IMPORTANT: If you have diabetes, you should see your podiatric physician at the first sign of pain or other problems with your legs, ankles, feet or toes, no matter how minor you may think they are. Patients with diabetes who develop podiatric problems often require special attention.  The following precautions and steps may be recommended by your podiatric physician, but should not be undertaken without his/her supervision and consent.

What is it?
A stress fracture is a break in a bone. Usually, it is a thin crack that develops over time because of repeated or prolonged forces against that bone. Bones where stress fractures often occur are those in the toes, foot, ankle, tibia or hip. Stress fractures are an injury common to athletes, particularly runners and dancers, or others who practice exercise that involves a repeated impact to a particular bone or joint. A stress fracture starts as a small crack and if left untreated, can worsen until it the bone breaks apart completely.

What is the difference between a stress fracture and a true fracture? Both injuries are a type of broken bone; the difference is how that break occurs. A traditional fracture is the result of one serious injury. A stress fracture is the result of repeated lesser trauma. To provide an example, if you fell off a ladder, landed hard and broke your leg, that break would be classified as a traditional fracture. If you jogged every day, and over time, the repeated impact caused the bone to crack, that would be a stress fracture. Either way, it’s a painful, debilitating  injury.

 Note: There are various types of traditional fractures, depending upon number and severity of breaks, and displacement of the bone once it has been injured; for the purposes of this article, we will concentrate only on stress fractures.  Your doctor can provide further information on other types of fractures.

What to look for:
 In the case of stress fractures, you’re not so much looking for symptoms, as you are feeling them. Stress fractures often begin as a minor pain or even as a feeling of weakness in the affected area. It is at this stage that the fracture is most easily treated, but unfortunately, most patients don’t recognize the problem as a fracture because it simply doesn’t hurt enough. (And since a fracture can only be diagnosed via x-ray, C.A.T. scan or M.R.I - which most people don’t have access to if they’re not medical professionals - it’s not surprising that most stress fractures aren’t diagnosed early.)

 The pain is felt in a very localized or specific area, and does not involve disturbance to the skin.  Instead, it’s a pain deep within the foot, the ankle or the toe, which may look like nothing at all when you take off your shoe and sock to see what is hurting.  (For injuries further up, it may be a pain deep within the leg or hip.)  Left untreated, the feeling progresses to a nagging ache, and from there, will escalate, either slowly or quickly, depending upon the individual’s level of activity. Eventually, it can become severe, often unbearable, pain. A stress fracture of one of the bones in your foot, for example, can begin as a simple discomfort which at first might feel like a pulled muscle or a minor sprain or strain. If you kept up your normal activities (walking, doing yard work, perhaps some form of exercise), you would soon find yourself limping, and eventually, would need to use crutches, as the foot would be too painful to bear weight of any kind.

What NOT to look for:
Common misconceptions concerning fractures are that in the case of a fracture, the patient will not be able to wiggle his or her toes, or to move the foot or ankle. This is not true; the nerves and muscles that allow for movement have not been affected by the fracture.  It may be painful to move the leg, ankle, feet or toes, but it’s certainly possible. The same goes for the misconception that you can’t walk on a fractured bone.  You can, at least in the early stages of a stress fracture, before it worsens and the pain becomes too extreme. You might also hear that the area around a fracture will be swollen. Swelling may appear or it may not.  Generally, if it does, it’s only about as big as a silver dollar.  Finally, don’t look for bruising around the area to confirm that you have a stress fracture. While a traditional fracture often has severe black and blue discoloration, it isn’t a “given” in the case of a stress fracture.

How can I know it’s a stress fracture?
Unfortunately, you can’t know, at least not without professional assistance.  A podiatric physician will need to examine you and make a determination after having an x-ray, or even an M.R.I. or C.A.T. scan performed.  Any number of problems, such as plantar fasciitis, sprains and strains and many other conditions can cause localized pain that worsens over time and makes walking painful or even impossible.

 Perhaps most frustrating to patients and doctors alike is the fact that in many cases, the thin cracks on the bone which cause so much pain, but do not actually produce separation of the bone itself, will not show up on x-ray until the healing process has begun.  Once the healing process is underway, the new bone material, which has been produced to mend the wounded area, is visible on x-ray as a thin white line.  The break itself may have been invisible on x-ray when the stress fracture was most painful.  Often, a doctor will have to rely on an M.R.I. or C.A.T. scan, which is a more accurate (though more expensive) diagnostic tool, in order to ascertain that the injury is indeed a fracture.

What it means to you:
While a stress fracture is not a life-threatening condition, any fracture is a serious problem. Left untreated and subjected to repeated impact, a hairline stress fracture (which is just a crack in the bone) can worsen, eventually becoming a total break if the patient does not curtail his or her activities.  A break that does not receive professional medical attention can heal improperly and become a lifelong source of pain and disability to the patient.  A podiatric physician can evaluate the symptoms and recommend a course of treatment. As with just about every other medical problem, the best way to rid yourself of a fracture once and for all is to get treatment for it as soon as possible.

What causes it?
Repeated, sustained impact over a period of time is the culprit here.  The more you work out, the more impact your muscles have to absorb in order to protect your bones.  After a certain amount of time, your muscles become fatigued, and the impact gets transferred to the bone.  Repeated stress to the bone eventually results in a small crack that can become bigger and bigger (and more and more painful) if it is ignored.  Because many ‘weekend warrior’ athletes still subscribe to the ‘no pain, no gain’ mantra, or because they don’t wish to disrupt their routine, they continue to exercise.  This in turn worsens the fracture.

What do I need to know before I visit the doctor?
The doctor will conduct a physical examination of the affected area, and will also ask a patient a series of questions about their activities of daily life.  Do they do much standing? Walking?  Running?  Dancing?  Playing tennis?  What forms of exercise?  On what kind of surface?  How often?  How much time? How many miles?  Has any change been made to the routine lately, such as adding extra miles to a running route, playing more games of tennis or spending extra time working out in the dance studio or the aerobics club?  Often, stress fractures occur when the patient increases the duration or intensity of exercise without gradually building up to it.  Patients meeting with their doctor should be completely honest and accurate in giving an account of their daily activities, as it will assist in understanding the type and extent of the injury and how it took place.

 The podiatric physician may also ask about injuries that have occurred to other family members, and whether there is a history of bone problems such as osteoporosis.  If possible, find out whether the family medical history includes a high number of broken bones. Be sure to tell the doctor whether you take vitamin or mineral supplements, use a lot of caffeine, or take any medications, prescription or otherwise.

 What cures it?
The course of action chosen by your doctor will depend upon the severity of the break. If the stress fracture is minor, the doctor may prescribe rest, and will ask the patient to refrain from activities such as running, dancing or other weight-bearing exercise.  Crutches are often the best option to insure that the bone doesn’t receive impact as it heals. More severe fractures may require immobilization of the affected area, coupled with use of crutches. Soft casts and injury shoes are often employed.  In cases where the bone has completely broken, the doctor may recommend casting or surgery, along with wheelchair use

One note of caution: It’s natural to want to get back to your normal activities as soon as possible. Stress fractures will begin to mend relatively quickly, as long as the patient is resting the injured area. As soon as the bone starts to knit, the pain will become noticeably less aggravating.  Many people, upon discovering that their pain isn’t as severe when they stand or walk, will immediately want to do just that. Remember that as long as you can feel pain - any pain at all - the bone is still fragile in that area, and is susceptible to a repeat of the same break, in the same place.  Keep on using the crutches, the soft cast, or any other measure prescribed by your doctor, as long as he or she directs.  You won’t heal a fracture by adding to the stress on the bone.  That was how it broke in the first place.

How can stress fractures be prevented? 
Stress fractures, as we’ve now said numerous times, are the result of sustained impact.  While many forms of exercise - and even regular activities of daily living - can involve impact to the feet and legs, it’s important to follow a few basic rules.  Check with a doctor before starting an exercise program or even before taking on a job that will involve a level of physical activity to which you aren’t accustomed. Begin slowly, and build up very gradually to a healthy level of activity.  If, once you are settled into an exercise or work routine,  you decide to increase your activity level, check with your doctor and get a recommendation of how much to add, and over what period of time. Many doctors will also be willing to give you a recommendation of any kind of limits to set on yourself, based on your age, family history and physical condition.

Most importantly of all, if you feel pain at any time, stop exercising.  See your podiatric physician immediately at the first sign of any problem with your feet, ankles or toes.  If he or she recommends that you not exercise, or that you stop any particular activity for a specific period of time, follow those instructions to the letter.  The longer you persist in working out with an injury, the worse the injury becomes. The worse the injury is, the longer it takes to heal, and the longer you’ll be unable to exercise or do active work.  Cutting out your routine for a few weeks can be a nuisance, but ignoring the doctor’s instructions and exercising for those next few weeks can mean months of inactivity in the future.

 Do these symptoms always mean a stress fracture? No - as mentioned before, multiple problems, including, but not limited to, injuries caused by improper footwear,  strains, sprains, plantar fasciitis and many other conditions (some very serious) can cause pain in varying degrees of severity.  Therefore, it’s essential to get a professional’s diagnosis of the problem. A delay in getting the correct treatment - not to mention the additional trauma you have inflicted on the damaged area in the meantime - can mean the difference between a fracture that heals improperly and one that heals cleanly, allowing you to return to normal activity as soon as possible.

 Who can help me?
The American College of Foot & Ankle Orthopedics & Medicine (ACFAOM) stands ready to help you find a podiatric physician in your area. Simply click on our  foot-help-finder link to find the professional who can help you find the most effective treatment.