La Semana

Stress Fractures

- By Paul L. Liebert , MD, Tomah Memorial Hospital, Tomah, WI

Stress fractures are small incomplete fractures that often involve the metatarsal shafts. They are caused by repetitive weight-bearing stress.

Stress fractures do not usually result from a discrete injury (eg, fall, blow) but occur instead following repeated stress and overuse that exceeds the ability of the supporting muscles to absorb the stress. Stress fractures can involve the proximal femur, pelvis, or lower extremity. Over 50% involve the lower leg and, in particular, the metatarsal shafts of the foot. Proximal stress fractures suggest the presence of metabolic bone disease such as osteoporos­is.

- Metatarsal stress fractures (march fractures)usually occur in

- Runners who too quickly change intensity of workouts, time of workouts, or both

- Poorly conditione­d people who walk long distances carrying a load (eg, newly recruited soldiers)

- They most commonly occur in the 2nd metatarsal. Other risk factors include the following:

- Cavus foot (a foot with a high arch)

- Shoes with inadequate shock-absorbing qualities

- Osteoporos­is

Symptoms and Signs of Stress Fractures

Forefoot pain that occurs after a long or intense workout, then disappears shortly after stopping exercise is the typical initial manifestat­ion of a metatarsal stress fracture. With subsequent exercise, onset of pain is progressiv­ely earlier, and pain may become so severe that it prohibits exercise and persists even when patients are not bearing weight. Signs can include evidence of acute in&ammation or only reproducti­on of the pain with regional pressure or foot squeeze.

Patients who have persistent deep groin or thigh pain with weight bearing must be evaluated for a proximal femur stress fracture. Patients with such fractures should be to a specialist.

Diagnosis of Stress Fractures


* X-ray or bone scan Standard x-rays are recommende­d but may be normal until a callus forms 2 to 3 weeks after the injury. Technetium diphosphon­ate bone scanning or MRI may be necessary for early diagnosis. Women with stress fractures of the proximal femur or pelvis may have undiagnose­d osteopenia and may require additional testing (eg, dual-energy x-ray absorptiom­etry.)

Treatment of Stress Fractures

* Restrictio­n of weightbear­ing activity

Treatment includes cessation of weight bearing, for example, on the involved foot (in case patients have a metatarsal stress fracture), and use of crutches. Although casting is sometimes used, a wooden shoe or other commercial­ly available supportive shoe or boot is preferable to casting to avoid muscle atrophy. Healing can take anywhere from 6 to 12 weeks.

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