Lower Extremity Stress Fractures and Physical Therapy

The constant stress experienced by the feet and the lower extremity from activities such as walking and running can have an impact on its structural integrity. Injuries can be many, and one such well recognized injury is a stress fracture. Typically, stress fractures are a result of constant and repetitive stress that is just below the threshold of overloading. The fractures are a consequence of high ground reaction forces exerted when placing the foot on the ground.

What is a fibula stress fracture?

The fibula is a long bone which lies on the outer aspect of the lower leg and is responsible for transferring some weight bearing forces from the shin to the foot (figure 1). Several muscles attach to the fibula so that when they contract, they exert a pulling force on the bone. Furthermore, weight bearing activity places compressive forces through the fibula. When these forces are excessive or too repetitive and beyond what the bone can withstand, bony damage gradually occurs. This initially results in a bony stress reaction, however, with continued damage may progress to a fibula stress fracture.

Stress Fractures on the Fibia or Tibia

Stress fractures of the tibia and fibula occur in many athletes, especially runners, and also in non-athletes who suddenly increase their activity level or have an underlying illness predisposing them to stress fractures. Many factors appear to contribute to the development of these fractures including changes in athletic training, specific anatomic traits, decreased bone density, and disease states

Signs and symptoms of a Lower extremity or fibula stress fracture

Symptom onset from stress fractures of the tibia or fibula is usually insidious over weeks; pain is exacerbated by running or jumping. Patients with this condition typically experience a localized pain in the outer lower leg that increases with weight bearing activity. In severe cases, walking may be enough to aggravate symptoms. Other symptoms may include night ache or pain on firmly touching the fibula.

How to manage lower extremity stress fractures

Treatment for patients with this condition typically involves an initial period of rest from weight bearing activity which may include the use of crutches or a protective boot. Treatment is progressed symptomatically with rest from activity until pain settles.

Once the patient is pain-free a gradual increase in weight bearing activity and exercise can occur provided symptoms do not increase. This should occur over weeks to months with direction from a physical therapist and will vary depending on the severity of the injury. Alternative exercises placing minimal weight bearing forces through the affected bones should be performed to maintain fitness such as swimming, cycling, and water running. While it might seem like a contradiction to exercise with a fracture, the basic principle that is involved is one of modification of activity. For example, athletes who are used to hard training regimes must gradually increase the intensity of the workout every week, rather than increase in large bursts.

Exercises to maintain flexibility, strength and balance are also important to ensure the ankle and knee are functioning correctly. The treating physical therapist can advise which exercises are most appropriate and when they should be commenced.

The role of physical therapy

Typically, physical therapists offer a program of muscle strengthening and conditioning in the treatment of stress fractures of the lower extremities. For example, runners can take a break from running and maintain the same level of fitness by performing cross training and cycling (1). Just a simple alteration in footwear used during exercise can be sufficient in most cases (2).

There are Contributing factors to the development of stress fracture

There are several factors that may contribute to the development of a stress fracture in the lower extremity or of the fibula . These should be assessed and where possible corrected with direction from a physiotherapist and may include:

  • poor foot mechanics

  • inappropriate or excessive training or footwear

  • joint stiffness

  • poor flexibility

  • muscle weakness

  • poor balance

When taking into consideration the risk factors for the development of stress fractures, numerous parameters must be taken into account. In women, an alteration in menstrual cycles, reduced bone density and change in the calf girth can all be predictors of stress fractures (3). On an average, stress fractures can take up to 12 weeks to heal, and this period is often marked by limited activity (4).

Prior to receiving physical therapy, most patients will attempt to use simple pain killers to relieve pain. While this may work in some patients, there is some evidence to suggest that pain medication use can delay healing (5).

The use of physical aids can also help patients with stress fractures. Simple aids such as crutches and pneumatic braces can reduce pain and thus healing time, possibly allowing for resumption of movement a lot sooner than expected. There are other methods that may be attempted such as electrical stimulation or ultrasound therapy, but clinical evidence supporting this is still insufficient.

Finally, no treatment is complete without prevention of future injury and the same holds true for stress fractures as well. Orthotic shoe inserts and simple changes in training schedules are often more than sufficient. A prescription of calcium and vitamin D supplements may add to the overall benefit of physical therapy. However, whether or not bisphosphonates will help is still doubtful.

In conclusion, physical therapists play an important role in the management of patients with stress fractures. Treatment options are variable, and often involve prescription of medicines along with different therapies.

References

  1. Matheson GO, Clement DB, McKenzie DC, Taunton JE, Lloyd-Smith DR, MacIntyre JG. Stress fractures in athletes. A study of 320 cases. Am J Sports Med. 1987;15(1):46–58.

  2. Nicola TL, El Shami A. Rehabilitation of running injuries. Clin Sports Med. Apr 2012;31(2):351-72.

  3. Bennell, Kim L., et al. “Risk Factors for Stress Fractures in Track and Field Athletes A Twelve-Month Prospective Study.” The American journal of sports medicine 24.6 (1996): 810-818.

  4. Ohta-Fukushima M, Mutoh Y, Takasugi S, Iwata H, Ishii S. Characteristics of stress fractures in young athletes under 20 years. J Sports Med Phys Fitness. 2002;42(2):198–206.

  5. Wheeler P, Batt ME. Do non-steroidal anti-inflammatory drugs adversely affect stress fracture healing? A short review. Br J Sports Med. 2005;39(2):65–69.