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• What Are Lower Extremity Stress Fractures?
• How Does It Feel?
• Signs and Symptoms
• How Is It Diagnosed?
• How Can a Physical Therapist Help?
• Can This Injury or Condition Be Prevented?
• What Kind of Physical Therapist Do I Need?

What Are Lower Extremity Stress Fractures?

Stress fractures are a type of overuse injury. They happen over time when someone repeats high-impact activities without enough rest between sessions. In runners, stress fractures can be linked to training errors, like increasing mileage too quickly or running high mileage too many days in a row. Stress fractures also can happen from increasing activity too quickly or walking on hard surfaces with poor footwear.

Bone is an active tissue that goes through a continuous process of breakdown and repair known as bone remodeling. High-impact activity, like running and jumping, increases the breakdown part of this process. With normal rest and activity, bone rebuilds aren’t rebuilding as fast as they are breaking down. Stress fractures occur when bone remodeling can’t keep up with the demands placed on the bone.

One of the first signs of weakening bone is a “stress reaction.” The area of bone under stress shows signs of inflammation like swelling and tenderness to touch. With repeated activity the damage in the bone builds up. This can progress to a crack or stress fracture. Rest and a full recovery are important to prevent the tiny crack from becoming a complete break.

How Does It Feel?

Signs and Symptoms

People who develop lower extremity stress fractures may experience:

• Pain during activity (such as walking, runn
• ing, or jumping)
• Sharp pain over a specific point on the bone (pinpoint tenderness)
• Aching pain after activity
• Swelling without bruising at the painful site
• Difficulty tolerating the usual demands of exercise or work

How Is It Diagnosed?

Your physical therapist will conduct a thorough evaluation. They will ask you about your health, daily activities, and how your injury happened. They also will check your posture, mobility, strength, flexibility, coordination, and balance. If your physical therapist suspects you have a stress fracture, your evaluation will be modified to reduce stress on your injured area.

Your physical therapist will perform movement-based tests to determine what is causing your symptoms. They may look for other contributing factors, such as the leg strength, muscle flexibility, joint stiffness, and the quality of your footwear.

Your physical therapist may work with an orthopedic physician to confirm your diagnosis. The physician may order further tests, such as magnetic resonance imaging or a bone scan to verify the cause of your symptoms.

How Can a Physical Therapist Help?

Stress fractures are first treated by resting the leg. The rest time required depends on the location of the stress fracture and how well the bone is healing. This can range from about three to 12 weeks.

If you have pain while walking, your physical therapist may recommend using an assistive device, like crutches or a walking boot, to decrease stress on the injured area. In some cases, they may recommend specific shoes or inserts to decrease stress on your legs.

Initial Treatment

Physical therapy first focuses on letting the injured bone heal while addressing the issues that contributed to your injury. Your movement precautions will guide treatment decisions. This may include exercises to address strength, flexibility, and mobility deficits. Early treatment also may include recommendations for alternative cardiovascular activity that does not stress the injured bone. If healing is delayed, shockwave therapy and a bone stimulator may be recommended to enhance bone healing.

As You Start to Recover

Your physical therapist will design a personalized treatment program, based on your unique condition and goals. Your treatment may include:

Range-of-motion exercises. Because you were less active while your bone healed, your range of motion may have decreased. Your physical therapist will teach you how to perform safe and effective exercises to restore full movement in the joints of your legs, ankles, and feet.

Muscle-strengthening exercises. Muscle strength helps reduce bone stress. Your physical therapist will develop a strengthening program to restore strength in your legs, ankles, and feet so you can return to full activity.

Body awareness and balance training. Because of the rest required to allow your bone to heal, your physical therapist will make sure your movement reactions are ready for a return to challenging activity. These exercises help your muscles and joints "learn" to respond to changes in your environment, like uneven or unstable surfaces.

Functional training. As your response to treatment allows, your physical therapist will gradually introduce more demanding activities. This involves progressive weight-bearing exercises. Your physical therapist will monitor how you control movement and how your symptoms respond to new challenges. They will make adjustments to your program as needed.

Activity-specific training. This portion of treatment depends on your job requirements or the type of sport you want to return to. Your physical therapist will work with you to make sure you are ready to safely return to full activity.

Education. Your physical therapist will work with you to address the causes of your injury and avoid reinjury. They may discuss shoe selection, training or activity schedules, and nutrition and may recommend changes to protect your body in the future.

Throughout your recovery, your physical therapist will adjust your treatment based on how you respond to new challenges. It is common to “take two steps forward and one step back” as your body responds to new stress. Your physical therapist will help you navigate your symptoms and minimize setbacks while you heal.

Can This Injury or Condition Be Prevented?

Including annual physical therapy visits in your health care routine is one way to avoid musculoskeletal injuries. Today’s physical therapists have doctoral-level education and are movement experts who can help you identify issues in strength, flexibility, or mobility that may contribute to injury. They can provide guidance on exercise frequency and intensity to help avoid overuse injuries.

To minimize your risk for stress fractures:

• Make any changes to your exercise program gradually.
• Incorporate rest or relative rest days into your fitness program.
• Pay attention to your nutrition. Calcium and vitamin D promote bone health.
• Make sure your diet provides enough energy for your chosen activities.
• Wear proper fitting shoes.

What Kind of Physical Therapist Do I Need?

All physical therapists are prepared through education and experience to treat lower extremity stress fractures. However, you may want to consider the following:

• A physical therapist who is experienced in treating people with lower extremity stress fractures. Some physical therapists have a practice with a sports or running focus.
• A physical therapist who is a board-certified clinical specialist or who completed a residency or fellowship in sports or orthopedic physical therapy. These physical therapists have advanced knowledge, experience, and skills that may apply to your condition.

You can search for physical therapists with specific experience or expertise using the American Physical Therapy Association’s Find a PT tool.

General tips when you're looking for a physical therapist (or any other health care provider):

• Ask family, friends, or other health care providers to recommend a physical therapist.
• Ask about the physical therapists' experience in helping people with lower extremity stress fractures when you contact the clinic for an appointment.
• Be prepared to describe your symptoms in as much detail as possible. Make a note of what makes your symptoms better or worse.