Conway McLean, DPM, Journal columnist

Modern life is difficult for many Americans. Financial challenges, family strife, social concerns, all lead to high stress levels as part of life. The psychologists say we are moving through life “stressed out” most of the time. Both physical and psychological damage can occur when this is a frequent situation. Many tissues of the human body can be injured by chronic stress. It is true; even bone can become “stressed out”. And when it does, an actual fracture can occur (depending, of course, on numerous factors). But this isn’t just any fracture. As you might expect, it is referred to as a stress fracture.

Most people instinctively imagine the prototypical long bone, cracked in half, a deformity so obvious you can see it from next door. A stress fracture is quite different, causing no change in positioning, often not even visible on x-ray. They are the result of the bone repetitively carrying some load, but less than one leading to an acute break. Structural fatigue results from this weighty burden, leading to cracks in the hard outer shell of bone.

Stress fractures are almost always seen in the lower extremities. The most common locations include the tibia, the metatarsal bones in the foot, the fibula, with less common locations being the femur, pelvis, or sacrum. Of all stress fractures, those of the tibia, the long bone of the lower leg, are the most common at about 24%. The sufferer of a stress fracture can present with tenderness or swelling after a recent increase in activity or perhaps some repeated action with limited rest. Stress fractures usually cause a dull pain at the fracture site, which often worsens with increased activities, like exercising, walking, even sometimes standing.

Many sports raise the risk of stress fractures since they entail activities requiring running and jumping. The volume and intensity of these high impact physical activities is a critical factor in the development of these osseous injuries. But stress fractures also can occur with normal usage, normal activities, if your bones have been weakened by osteoporosis. Another term for these are “insufficiency fractures” since there is insufficient bone to withstand the normal stress of daily life.

Diagnosing a stress fracture can be difficult. As mentioned, there are no visible signs on x-ray. And they can mimic some everyday conditions like tendinitis, shin splints, or a compartment syndrome. Without a high index of suspicion, these may be misdiagnosed for months. The treating physician should be intimately familiar with these injuries if they are to diagnosis it correctly. The vague discomfort of a stress fracture can be misleading, resulting in an ineffective treatment plan.

The physical exam is critical in making an accurate diagnosis when performed by a physician familiar with these. An MRI can be helpful, although these are often treated empirically. This means if it fits all the characteristics of a stress fracture, it probably is and should be treated appropriately. It is especially true since the typical treatments are benign and beneficial for many other problems.

When a stress fracture is diagnosed, basic concepts of medicine apply. Immobilization of some sort is the primary recommendation, although how that is manifested varies greatly. To reduce the bone’s weight-bearing load until healing occurs, use of a walking boot is the most common prescription. Depending on the bone affected, a brace of some type might be prescribed, or even the use of crutches (more likely with a stress fracture of the tibia).

Although unusual, surgery is sometimes necessary to ensure proper healing of certain structures. Surgery is also performed more commonly in elite athletes who want to return to play quicker. The fifth metatarsal, the bone running out to the little toe, is infamous for problems with proper healing and so requires operative intervention more frequently.

A critical factor in the manifestation of a stress fracture is your musculoskeletal mechanics. The foot and leg go through various motions and changes with each step. If these are not normal and proper, various bones will be stressed and encourage bone injury. Foot orthotics, prescription arch supports, have been found to lower risk of injuries in general, especially the risk of stress fractures.

These customized inserts should be fabricated with an intimate knowledge of anatomy and function of the lower extremity, the foot, ankle, and leg. By optimizing extremity alignment and biomechanics, these shoe inserts can shift weight distribution, and so reduce forces experienced by the metatarsal bones. Studies have revealed a reduced risk of many problems that can be traced to overuse and faulty mechanics, like heel pain and many types of foot and leg pain. Also studied have been shock-absorbing insoles which were found not to provide a reduction in the number of injuries, in contrast to prescription supports.

Improving your bone health will reduce the likelihood of this type of fracture. Making vegetables the foundation of your nutrition has been proven beneficial. Especially effective is strength training and resistance exercises. Foods providing plentiful vitamin D and calcium are helpful, as is consuming enough protein. Predictably, maintaining a healthy body weight means there will be less force exerted on the bones of your lower extremity. This naturally equates to a reduced risk of a stress fracture.

These tiny cracks in a weight-bearing bone can sometimes develop slowly due to overuse. The cracks may take time to develop, but the onset of pain may be sudden, with no inciting event, following ‘just another day.’ In contrast, it can also coincide with some new activity, or using old, collapsed shoes. Or having poor bone stock due to inactivity.

It’s a common scenario; someone is seen by a primary care provider with complaints of a vague musculoskeletal pain. Without the appropriate diagnosis, effective treatment is not utilized. This equates to further complications and an increased risk of secondary problems. If you are experiencing increasing pain in the foot or leg, or pain that isn’t responding to care, perhaps a recurrently aching foot, getting the right diagnosis is critical: you may have a stress fracture and require specific and necessary treatment. Don’t live with chronic pain: you could have a broken leg!

Editor’s note: Dr. Conway McLean is a physician practicing foot and ankle medicine in the Upper Peninsula. Dr. McLean’s practice, Superior Foot and Ankle Centers, has offices in Marquette and Escanaba, and now the Keweenaw following the recent addition of an office in L’Anse. McLean has lectured internationally, and written dozens of articles on wound care, surgery, and diabetic foot medicine. He is board certified in surgery, wound care, and lower extremity biomechanics.