A Physical Therapy Guide to Lower Extremity Stress Fractures

Stress fractures are a common injury among athletes, especially runners. However, anyone can suffer from a stress fracture. This guide will discuss the symptoms, causes, and top conservative treatment options for stress fractures.

Up to 20% of overuse injuries in the lower body are stress fractures.¹ A CityPT physical therapist will guide activity modification and how to gradually get back to previous activity levels.

Table of Contents

• Understanding Stress Fractures
• Symptoms of Lower Extremity Stress Fractures
• Risk Factors for a Stress Fracture
• Diagnosing a Stress Fracture
• What to Expect from Physical Therapy for Stress Fractures
• Preventing Stress Fractures
• Getting Conservative Treatment for Stress Fractures

Understanding Stress Fractures

Stress fractures happen when a small crack in a bone occurs from repetitive stress or overuse. When the load placed on the bone exceeds its ability to rebuild with repetitive activities like running, marching, and jumping, the bone can develop a stress injury, including localizing swelling in the bone that can progress to a fracture.

Stress fractures are different from acute fractures (i.e., broken bone from a fall) in that they develop over time from repetitive stress instead of one traumatic event. Chronic overuse of the lower legs leads to a stress reaction in the body that compromises bone tissue and can lead to non-traumatic fractures.

The most common location for stress fractures is in the lower extremities since they bear weight with daily activities (up to 95%). Common locations include the shin bone, foot, and ankle — particularly the tibia (tibial stress fracture) and second metatarsal (base of the second toe).² However, they can occur in any body bone.

Symptoms of Lower Extremity Stress Fractures

The most common symptom of a stress fracture is pain that worsens with weight bearing. Typically, the pain will start slowly and progress over time if not addressed.

Other symptoms include:

• Pain during weight-bearing activities, particularly high impact
• Depending on the location of the fracture, shin pain, foot pain, and/or ankle pain will be present
• A tender point along the bone fracture that elicits sharp pain
• A dull ache after activity (although the pain might subside with rest if less severe)
• Redness or swelling without bruising
• Inability to tolerate normal daily activities, sports, work, etc.

Risk Factors for a Stress Fracture

Many risk factors can predispose someone to develop a stress fracture. These include:

• Osteoporosis (poor bone health)
• Female gender³, specifically when hormone imbalances occur
• Irregular menstrual periods
• Older age (over 60 years old)
• Smoking
• Shin splints (medial tibial stress syndrome)
• Obesity or sudden weight gain
• Participating in high-impact sports or intense exercise
• A sudden increase in activity level that puts too much stress on the lower leg
• Shoe wear
• Flat feet⁴
• Work or hobbies that require a lot of time standing or walking on hard surfaces (i.e. concrete)
• Poor nutrition
• Sleep deprivation
• Sedentary lifestyle
• Chronic use of anti-inflammatory drugs (NSAIDs)
• Relative energy deficiency in sport (RED-S)

Diagnosing a Stress Fracture

Diagnosing a stress fracture is often a matter of ruling out other potential causes of the lower leg (shin), foot, and ankle pain first, such as shin splints and plantar fasciitis. Thus, your physical therapist will focus on looking at your history and functional deficits. During an initial exam, you can expect:

• An in-depth review of medical history, symptoms, and activity levels
• A physical examination of the painful area to assess tender points and swelling of the lower leg
• Assessment of risk factors for developing a stress fracture
• Lower leg range of motion
• Leg length assessment
• Posture and gait analysis

Imaging tests, such as an x-ray or magnetic resonance imaging (MRI), may be ordered if a stress fracture is suspected. Imaging will likely need to be repeated several times throughout the treatment process. This is because as high as 80% of stress fractures won't appear on an initial assessment.⁴

What to Expect from Physical Therapy for Stress Fractures

If you are diagnosed with a stress fracture of the shin bone, foot, or ankle, your physical therapist will work with you to develop a treatment plan.

The first step in treating any stress fracture is initial rest from any activity that overloads the healing bone. Depending on the location and severity of the injury, this may mean complete rest or just modifying your activities for approximately four to six weeks.

When your body is ready, your physical therapist can then progress you back to your previous activity levels while carefully monitoring the response to increased training load. This will likely include a gradual increase in your activities' frequency, duration, and intensity.

As you return to your normal activities, you can expect guidance on how to:

• Education about the underlying cause(s) of the lower leg stress fracture, such as overuse injuries
• Tactics for promoting tissue health and allowing the injured area to heal properly
• Boost your bone health with appropriate weight-bearing exercise and activity
• How to effectively relieve pain
• How to progress physical activity safely
• Biomechanical training to reduce unnecessary strain with activity, particularly with running and jumping
• Assessment and recommendations for footwear and/or orthotics
• Designing a comprehensive home exercise program with a focus on regaining strength, endurance, range of motion, coordination, and balance of the affected lower extremity
• Collaborating with your coach/trainer and physician (typically an orthopedic or sports medicine specialist)
• When to consult with a dietician to address any issues with slow healing via healthy diet changes

Why Do I Need PT for a Stress Fracture?

While you may be able to manage some stress fractures on your own, seeking out the help of a physical therapist for this lower leg injury has many benefits. They will help you find the right balance between rest and activity — thus, optimizing your speed to recovery without compromising bone health or risking future injury.

Do I Need Surgery?

Whether you need surgery or not will depend on several factors. These include:

• The severity of the fracture
• The risk of fracture progression
• Location of the fracture (whether there's adequate blood flow for the healing process)
• Activity level and overall health

With severe cases, poorly vascularized areas, and some athletes that want to recover as soon as possible, surgery will likely be recommended by a sports medicine specialist for the best outcomes.⁴

Preventing Stress Fractures

The best way to deal with a stress fracture is to avoid getting one in the first place. Some ways you can do this include:

• Wearing proper footwear and implementing proper technique, including knee and foot biomechanics, for your sport or activity
• Gradually increasing the frequency, duration, and intensity of your activities to keep them relatively pain-free
• Eating a well-balanced diet rich in calcium and vitamin D
• Maintaining a healthy weight
• Avoiding smoking and alcohol
• Treat shin splints and other overuse-related injuries that are correlated to stress fractures
• Incorporating cross-training activities into your routine to allow the body to rest
• Listening to your body and taking breaks when you're feeling off or sore
• Maintaining a caloric load sufficient for your activity level
• If you are at high risk for osteopenia or osteoporosis, consider getting a regular bone scan

Getting Conservative Treatment for Stress Fractures

Dealing with a stress fracture can be frustrating. However, it's a sign from your body that it's time to slow down and rest.

Let your physical therapist and symptoms guide you for the best results on your road to recovery. When you tune in and get expert advice, you can return to your normal sport and activities as soon as possible.

Get in touch with one of our specialized orthopedic CityPT therapists to optimize your recovery potential.

This guide is intended for informational purposes only. We are not providing legal or medical advice and this guide does not create a provider-patient relationship. Do not rely upon this guide (or any guide) for medical information. Always seek the help of a qualified medical professional who has assessed you and understands your condition.

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