Leg and Foot Stress Fractures

Welcome to Texas State University's Evidence-based Practice project space. This is a wiki created by and for the students in the Doctor of Physical Therapy program at Texas State University - San Marcos. Please do not edit unless you are involved in this project, but please come back in the near future to check out new information!!

Original Editors

Lead Editors - Holly Pulket, Corin Arundale, Brenda Walk, Brittany Buenteo, Melissa Osti

Search Strategy

Databases Searched:  CINAHL, OVID, Google Scholar

Keyword Searches:  Leg stress fractures, foot stress fractures, military and stress fractures

Search Timeline:  June 10, 2011 - 

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Definition/Description

Stress fractures are partly due to bone that undergoes mechanical fatigue. Stress fractures are a consequence of exceeding amounts of repetitive submaximal loads placed on bones which create an imbalance between bone resorption and bone formation. The fractures usually begin in locations where the bone is experiencing a great deal of stress; this is called “crack initiation”. If this microscopic crack is not able to heal and is subjected to further loading, the microdamage will increase and the crack will enlarge. This increase in damage can cause the bone to break on a macroscopic level. 

Epidemiology/Etiology

It is estimated that 15-20% of overuse injuries are stress fractures. It is believed that activities of impact with repetitive loading such as marching and running are associated with these types of fractures. About 50% of stress fractures take place in the tibia; however, a stress fracture can occur in any bone. For instance, the foot (especially the second metatarsal) is another common place for stress fractures. Moreover, females are depicted to have a greater percentage of stress fractures; it has been reported that females have a 1.5 to 12 times higher risk of getting a stress fracture as compared to males.

Stress fractures may be due to several factors such as activity level, bone quality, anti-inflammatory drugs, radiation, nutritional status, osteoporosis, imbalanced hormones, sleep deprivation, and collagen anomalies. How often stress fractures occur is dependent upon the composition of bone, adjacent muscle attachments, the vasculature, systemic factors, and the mode of athletic activity. Other possible stress fracture risks include age, sex, footwear, and training regimen. High level female athletes (who are inclined to the athlete triad) and male endurance athletes (who have unusually low levels of sex hormones) are also at risk for stress fractures.

From a biomechanical perspective, stress fractures may be a consequence of fatigued muscle which then causes the bone to receive excessive amounts of force. In addition, the alignment of the lower extremity has been proposed to play a role in the risk of stress fractures, but the evidence is inconclusive. Furthermore, earlier studies have shown that narrow tibias, a high degree of hip external rotation, a varus ankle and forefoot, ankle hyperpronation, a foot with a high longitudinal arch, and leg-length discrepancy may increase an athlete’s risk to stress fractures.

Characteristics/Clinical Presentation

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Differential Diagnosis

Depending on the location of the pain, the differential diagnosis may vary. Other diagnoses may include infection, tumor, compartment syndrome, arthritis, nerve entrapment, medial tibial stress syndrome, and other soft tissue injuries.1 Compartment syndrome is developed from pressure within the muscle compartments of the lower leg which are divided up by fascial layers. Pressure within the compartments can result from increased oxygen demand and subsequent blood flow to the exercised muscle.3 Compartment syndrome patients may present with leg cramps, muscle tightness, severe pain, foot drop, and par aesthesia of the foot.3 Compartment syndrome is a red flag condition and surgical fasciotomy is the preferred treatment.3 If there is a suspected stress fracture after the initial evaluation, including a thorough history, the therapist should refer for medical imaging to rule in or out the diagnosis. Standard radiographs are initiated early on despite the poor sensitivity for diagnosis of stress fractures (show up after first 2-3 weeks), followed by the gold standard imaging of a bone scan (show up within 2-3 days of injury).2 Medial tibial stress syndrome (MTSS) comprises periostitis at the junction of the middle and distal thirds of the medial tibial border. This syndrome can result from traction stress of the soleus, flexor digitorum longus, or deep crural fascia.1 Bone scans can also be used to diagnosis MTSS with increased uptake of longer segments of the bone, compared to focal areas with stress fractures.1 When examining those with MTSS, patient may experience diffuse tenderness along the tibial border.

Outcome Measures

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Examination

When evaluating an adult with a LE stress fracture a thorough history is important.

Key history findings of an individual with a stress fracture (Lassus, Van der Velde):

• Pain with WB
• Recent increase in activity (i.e. high intensity and/or high frequency)
• Gradual onset
  
• Begins as pain with stress, eventually progressing to pain at rest and during the night

During the physical examination, the clinician will want to take an impairment based approach. Important aspects of the evaluation will include observation, gait analysis, leg length discrepancy, tenderness with palpation, and ROM (Duran-Stanton et al 2011). Patients with stress fractures typically will have tenderness to palpation and edema in surrounding soft tissues (Lassus). According to Hatch et al 2007, during the physical examination it may be important to perform all of the following:  a neurologic screen for sensation, a vascular examination (capillary refill and LE pulses), inspect the skin for deformity, edema, or ecchymosis, and ROM to determine if there is a disproportionate amount of pain with movement. 

In regards to navicular stress fxs (which is one of the most common types of foot stress fxs), foot shape has been implicated in the past as a risk factor but evidence is inconsisent (Oddy et al 2009, Tuan et al 2004). Injuries appear to occur in patients with pes planus, pes cavus, and normal feet.

Radiographs still are the first tool used for the diagnosis of stress fractures (Lassus). Stress fractures usually don't appear on xrays for two to six weeks (Hatch, Lassus) but when they are visible they will appear as a radiolucent line and may have cortical thickening (Van der Velde, Lassus, Duran-Staton, Baublitz). 

Medical Management

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Physical Therapy Management

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Key Research

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Resources

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Clinical Bottom Line

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Recent Related Research (from Pubmed)

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References

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