Tuesday, July 31, 2012

Stress Fractures: Are You At Risk?

With the Olympics now well under way, it never ceases to amaze me what the human body can do. Yes, the accomplishments and speed of the runners and swimmers is outstanding, but I see these guys in clinic everyday. What I don't see as often are the incredible gymnasts and divers that tumble and fly through the air. I am amazed, not so much that they don't injure themselves on their landing or entry into the water. They're too good at this level to miss by much. What amazes me is that they don't have more repetitive injuries like stress fractures.

Back in the "olden" days, stress fractures were extremely rare. They tended only to occur in highly repetitive activity. The old nickname was "march" fracture, due to the frequency they occurred in the military.  Other activities simply weren't done often enough to cause the fractures. These days, it would be a slow week at the sport clinic if I didn't see one or two stress fractures come through the doors.
In fact, in my practise, the group I most often see now, are middle aged females training for their first long distance race.

Risk Factors

1. Highly Repetitive Activity.
Sports involving running, where the body is exposed to the same pounding over and over are at most risk. Other activities like gymnastics, figure skating, rowing are also at risk, where the same motion occurs over and over.

2. Being Female
Simply being female is, unfortunately a risk factor for a number of reasons. Bone density may not be as strong, if periods aren't regular, it contributes to increasing risk, and if body fat is extremely low, it elevates the risk of stress fractures.
There is a syndrome called the female athlete triad, which consists of amenorrhea (lack of periods), low bone  density, and eating disorders (like anorexia), which should be screened for if a woman comes in with stress fractures.

3. Sports Where Weight/Appearance is an Issue
Any sport where the athlete has to "make" weight, like rowing or even boxing can put one at risk, as these athletes commonly have to drop their weight dramatically over a short period of time. Appearance sports like gymnastics, diving, figure skating etc, also contribute to weight/body image issues.

Bones at Risk

The areas at risk depend a lot on what the activity is that you are doing. Runners tend to experience stress fractures in the foot, most commonly at the 2nd metarsal, and the navicular (inside portion of the foot). They can also fracture the tibia, and more rarely in the hip.

Gymnasts and divers, who commonly put many times their body weight through their wrists, can cause stress fractures in the distal radius, and a number of small bones in the wrist. If growth plates are not closed yet, these can also occur in the elbow.

How Do I Prevent Stress Fractures?
At a non-Olympic level, the more cross-training you can do the better. Try to change the activity you do each day. If you're a runner, cycle of use an elliptical machine on alternate days.

Eat! Not a problem for most of us, but if you are involved in an appearance sport, get the advice of a dietician to ensure you are getting enough calories. I can't emphasize this enough. Find out how much calcium/Vitamin D you need for your age and sex. Don't worry about your appearance. You look great. Trust me.

Proper equipment is essential. Runners need to change out their shoes every 6 months, or approximately 500 miles, whichever comes first. Get the right shoe for your foot type. Get proper wrist protection if you dive or tumble. Make sure your skates and technique are correct if you are figure skating.

Women over 65 or those who have other risk factors should have a bone density done.

Have you ever had a stress fracture? Know anyone at risk? Let me know what you think!

APPENDIX: Quick Screen for Female Athlete Triad
1. Do you ever worry about your body weight/composition?
2. Do you limit/carefully control your food intake?
3. Do you try to lose weight for your appearance/weight due to your sport?
4. Does your weight affect the way you feel about yourself?
5. Have you felt that you have lost control of the way you eat?
6. Do you make yourself throw up after you eat?
7. Do you currently or have you ever suffered from an eating disorder?
8. Do you every eat in secret?
9. At what age was your first period?
10. Do you have regular monthly cycles?
11. How many periods have you had in the last year?
12. Have you ever had a stress fracture?

Answering yes to any of these questions should prompt a further evaluation by a trained sport medicine specialist.


  1. Isn't confirmation a risk factor? I'm thinking physical attributes like high arches or Morton's Toe.

    1. Confirmation? Do you mean a previously diagnosed stress fracture? I agree, physical anatomy can contribute, as unusual alignment, like you describe can contribute to unusual weight bearing patterns. Morton's Toe may cause somewhat more stress to the 2nd MT, and may increase the risk. Generally, flatter arches cause more stress to the navicular, although any abnormal arch pattern may contribute.
      Some of this can be mitigated with appropriate footwear/orthotics.
      Thanks for the comments!

    2. Sorry, meant "conformation" — so anatomy.