Stress fracture

• Disease description (causes and symptoms)

  • Definition and pathophysiology
    • A stress fracture is a condition in which microscopic fractures occur in a bone due to repetitive and cumulative mechanical stress without trauma. When muscle fatigue reduces shock-absorbing capacity, the load transmitted to the bone increases, causing microcracks; with repeated stimulation, the cracks progress.
    • Common sites: weight-bearing areas such as the tibia (shinbone), metatarsals (bones of the foot), tarsal bones (around the top of the foot/ankle), fibula, femur (especially near the pelvis and thigh), and heel.
  • Main causes and risk factors
    • A sudden increase in exercise volume (distance, intensity, or frequency), and repetitive impact such as excessive running or jumping
    • Long-distance exercise on hard surfaces and shoes with poor shock absorption
    • Biomechanical abnormalities such as flat feet and excessive varus/valgus alignment
    • In female athletes, low energy intake, amenorrhea, and reduced bone density (female athlete triad)
    • Smoking, excessive alcohol consumption, osteoporosis, steroid use, and chronic diseases such as diabetes
  • Symptoms
    • Early stage: localized pain during activity (initially improving with rest), pain and stiffness with the first steps in the morning
    • As it progresses: pain that persists even at rest, inability to bear weight, and possible localized tenderness or swelling
    • Some cases are asymptomatic and discovered incidentally

• Treatment methods

  • Diagnosis
    • X-ray examination: May be normal in the early stage (the first 10–14 days). Bone changes (hyperostosis) or a fracture line may be observed later.
    • Additional tests: If symptoms suggest a stress fracture but the X-ray is negative, MRI (high sensitivity), a bone scan, or CT (for detailed anatomical evaluation) may be considered.
  • Conservative treatment (first-line choice in most cases)
    • Activity restriction and reduced weight-bearing: Complete non-weight-bearing may be necessary, depending on the site and severity.
    • Protective immobilization: Stabilization with a splint, brace, cast, or similar device.
    • Pain control: Short-term use of NSAIDs (as directed by a doctor) and, if necessary, analgesics.
    • Physical therapy: Recovery of strength and flexibility through non-weight-bearing exercises such as low-intensity water exercise, swimming, and stationary cycling.
    • Nutrition and lifestyle management: Assessment and supplementation of calcium and vitamin D status, appropriate body weight and energy intake, smoking cessation, and moderation of alcohol consumption.
    • Rehabilitation and gradual return: Gradual increase in load after symptoms have resolved (as directed by a doctor or physical therapist).
  • Surgical treatment
    • Indications: Complete fracture (if displaced), high-risk sites (e.g., the tension side of the femoral neck, atypical anterior or other posterior high-risk areas of the tibia), or nonunion or persistent pain due to failure of conservative treatment.
    • Surgical methods: Reduction and fixation of the fracture through internal fixation (pins, plates, screws, etc.); bone grafting may be necessary in rare cases.
  • Precautions (during and after treatment)
    • Because delayed treatment can lead to complete fracture, delayed union, or nonunion, specialist evaluation is recommended if pain persists for more than 1–2 weeks.
    • An excessively early return to activity can cause recurrence or worsening.
    • Long-term use of NSAIDs may affect bone healing, so consult a doctor.

• Checklist before an outpatient visit (including preparation items and sample questions)

  • Items to prepare
    • A record of when the pain started and how it has progressed (when it worsens and after which activities)
    • A list of currently used medications (including steroids, anticoagulants, etc.)
    • A history of previous fractures, osteoporosis, and surgery, and, for women, menstrual history (including whether amenorrhea is present)
    • Dietary and nutritional status (weight changes and amount of food intake), and whether supplements (calcium and vitamin D) are being taken
    • Results of imaging already performed, if any (X-ray, MRI, or CT files and reports)
    • Changes in exercise volume (whether training volume has recently increased), and information about footwear and exercise surfaces
  • Things to show the doctor during the outpatient visit
    • A drawing or photograph indicating the location of the pain, if possible
    • Factors that worsen or relieve the pain (when bearing weight, while running, etc.)

• Examples of general questions to ask the doctor

  • How can we confirm whether this pain is truly a stress fracture?
  • What tests are needed (MRI, bone scan, etc.), and when should they be performed?
  • How quickly will it improve with conservative treatment? When can I return to exercise (running)?
  • What are the criteria for requiring surgery, and what is the expected recovery period?
  • What should I adjust in my diet, exercise, and footwear to prevent recurrence?

• Examples of condition-specific questions

  • In my case (site: e.g., shinbone/metatarsal), is conservative treatment sufficient, or should surgery be considered?
  • In women, if there is a menstrual abnormality (amenorrhea), how does it affect fracture healing or the risk of recurrence, and how should hormone and nutritional management be handled?

(Summary for reference) X-rays may be normal in the early stage, so if symptoms persist, additional evaluation with MRI or a bone scan is needed. Most cases improve with activity restriction, protective immobilization, and non-weight-bearing rehabilitation; however, surgical fixation may be necessary for high-risk sites or when conservative treatment fails. Appropriate testing and early management, a rehabilitation plan, and correction of nutritional and lifestyle habits are important for prognosis and prevention of recurrence.