fractures are common in athletes, especially those who participate in high-impact activities.

The important thing is not to do it TOO FAST…

Pathophysiology

1. Repetitive Stress: Stress fractures typically develop in response to repetitive stresses on a particular bone. These stresses may result from intense physical activities, repetitive movements, or excessive loading on a specific bone.
2. Initial Microdamage: Repetitive stress initially creates microdamage in bone tissue. This microdamage is often too small to be detected by imaging tests such as X-rays.
3. Bone Repair Failure: Normally, the body continually repairs microdamage to bone through a process called bone remodeling. However, in the case of stress fractures, the constant strain can exceed the body’s ability to repair.
4. Accumulation of Microfractures: Over time, unresolved microdamage accumulates, forming microfractures. These microfractures can slowly progress and increase in size.
5. Local Inflammation: Accumulation of microfractures can trigger a local inflammatory response in the affected area. Inflammation is the body’s attempt to repair the damage, but it can also contribute to pain and progression of microfractures.
6. Complex Fracture Risk: If stress persists and repair mechanisms cannot keep up, microfractures can develop into a complete fracture. This fracture can occur across the microfracture zone or at an adjacent location.
7. Clinical Symptoms: As a stress fracture progresses, symptoms such as pain, tenderness, swelling, and possible inability to bear weight may occur. These symptoms may vary in intensity depending on the severity of the stress fracture.

Causes

1. High-impact activities: Athletes involved in high-impact activities, such as running, jumping, ballet, or ball sports, are more likely to develop stress fractures due to the repetitive stress on the bones.
2. Sudden changes in activity: A rapid increase in the intensity, duration, or frequency of physical activity can overload bones and lead to stress fractures. This can happen, for example, when a person goes from a low activity level to an intense training program.
3. Poor training technique: Poor training technique or errors in biomechanics can increase the load on certain bones, increasing the risk of stress fractures.
4. Improper footwear: Poorly fitting or worn athletic shoes can alter the distribution of forces on the feet and legs, contributing to the development of stress fractures.
5. Biomechanics disorders: Problems such as flat feet, overpronation or leg length discrepancy can change the way forces are absorbed by bones, increasing the risk of stress fractures.
6. Low bone density: Osteoporosis or low bone density can make bones more vulnerable to stress fractures, especially in older people.
7. Dietary restrictions: Nutritional deficiencies, particularly calcium and vitamin D, can weaken bones and increase the risk of stress fractures.
8. Pre-existing medical conditions: Certain medical conditions, such as female athlete syndrome, which is often associated with eating disorders, may increase the risk of stress fractures.

Symptoms

1. Pain: Pain is the dominant symptom. It is usually localized to the area of ​​the fracture and can be described as a dull, persistent ache. The pain may gradually increase over time with physical activity and decrease with rest.
2. Swelling: Local swelling may occur around the affected area. This may be accompanied by redness.
3. Tenderness: The area of ​​the stress fracture may be tender to the touch. Light pressure on the area may cause pain.
4. Inability to bear weight: With stress fractures in the lower limbs, the person may have difficulty bearing weight on the affected limb.
5. Limping: To minimize pain, the person may adopt a limping gait, avoiding putting too much weight on the injured area.

Preventive measure

1. Gradual Progression:
   • Avoid drastic changes in the intensity, duration, or type of physical activity. Gradual progression allows bones to gradually adapt to increased stress levels.
2. Suitable Shoes:
   • Use appropriate footwear for your activity, providing good cushioning and adequate support. Consult a sports footwear specialist for advice on choosing footwear that is appropriate for your body shape and activity.
3. Training Surface:
   • Opt for softer workout surfaces when possible. Avoid hard, rigid surfaces, especially if you regularly engage in high-impact activities.
4. Variety of Activities:
   • Incorporate a variety of physical activities into your training program. This reduces stress on specific areas and promotes balanced development of muscular strength.
5. Muscle strengthening:
   • Strengthen the muscles surrounding areas at risk for stress fractures, focusing on the legs, hips, and core. A strong core provides better support for bones.
6. Proper Warm-Up:
   • Perform a proper warm-up before any physical activity, focusing on the muscles and joints involved. This improves flexibility and prepares the body for the activity ahead.
7. Adequate Rest:
   • Allow your body adequate recovery time between workouts. Adequate rest allows bones to regenerate and minimizes stress buildup.
8. Balanced Nutrition:
   • Make sure you eat a balanced diet rich in calcium, vitamin D and other nutrients essential for bone health.
9. Monitoring Symptoms:
   • Be alert for signs of fatigue, persistent pain, or changes in how you feel during or after exercise. Consult a healthcare professional if you experience any concerning symptoms.
10. Regular Medical Monitoring:

• If you are particularly active or have a history of injuries, consult a healthcare professional regularly for medical monitoring and appropriate advice.

Risk groups

1. High Level Athletes:
   • Athletes who train intensively, especially in high-impact sports such as running, jumping or dancing, are at greater risk for stress fractures due to the constant repetition of movements.
2. Military:
   • Members of the armed forces, particularly those subjected to intensive training exercises and missions on hard surfaces, may be more vulnerable to stress fractures.
3. Dancers and Gymnasts:
   • Dancers and gymnasts experience significant forces on their lower limbs, which can increase the risk of stress fractures, particularly in the bones of the foot, ankle, and shin.
4. Runners or Runners:
   • Runners, especially those who train over long distances or on hard surfaces, have an increased risk of stress fractures, particularly in the tibia.
5. People with Low Bone Density:
   • Individuals with reduced bone density, such as people with osteoporosis, are more likely to experience stress fractures.
6. Growing People:
   • Adolescents experiencing rapid growth may be more vulnerable to stress fractures because their bones may have difficulty keeping up with their growth.
7. People with Hormonal Disorders:
   • Hormonal disorders, such as menstrual disorders in women, can affect bone density and increase the risk of stress fractures.
8. People Starting Intensive Physical Activity:
   • Those who suddenly begin intense physical activity without gradual progression are more likely to suffer stress fractures.
9. Individuals with a History of Stress Fractures:
   • People who have had stress fractures in the past have a higher risk of recurrence, especially if the underlying factors have not been addressed.
10. People with Pre-existing Medical Conditions:
    • Certain medical conditions, such as rheumatoid arthritis, can increase the risk of stress fractures.

Differentiation from other injuries

Stress fractures are distinguished from other bone and muscle injuries by several characteristics, including their cause, mechanism, symptoms, and treatment options. Here’s how stress fractures are differentiated from other common injuries:

Causes and Mechanisms

1. Stress fractures: These usually result from repeated or excessive stress on a bone, rather than acute trauma. These stresses may be related to intense physical activity or repetitive movements.
2. Acute fractures: These are often caused by a sudden, single trauma, such as a fall, car accident, or direct impact to the bone.

Symptoms

1. Stress fractures: Symptoms develop gradually and may include mild pain at first, which becomes more intense with activity. Pain often lessens with rest.
2. Acute fractures: Symptoms, such as severe pain, swelling, and bone deformity, are usually immediate after trauma.

Diagnostic

1. Stress fractures: Diagnosis can be difficult because standard X-rays may not reveal initial injuries. More advanced imaging tests such as bone scan, MRI (magnetic resonance imaging), or computed tomography (CT) scan may be necessary.
2. Acute fractures: Fractures are usually detected by standard X-rays, which show obvious breaks in the continuity of the bone.

Localisation

1. Stress fractures: These often occur in areas subjected to repetitive stress, such as the tibia, foot, femoral neck, or metatarsal.
2. Acute fractures: These can occur in any part of the body depending on the trauma, and their location depends on the point of impact.

Evolution and Treatment

1. Stress Fractures: With adequate rest and proper management, stress fractures tend to heal without surgery. Return to activity should be gradual.
2. Acute fractures: Treatment depends on the severity of the fracture. It may include immobilization using casts, splints, or surgery, depending on the nature of the injury.

Muscle tears and sprains

1. Muscle tears and sprains usually involve damage to soft tissues rather than bone.
2. Muscle tears are ruptures of muscle fibers, while sprains are stretches or tears of the ligaments that connect bones together.

In summary, the main distinction of stress fractures from other injuries is their gradual development related to repetitive stress rather than acute trauma. Early diagnosis, appropriate management, and adaptation of physical activity are essential for optimal recovery from stress fractures. If a person suspects a bone or muscle injury, it is crucial to consult a healthcare professional for an accurate diagnosis and an appropriate treatment plan.

Prevalence in specific populations

1. Children and Adolescents:
   • Children and adolescents may develop stress fractures due to participation in intensive sporting activities, particularly those involving repetitive movements or heavy loads.
   • Activities such as gymnastics, dancing, soccer, and running can increase the risk of stress fractures in young people because of the pressure placed on growing bones.
2. Elderly people:
   • In older adults, bone density decreases with age, which may increase susceptibility to stress fractures.
   • Stress fractures in older adults may result from a combination of factors, including inadequate physical activity, decreased muscle mass, and increased bone fragility.
3. Pregnant women:
   • Pregnant women may be prone to stress fractures due to hormonal changes, weight gain, and changes in posture during pregnancy.
   • Bones and joints may experience increased stress due to fetal growth, which can contribute to the development of stress fractures.
4. Female Athletes:
   • Female athletes, particularly those participating in sports that place significant stress on the bones (such as running), may be at increased risk of stress fractures due to amenorrhea (absence of menstruation) associated with intense levels of physical activity.
5. Elite Military and Athletes:
   • Individuals involved in military activities or elite sports may be at high risk of stress fractures due to intensive training, heavy loads and constant physical stress.
6. People with eating disorders:
   • Individuals with eating disorders such as anorexia or bulimia may have reduced bone density due to inadequate nutrition. This can increase the risk of stress fractures.
7. People with osteoporosis:
   • People with osteoporosis, a condition characterized by decreased bone density, are more likely to suffer stress fractures, even during light activities, because of the fragility of their bones.
8. Physically active workers:
   • Some workers, such as military personnel, firefighters, police officers, and construction workers, are exposed to significant physical loads as part of their jobs. This can increase their risk of stress fractures, especially if they are subjected to physically demanding tasks repeatedly.
9. Patients on specific drug treatment:
   • Certain medications, such as long-term corticosteroids, can impact bone density and increase the risk of stress fractures.
10. Professional dancers:
    • Professional dancers, due to the repetitive movements and high physical demands of their art, may be more susceptible to developing stress fractures, particularly in the lower extremities.
11. People practicing high impact sports:
    • Participants in high-impact sports, such as basketball, tennis, and soccer, may be at increased risk due to the repetitive impact forces placed on the bones.
12. People in remission from eating disorders:
    • Even after overcoming eating disorders, individuals may retain reduced bone density, increasing the risk of stress fractures.

Psychological factors that influence stress fracture

1. Mental stress and bone fragility: Chronic mental stress can negatively impact bone health. The stress hormone cortisol can influence bone metabolism by promoting bone resorption (breakdown of bone). This can make bones more vulnerable to stress fractures.
2. Stress Hormones and Bone Density: Prolonged stress can affect bone mineral density by altering hormonal balance. Hormones such as adrenaline and cortisol can influence the regulation of calcium in bones.
3. Relationship between stress and posture: Mental stress can also affect posture and how a person uses their body. Poor posture can increase pressure on certain bones, which could contribute to stress fractures.
4. Impact on the healing process: Mental stress can slow down the healing process by affecting blood circulation, the inflammatory response, and the body’s ability to regenerate. Slower recovery may be observed in people who are under constant stress.
5. Stress-related behaviors: People under mental stress may engage in less healthy behaviors, such as excessive alcohol consumption, smoking, or unhealthy diet, which can also affect bone health.
6. Stress Management for Prevention: Effective stress management can play a crucial role in preventing stress fractures. Stress management techniques, such as meditation, relaxation, and exercise, can help reduce the negative impact of stress on bone health.

Radiographic signs of stress fracture

Stress fractures are often not visible on X-rays immediately after they occur because the initial bone changes may be subtle. However, as the fracture progresses, radiographic signs may become apparent. Some possible radiographic signs of stress fractures include:

1. Fracture lines or calluses:
   • In later stages, fracture lines or bone calluses may appear on X-rays. These signs indicate the body’s attempt to repair the fracture.
2. Enlargement of the spinal canal:
   • A stress fracture can cause a widening of the medullary canal (the cavity inside the bone) that can be seen on X-rays.
3. Bone Sclerosis:
   • Bone sclerosis, a thickening or hardening of the bone, may be seen around the fracture area on X-rays.
4. Displacement of Adjacent Bones:
   • In some cases, particularly with more severe stress fractures, displacement of adjacent bones may be visible on X-rays.
5. Osteophyte Formation:
   • Osteophytes, abnormal bony growths, may form near the fracture area in response to repeated stress.
6. Cortical Enlargement:
   • Cortical widening, an increase in bone thickness at the periphery, may be a radiographic sign of stress fractures.
7. Perimetaphyseal reaction:
   • A perimetaphyseal reaction, a response of the bone near the metaphysis, may be visible on radiographs.

Conclusion

Stress fractures are bone injuries resulting from repeated overload on a bone, usually due to intense physical activity or excessive repetition of movements. Although these fractures are often considered low-impact injuries, they can lead to complications if not properly diagnosed and treated. The key to managing stress fractures is early identification, adequate rest, and appropriate adjustments in physical activity.

In conclusion, it is imperative to pay close attention to warning signs such as persistent and localized pain, in order to prevent the development of stress fractures. A multidisciplinary approach, involving healthcare professionals such as physicians, physiotherapists and sports specialists, is essential for an accurate diagnosis and a treatment plan tailored to each individual. Modification of training habits, adequate rest and rehabilitation can play a crucial role in the recovery and prevention of stress fractures. It is always recommended to consult a healthcare professional for a complete assessment and personalized advice.

References

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Questionnaire (answer at the end)

1. What is the main cause of stress fractures?
a) Acute trauma
b) Repetitive strain
c) Poor training technique
d) Lack of calcium
e) All of the above

2. Where do stress fractures commonly occur?
a) Arm
b) Back
c) Foot bones
d) Skull
e) All of the above

3. What symptoms are associated with stress fractures?
a) Persistent pain
b) Swelling
c) Tenderness
d) Inability to bear weight
e) All of the above

4. Which groups are particularly at risk for stress fractures?
a) Children
b) Elderly
c) High-performance athletes
d) Pregnant women
e) All of the above

5. What is a recommended preventive measure?
a) Gradual progression
b) Proper footwear
c) Adequate rest
d) Balanced nutrition
e) All of the above

6. What imaging test is often needed to diagnose stress fractures?
a) X-ray
b) Bone scan
c) CT scan
d) MRI
e) All of the above

7. What psychological factor can influence stress fracture?
a) Chronic mental stress
b) Good posture
c) Balanced diet
d) Adequate sleep
e) All of the above

8. Which population group is more vulnerable to stress fractures due to rapid bone growth?
a) Elderly people
b) Adolescents
c) Pregnant women
d) Military personnel
e) All of the above

9. What is one possible radiographic sign of stress fractures?
a) Fracture lines
b) Cortical widening
c) Bone sclerosis
d) Osteophytes
e) All of the above

10. How important is stress management in preventing stress fractures?
a) Not important
b) May slow the healing process
c) Does not affect bone health
d) Essential for prevention
e) All of the above

11. What is the alternate term for a stress fracture?
a) Traumatic fracture
b) Acute bone injury
c) Fatigue fracture
d) Instantaneous fracture
e) All of the above

12. Which physical activity is associated with an increased risk of stress fractures?
a) Yoga
b) Swimming
c) Running
d) Slow walking
e) All of the above

13. What is the role of inflammation in the development of stress fractures?
a) Accelerate healing
b) Cause microdamage
c) Reduce pain
d) Does not affect stress fractures
e) All of the above

14. Which population group may be at increased risk due to hormonal disorders?
a) Adolescents
b) Adult men
c) Pregnant women
d) Elderly
e) All of the above

15. What is the consequence of an untreated stress fracture?
a) Spontaneous healing
b) Increased risk of complete fracture
c) Decreased sensitivity
d) Improved bone function
e) All of the above

16. What type of footwear is recommended to reduce the risk of stress fractures?
a) High-heeled shoes
b) Poorly fitting athletic shoes
c) Shoes appropriate for the activity
d) Slippers
e) All of the above

17. What is the effect of nutritional deficiencies on stress fractures?
a) Reduced risk
b) Strengthened bones
c) Increased risk
d) Does not affect stress fractures
e) All of the above

18. What is the best way to strengthen muscles to prevent stress fractures?
a) Sitting all day
b) Strengthening muscles
c) Avoiding all exercise
d) Eating sweets
e) All of the above

19. What medical condition may increase the risk of stress fractures?
a) Excessive hydration
b) Female athlete syndrome
c) Excessive sleep
d) All of the above
e) None of the above

20. How do stress fractures differ from acute fractures?
a) Repetitive causes
b) Acute traumatic causes
c) Immediate symptoms
d) No difference
e) All of the above

21. What type of physical activity is likely to contribute to the development of stress fractures in rapidly growing adolescents?

a) Swimming
b) Yoga
c) Running
d) Moderate walking
e) All of the above

22. What factor can make bones more vulnerable to stress fractures in older people ?

a) Increased muscle mass
b) Increasing bone density
c) Regular physical activity
d) Decreased bone density with age
e) All of the above

23. What is the risk for pregnant women regarding stress fractures?

a) Reduced risk due to pregnancy
b) Increased risk due to hormonal changes
c) No increased risk
d) Does not affect pregnant women
e) All of the above

24. How can mental stress affect bone health?

a) Strengthen bones
b) Negatively impact bone density
c) Does not affect bone health
d) Improve bone flexibility
e) All of the above

25. Which group of people may maintain reduced bone density even after overcoming eating disorders?

a) Children
b) Adolescents
c) Adults
d) Elderly
e) All of the above

26. What is the effect of the stress hormone cortisol on bone metabolism?

a) Accelerate bone healing
b) Promote bone growth
c) Promote bone resorption
d) Does not affect bone metabolism
e) All of the above

27. What type of physical training is recommended to reduce the risk of stress fractures?

a) Avoid all exercise
b) Intense training every day
c) Gradual progression of intensity
d) Exercise only on weekends
e) All of the above

28. What impact do high heels have on the risk of stress fractures?

a) Reduce risk
b) No impact
c) Increase risk
d) Does not affect stress fractures
e) All of the above

29. What is the possible consequence of poor training technique on bones?

a) Reduced risk of stress fractures
b) No impact
c) Increased risk of stress fractures
d) Does not affect bone health
e) All of the above

30. What is the effect of local inflammatory reaction on stress fracture symptoms?

a) Decrease pain
b) Worsen pain
c) No impact on pain
d) Does not affect symptoms
e) All of the above

Answers:

1. b) Repetitive constraints
2. c) Bones of the foot
3. e) All of the above
4. e) All of the above
5. e) All of the above
6. e) All of the above
7. a) Chronic mental stress
8. b) Adolescents
9. e) All of the above
10. d) Essential for prevention
11. c) Fatigue fracture
12. c) Running
13. b) Cause microdamage
14. c) Pregnant women
15. b) Increased risk of complete fracture
16. c) Shoes suitable for the activity
17. c) Increased risk
18. b) Muscle strengthening
19. b) Female athlete syndrome
20. a) Repetitive causes
21. c) Running
22. d) Decrease in bone density with age
23. b) Increased risk due to hormonal changes
24. b) Have a negative impact on bone density
25. c) Adults
26. c) Promote bone resorption
27. c) Gradual progression of intensity
28. c) Increase the risk
29. c) Increased risk of stress fractures
30. b) Worsen the pain