Stress or Insufficiency Fractures

What is a stress fracture or insufficiency fracture?

A stress or insufficiency fracture is a crack in a bone that occurs without a definite injury. It occurs as result of repetitive activity as opposed to a single traumatic event that causes a more traditional break or fracture. They are much more common in the lower extremity as these bones are considered weightbearing. However, they can be seen in the spine or pelvic region at times.

At OrthoArizona, we often demonstrate stress or insufficiency fractures using a paper clip. If we take a normal paperclip and begin to repetitively stress the paperclip by bending it back and forth, eventually the metal weakens in the center and will get small defects or cracks before it finally breaks in two. This helps our patients understand how the bone can crack without one memorable traumatic event.

What causes a stress fracture or insufficiency fracture?

Stress fractures or insufficiency fractures are caused by too much relative load or stress on a bone over a period of time. We describe the load or stress as relative because an 18 year-old runner’s foot can tolerate much more activity than can the foot of a 70 year-old bingo champion. So while the general cause is overuse, this is really patient dependent.

Who gets stress fractures or insufficiency fractures of the foot and ankle?

At OrthoArizona, we see these fractures in a few different scenarios or patient populations.

The first group is the young, active group. These patients may be competing in sports such as gymnastics, track, cross-country, basketball, soccer, etc. Typically they have good bone density but are training too hard or too frequent. They also may be using improper shoes/equipment/technique or training in an improper environment. Poor relative muscle condition can also contribute to a lesser extent. Bone density plays a smaller role, but rather too much stress on the bone is the cause of the eventual crack.

The second group is usually older and may not necessarily be participating in athletics. In this group, bone density or lack of muscle play are primary driving forces. Because the bone density may be insufficient, we sometimes call these non-traumatic fractures insufficiency fractures instead of stress fractures, but the concept is similar. As we age, our bone mineral density often decreases along with our muscle mass. Additionally, our ligaments in the foot relax and the foot may change shape. The change in alignment or shape coupled with lower muscle mass or bone density can lead to insufficiency fracture or stress fracture even without an increase in activity level/frequency.

Additionally, we have some patients who seek evaluation early in the stages and have pain but happen to visit us before they develop a crack in the bone. This is typically described as a stress response or stress reaction. Here the bone is painful and responding or reacting and trying to strengthen itself and heal.

Lastly, many of our patients have other conditions of their foot or ankle that may alter their gait and lead to a stress response/reaction or fracture. For example, the patient with arthritis in their great/big toe may walk on the outside of their foot to avoid painful motion of the big toe. They may present to us with a stress reaction on one of the bones on the outside of their foot that may resolve by improving their pain at the big toe.

What are the symptoms of a stress fracture or insufficiency fracture of the foot and ankle?

At OrthoArizona, the main complaint we hear from our patients is pain. Initially the pain is often with prolonged activities. However, pain may become present with every step if the stress reaction/response worsens or evolves into a stress fracture. Many patients have a limp as a result. Some patients develop swelling and are often tender along the bone that is affected.

How is a stress fracture or insufficiency fracture of the foot and ankle diagnosed?

Obtaining a diagnosis usually begins with a good history and physical exam.

Important history topics may include:

• Type of sport/training
  • Environment, duration, frequency, intensity, recent changes
  • Shoe wear
  • Nutritional status
  • History of stress fracture
  • History of bone density abnormalities
  • Physical exam but evaluation of alignment and any presence of swelling or tenderness with palpation is important.

X-Rays are usually taken and may show a crack in the bone or new bone growth in an area where the bone is trying to heal. However, in many cases the X-Rays may be negative. This can be the case with new onset pain or in patients with a stress response/reaction. Additionally, many of the bones of the foot and ankle are irregular in shape and sometimes fractures can be difficult to visualize.

Occasionally, advanced imaging such as MRI, bone scan, or CT scan may be utilized if your provider determines it necessary.

How are stress fractures or insufficiency fractures of the foot and ankle treated?

Initial treatment is almost always non-surgical.

Rest is by far the most crucial treatment. There are different ways to rest the foot or ankle. Sometimes we will recommend just eliminating certain activities. In other cases we may recommend resting the foot or ankle by wearing a hard soled shoe, walking boot or cast. In certain cases, we may even recommend crutches, walker, or knee scooter to limit weight on the affected foot or ankle.

Typically we discourage the use of pain medicines. With stress/insufficiency fractures, pain is meant to be a protective response. Masking it can slow the recovery. Pain is better managed by immobilization or modifying activity.

Recovery can be a period of weeks or months depending on the severity and location. Additionally, we individualize return to previous activities based on multiple factors including the severity and location of the fracture as well as the patients age, health and goals.

Surgery is typically reserved for patients who are not successful with conservative treatment. However, there are specific stress fractures in certain patients that may be treated surgically at their initial presentation.

*This information is not intended as substitute for the medical recommendations of your medical provider.  Please consult your physician regarding advice about a particular medical condition as several conditions may have similar presentations.