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Thursday, November 11, 2010

Foot Stress Fractures: Answers to an Email

Hello Dr. Blake,

I'm not sure if you remember, but I emailed you a couple of weeks back about Vibram Five Fingers for my school newspaper.

I am now writing about stress fractures and I thought you may know something about them. So I would love it if you could answer a few questions for me about them, or if you're really busy or something, if you could pass them along to a colleague, that would be wonderful.

So I'll tell you the questions anyways, and I look forward to hearing back from you or a fellow orthopedic/podiatrist.

1. What exactly is stress fracture on the anatomical level?

2. What long-term effects does sustaining a stress fracture have on a person?

3. Is there a particular sport or activity that is a person most likely to sustain a stress fracture?

4. What can an athlete do to try and prevent this type of injury? What is the best thing for a player to do after incurring something like this?

Thanks, as always for the help,

     Elizabeth, a stress fracture is a tiny crack in a bone when the stress load it receives is higher the stress load it can withstand. A better term that means the same thing is a "fatigue fracture". The bone fatigues with stress and cracks when the stress is too much to bear.
     Stress fractures are very common and there are no long term sequellae from them. The body completely heals stress fractures, in fact they heal them better than they were originally, called "double healing". The bone around a stress fracture is probably 2 times stronger than before it broke due to the remodelling process of the bone for at least 5 to 10 years. Thus the saying "you can't break a bone in the same place twice". Quite accurate for a few years.
     Stress fractures are fatigue spots in bones, and every sport can produce them due to some over use pattern of activity. Judo experts intentionally stress their fifth metacarpal of the hand by repeatedly striking a hard object to build up the thickness of that bone. This is why they can break those bricks on TV. Ballet dancers en pointe are prone for 2nd metatarsal stress fractures since the weight with proper technique goes primarily into the 2nd metatarsal. The male dancers in ballet get shin (tibial) stress fractures with their overuse landing from jumps. Rowers on a crew team are prone for rib stress fractures due to the force of the chest muscles pulling on the ribs. If the bone is weaker than the muscles, the bone breaks. Cross Country runners get tibial stress fractures due to either the impact pounding or the pull of the powerful soleus muscle at push off. And the list goes on, and on, and on.
Stress Fracture with Bony Remodeling in the Bone under the Ball of the Foot. Compare the 2 bones seen under the first metatarsal and tell which one is injured.

     If the athlete is on a team, smart coaches know alot about preventing stress fractures by avoiding overuse situations, and varying workouts. As an athlete, getting the recommended doses of 1500mg of calcium per day during months of strenuous workouts, getting some sun without block in the early morning or late afternoon, consuming 400 units of Vit D daily, training at at least a  50 % level during the off season for a sport to avoid the excessive loads at the beginning of a season, making sure that your workout shoes are well padded and fairly new, getting plenty of rest allows tissues to heal and when we exercise with tired muscles more stress goes to the bones, and never working through pain or extreme fatigue.
     If you develop a stress fracture, you have to respect that the bone needs time to heal. This is the world of cross training so that you do not decondition as much. Runners bike, bikers swim, etc. There are so many cross training avenues out there to keep your muscles in tone and your heart and lungs pumping. Try to analyze why this happened. If you have a coach, work with them to attempt full discovery. Play Sherlock Holmes. It is normally 2 to 4 factors which all pile up against you.  Do you have a family history of osteoporosis? Is your diet low in Calcium or Vitamin D? Do you wear sun block at all times? Are your workout shoes fairly well padded or relatively new? Did you just increase your activity too abruptly with a poor off season program? Is there something in your walking or running style, or a short leg, that adds too much stress to an area? And there are many more factors. It is always a fun challenge.
     Elizabeth, I must sign off but I hope this helps. Good luck with your article. Dr Rich Blake


  1. A basket player here in uruguay suffer fron a fifith metacarpal fracture without displacement
    Is there any functional orthesis to play ? without making 8 weeks of rest
    his team is playing the las games (finals)
    Any consideration in the case of fifth metatarsal fracture without displacement and the use of an orthosis to continues to play

    thanks for the persevering effort in provide us access to quality data and knowledge

    Gerardo Amilivia

  2. Dear Gerardo, Thanks for the comment. With fifth metatarsal fractures, 5/32" polypropylene Root Balanced Orthotics are the best. See the posts on Root Balancing. You hope to have a foot with an everted forefoot (forefoot valgus or plantarflexed first ray), since that gives you the best lateral arch for 5th met support. But, take what you get. Experiment with multiple circumferential taping techniques with elastacon or a similiar stretch tape. Between the tape and orthotic, I would let the athlete play if they did not limp. If they limp, and hurt their knee, it could be a worse problem. I team that up with the players, parents, and coaches, to pull out of the game if limping is noted. Hope this helps. Rich


Thank you very much for leaving a comment. Due to my time restraints, some comments may not be answered.I will answer questions that I feel will help the community as a whole.. I can only answer medical questions in a general form. No specific answers can be given. Please consult a podiatrist, therapist, orthopedist, or sports medicine physician in your area for specific questions.