How To Treat A Stress Fracture In The Foot
A stress fracture can be tricky to diagnose since it may not show up on an x-ray right away. If you have pain that does not go away or is otherwise not responding to treatment it’s time to see a doctor who is experienced in diagnosing and treating stress fractures. The most important to remember is the fractured foot must be immobilized or protected in a fracture boot or shoe for the fracture to heal.
Stress fracture of the foot, shin, or lower leg are very common and most people don’t know they have one! Stress fractures are also known as ‘hairline fractures’.
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According to the National Institutes of Health, NIH; 20% of Sports Medicine treated injuries are the result of stress-related injury https://www.ncbi.nlm.nih.gov/books/NBK507835/
Stress injuries are commonly seen in running and jumping sports and the lower extremity, namely the foot, ankle, tibia (or shin bone) are most commonly involved. Although much less common, upper extremity and rib injuries do occur.
How painful is a Stress Fracture?
The term “Stress Fracture” is a common term to describe a fracture which is symptomatic but does not show up on x-ray. Symptoms include pain and swelling. A stress fracture may occur as the result of an injury or, in the case of osteoporosis (Brittle Bones) may occur spontaneously.
How do you detect a Stress Fracture?
Stress fractures may take up to two weeks or 14 days to show up on an x-ray. In my practice I use in-office diagnostics to view these fractures before they become visible on x-ray. Why is it important to have an injury diagnosed early rather than late? Several reasons: First, to identify the cause of pain and relieve the pain as much as possible. Second, to immobilize the fracture to improve healing but more importantly to prevent further damage to the bone! Third, early, proper diagnosis leads to a more timely, faster healing and reduces the severity of post-traumatic arthritis.
Why do Stress Fractures occur?
In a recent study of adolescent athletes, researchers Drs. Nussbaum, Bjornaraa and Gatt found that the athletes who suffered stress fractures competed in more seasons during the year, participated less in weight training had a history of “Shin Splints” and consumed less dairy.
Who is at Risk for Stress Fracture?
In a different study, researcher Dr. Kathrine H. Rizzone et.al. looked at College Student Athletes and found that women experienced more frequent stress fractures than men, more so in the preseason and predominantly in the foot and lower leg.
How Does Bone Heal?
So how does bone normally heal? Let’s cover that topic. When a fracture occurs two types of bone healing may take place, either primary or secondary. Primary bone healing happens when a fracture is ‘unstable’ or is able to move too much and surgery through a skin incision (open reduction) or a repositioning (closed reduction) is performed to help the fractured bone ends heal. If repositioning of the fractured ends of bone is successful, no bone callus forms. In the case of Secondary bone healing bone callus forms to help immobilize the fracture.
Stages of Secondary Bone Healing are hematoma formation, fibrocartilagenous callus formation, bony callus formation and bone remodeling. Hematoma formation begins immediately after a fracture and continues for about four days. The broken bone begins to bleed and various cells and chemicals travel to the fracture through the blood to assist in healing the bone. When the bleeding clots the hematoma (a collection of blood) acts as an early form of immobilization. Bone injury causes secretion of inflammation-causing chemicals like tumor necrosis factor-alpha (TNF-a), bone morphogenic proteins (BMP) and interleukins (IL-1, IL-6, IL-11, IL-23). These cytokines attract macrophages, monocytes and lymphocytes which work together to remove damaged cells and secrete chemical messengers (cytokines) like Vascular Endothelial Growth Factor (VEGF) to enhance healing.
Fiobrocartilaginous callus formation begins on day 5 when VEGF stimulates new blood vessel formation (angiogenesis). Through the blood mesenchymal stem cells arrive and influenced by BMP differentiate (develop) into fibroblasts, chondroblasts and osteoblasts. The fracture ends begin to knit together through a fibricartilaginous connection surrounded by hyaline cartilage. Osteoprogenitor cells, primitive bone cells are producing a layer of woven. bone. This continues until day 10.
Bony callus formation starts on day 11. The cartilaginous callus undergoes endochondral ossification (bone forms within cartilage). During this process RANK-L is expressed thus differentiating chondroblasts and chondroclasts (cells which both produce and remove cartilage); osteoblasts and osteoclasts ( cells which produce and remove bone). The cartilaginous callus begins to calcify. More woven bone forms. More blood vessels form attracting more mesenchymal stem cells. Finally, a hard calcified callus containing immature bone has formed.
Bone remodeling begins on day 18 and continues for months to years. The hard callus undergoes repetitive remodeling (rebuilding) called ‘Coupled Remodeling’, a harmonious process of laying down new bone by osteoblasts and removing bone by osteoclasts until the immature woven bone is replaced by mature lamellar bone.
Whether a fracture is healing via primary or secondary healing in some cases the bone does not heal properly, this is termed non-union or mal-union of bone.
Some fractures take longer to heal, Stress Fracture Treatment
I have successfully treated hard-to-heal fractures as in patients with diabetes, rheumatoid arthritis and osteoporosis. Patients with chronic medical conditions may experience a longer recovery than those with no chronic conditions.
What is the fastest way to heal a Stress Fracture?
The fastest way to heal a stress fracture is to get the correct diagnosis right from the start. See a sports doctor experienced in treating stress fractures. Your sports doctor will order xrays and more. Sometimes a cast or a special shoe are required to immobilize your fracture. If you have a chronic health condition your sports doctor may check your vitamin D level or other blood tests to optimize your chance of healing the fracture.
Can you walk with a Stress Fracture?
It is possible to injure the fracture by walking on it especially if you have not yet seen a sports doctor. Don’t delay an evaluation of your injury.
Why suffer? I have the knowledge and experience to treat your injury. Call for your appointment today!