Physical Therapist's Guide to Lower Extremity Stress Fractures
Lower extremity stress fractures are fractures of the bones in the lower legs or feet that occur with repeated activities. They are a relatively common injury, seen most often in athletes playing sports that require repetitive impacts (eg, running and jumping). Stress fractures comprise 5% to 30% of all activity-related injuries of the lower extremities. Female athletes are more likely to develop stress fractures in the legs and feet than male athletes. Although athletes may be more susceptible to these types of injuries, individuals who walk, march, or spend much of their workday on hard floors (eg, concrete) also are at risk. Physical therapists help people with lower extremity stress fractures recover strength, movement, and flexibility, and help them identify risk factors for future injury.
What is Lower Extremity Stress Fractures?
Lower extremity stress fractures are fractures of the bones in the lower legs or feet. Stress fractures are tiny cracks that occur in bone, usually related to repetitive activities that impact the bone in a similar way over time. These stresses lead to changes in the normal process of bone breakdown and reformation. Stress fractures are most common in the feet and legs, as these structures bear a person’s weight during walking, running, and jumping.
How Does it Feel?
Stress fractures are characterized by a sharp pain in a very specific point over the top of a bone. Lower extremity stress fractures generally hurt when you are walking, running, or jumping. You may also experience aching pain in the area after activity. Symptoms typically improve with rest.
Signs and Symptoms
Individuals who develop activity-related lower extremity stress fractures may experience:
- Pain during activity (eg, walking, running, jumping)
- Sharp pain over a specific point on the bone (eg, point tenderness)
- Aching pain after activity
- Swelling without bruising at the painful site
- Difficulty tolerating usual recreational/occupational demands
How Is It Diagnosed?
If you see your physical therapist first, your therapist will conduct a thorough evaluation that includes taking your health history. Your physical therapist may ask whether you:
- Increased your activity significantly over the past weeks or months
- Noticed an increase in pain with activity that slowly subsides after activity
- Can touch a specific area on the bone that hurts
- Experienced any specific event that caused your pain (eg, fall, twist, collision)
Your physical therapist will perform gentle physical tests to help determine the likelihood that you have an activity-related lower extremity stress fracture. Your therapist also may test for other contributing factors to your injury, such as the strength of your legs, the flexibility of your muscles, the stiffness of your joints, and the quality of your footwear.
To provide a definitive diagnosis, your physical therapist may collaborate with an orthopedic physician or other health care provider. The physician may order further tests, such as magnetic resonance imaging (MRI) or a bone scan, to confirm the diagnosis.
How Can a Physical Therapist Help?
Stress fractures are initially treated by resting the leg as much as possible. Stopping or modifying activities that increase stress on the legs (eg, running, jumping, or "cutting" in sports) for at least 3 weeks may be recommended to allow the bone to begin the healing process.
Based on your specific injury and condition, your physical therapist can decide whether you should use a compressive brace, crutches, or a walking boot to protect your bone while it is healing.
Initial treatment may include muscle-strengthening exercises for the lower extremities and core, stretching exercises, and alternative cardiovascular training, such as swimming or aqua aerobics. Shockwave therapy or the use of a bone stimulator may be warranted if the bone exhibits difficult or delayed healing.
During your rehabilitation, your physical therapist also can design a specific treatment program for you to follow at home to help speed your recovery.
As You Start to Recover
Your physical therapist's overall goal is to return you to your normal daily tasks at home, at work, and in the community. Without proper rehabilitation, serious problems such as chronic pain, swelling, weakness, and more severe fracture could arise, further limiting your ability to perform your usual activities.
Your physical therapist will design an individualized treatment program for you, based on your unique condition and goals. Your treatment may include:
Range-of-motion exercises. Because you have been less mobile over the past few weeks, 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.
Muscle-strengthening exercises. Even short-term inactivity weakens the muscles of the legs, increasing the potential for new injuries. Additionally, your stress fracture may have been related to some underlying weakness in the legs. Your physical therapist can determine which strengthening exercises are right for you based on the severity of your injury and where you are in your recovery.
Body awareness and balance training. Specialized training exercises help your muscles "learn" to respond to changes in your environment, such as uneven or unstable surfaces. When you are able to put your full weight on your foot without pain, your physical therapist may prescribe these training exercises to help you return stronger to your normal activities.
Functional training. When you can walk freely without pain, your physical therapist may begin "progressing" your treatment program to include activities that you were doing before your injury. This program will begin with slow, progressive weight-bearing activities, such as hopping and light jogging. Your physical therapist will create your own unique training program, based on your condition, your goals, and your activity levels.
Activity-specific training. Depending on the requirements of your job or the type of sport you play, you might need additional rehabilitation tailored for your job or sport. Your physical therapist can develop a program that takes into account all of these demands as well as your specific injury.
Orthotic therapy. In-shoe orthotics may be beneficial to support your return to activity with no pain as well as possibly prevent future stress fractures, if your foot posture or mechanics were a contributing factor to the development of the original stress fracture.
Education. Proper shoe selection, nutrition, training regimens, and other topics are an essential part of your rehabilitation. Your physical therapist will provide specialized education to aid in your recovery as well as in the prevention of future musculoskeletal issues.
Can this Injury or Condition be Prevented?
Although there are no guaranteed ways to prevent lower extremity stress fractures, there are a number of factors known to be associated with their occurrence. Risk factors that should be avoided include:
- Excessive impact physical activity (eg, running, jumping, cutting) with inadequate rest
- Running more than 25 miles per week
- A sudden increase in physical activity
- Consumption of more than 10 alcoholic beverages per week
- Inadequate nutrition, including low vitamin D and calorie intake
- Hormonal imbalances
- Low bone density
- High BMI (body mass index)
Real Life Experiences
Joan is a 27-year-old business executive who has been training for her first marathon. She recently ran her longest distance to date—15 miles. However, at about 9 miles into her run, Joan noticed some pain on the lower inside portion of her right shin. It increased over the next 6 miles; by the end of the training run, it was sharp and throbbing, and the area appeared slightly swollen. The site continued to be painful to touch. That day and the next, Joan had difficulty walking even short distances without pain. She contacted her physical therapist.
Joan’s physical therapist took measurements of her hip, knee, and ankle strength and range of motion. He noted that she had no previous history of bone or joint disease. He gently pushed on her lower shin and bumped the bottom of her foot to test for a possible lower extremity stress fracture. Joan stated that both of these tests recreated her pain. Joan consulted with her physician, who agreed to order a bone scan of her lower leg. Joan was diagnosed with a lower extremity stress fracture.
Joan's physical therapist provided her with a walker boot and placed a compressive brace over her shin, which she wore for 4 weeks. He instructed her not to walk without the boot. During that recovery time, he also taught her how to gently exercise on a stationary bike and complete specific leg-strengthening exercises with elastic bands. She also swam periodically for exercise.
Joan learned about proper training techniques, nutrition, and other lifestyle factors that affect healing and contribute to the risk of recurring injury.
After 4 weeks, Joan’s physical therapist discontinued the use of the boot, and added gradual weight-bearing activities (ie, weight shifting, stair climbing, small hops) to her treatment regimen.
Over the next few weeks, Joan's physical therapist taught her additional specific lower-leg strengthening exercises and helped her slowly return to jogging—and eventually running. He monitored her running form and suggested any changes she should make in her training.
Two months after her injury, Joan was able to resume her training with much more care and attention to preventing injury.
Just this week, Joan’s friends cheered her on as she crossed the finish line of her first marathon—pain free!
What Kind of Physical Therapist Do I Need?
All physical therapists are prepared through education and experience to treat activity-related lower extremity stress fractures. However, you may want to consider the following:
- Choose a physical therapist who is experienced in treating people with activity-related lower extremity stress fractures. Some physical therapists have a practice with a sports or running focus.
- Choose a physical therapist who is a board-certified clinical specialist or who completed a residency or fellowship in sports or orthopaedic physical therapy. This physical therapist has advanced knowledge, experience, and skills that may apply to your condition.
You can find physical therapists who have these and other credentials by using Find a PT, the online tool built by the American Physical Therapy Association to help you search for physical therapists with specific clinical expertise in your geographic area.
General tips when you're looking for a physical therapist (or any other health care provider):
- Get recommendations from family and friends or from other health care providers.
- When you contact a physical therapy clinic for an appointment, ask about the physical therapists' experience in helping people who have stress fractures.
- During your first visit with the physical therapist, be prepared to describe your symptoms in as much detail as possible, and say what makes your symptoms worse.
The American Physical Therapy Association believes that consumers should have access to information that could help them make health care decisions and also prepare them for a visit with their health care provider.
The following articles provide some of the best scientific evidence related to physical therapy treatment of activity-related lower extremity stress fractures. The articles report recent research and give an overview of the standards of practice both in the United States and internationally. The article titles are linked either to a PubMed* abstract of the article or to free full text, so that you can read it or print out a copy to bring with you to your health care provider.
Saunier J, Chapurlat R. Stress fracture in athletes. Joint Bone Spine. 2018;85:307–310. Article Summary in PubMed.
DeFroda SF, Cameron KL, Posner M, Kriz PK, Owens BD. Bone stress injuries in the military: diagnosis, management, and prevention. Am J Orthop (Belle Mead NJ). 2017:46(4):176–183. Article Summary in PubMed.
Wright AA, Taylor SB, Ford KR, Siska L, Smoliga JM. Risk factors associated with lower extremity stress fractures in runners: a systematic review with meta-analysis. Br J Sports Med. 2015:49(23):1517–1523. Article Summary in PubMed.
Brewer RB, Gregory AJ. Chronic lower leg pain in athletes: a guide for the differential diagnosis, evaluation, and treatment. Sports Health. 2012;4(2):121–127. Free Article.
American Academy of Family Physicians. Information from your family doctor: stress fractures. Am Fam Physician. 2011;83(1):47. Free Article.
Patel DS, Roth M, Kapil N. Stress fractures: diagnosis, treatment, and prevention. Am Fam Physician. 2011;83(1):39–46. Free Article.
Tenforde AS, Sayres LC, Sainani KL, Fredericson M. Evaluating the relationship of calcium and vitamin D in the prevention of stress fracture injuries in the young athlete: a review of the literature. PM R. 2010;2(10):945–949. Article Summary on PubMed.
Thelen MD. Identification of a high-risk anterior tibial stress fracture. J Orthop Sports Phys Ther. 2010;40(12):833. Free Article.
Heyworth BE, Green DW. Lower extremity stress fractures in pediatric and adolescent athletes. Curr Opin Pediatr. 2008;20(1):58–61. Article Summary on PubMed.
Niva MH, Sormaala MJ, Kiuru MJ, et al. Bone stress injuries of the ankle and foot: an 86-month magnetic resonance imaging-based study of physically active young adults. Am J Sports Med. 2007;35(4):643–649. Article Summary on PubMed.
Drabicki RR, Greer WJ, DeMeo PJ. Stress fractures around the knee. Clin Sports Med. 2006;25(1):105–115. Article Summary on PubMed.
*PubMed is a free online resource developed by the National Center for Biotechnology Information (NCBI). PubMed contains millions of citations to biomedical literature, including citations in the National Library of Medicine’s MEDLINE database.
Revised by Lisa Noceti-DeWit, PT, DPT. She is a board-certified orthopaedic and sports clinical specialist. Authored by D.S. Blaise Williams, PT, PhD. Reviewed by the MoveForwardPT.com editorial board.
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