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Stress Fracture of the Foot (Members Only)

Injuries > FootStress Fracture of the Foot (Members Only)

 

(Also known as Foot Stress Fractures)

 

What is a stress fracture of the foot?

A stress fracture of the foot is a condition characterized by an incomplete crack in one of the foot bones.

The foot comprises of many small bones 7 of which are located in the rear foot and are collectively known as the tarsals. The mid foot comprises of 5 long bones known as the metatarsals. The toes each comprise of several small bones known as the phalanges (figure 1). Each bone within the foot forms joints with adjacent bones.

The bones of the foot provide attachment points for many muscles of the lower leg and foot. When these muscles contract, a pulling force is exerted on the respective bone. In addition, weight bearing activity places stress on the bones of the foot. When these forces are excessive or too repetitive, and beyond what the bones of the foot can withstand, bony damage can gradually occur. This may initially result in a bony stress reaction, however, with continued damage may progress to a stress fracture of the foot.

Cause of a stress fracture of the foot

A stress fracture of the foot typically occurs over time with excessive weight bearing activity such as distance running, sprinting, jumping or dancing. They often occur following a recent increase in activity or change in training conditions (such as surface, footwear or technique changes etc). A stress fracture of the foot may sometimes occur traumatically such as landing onto a hard surface from a height.

Signs and symptoms of a stress fracture of the foot

Patients with a stress fracture of the foot typically experience a localized pain in the foot, toes or ankle that increases with impact activity (such as running, jumping, sprinting and hopping) and may decrease with rest. As symptoms worsen, the patient may limp during weight bearing activity and may have to stop activity due to pain.

Occasionally, pain may radiate to other areas of the foot that are not specifically involved in the injury. In severe cases, walking or standing may be enough to aggravate symptoms. Other symptoms may include night ache or pain on firmly touching the affected bone.

Diagnosis of a stress fracture of the foot

A thorough subjective and objective examination from a general practitioner or physiotherapist may be sufficient to diagnose a stress fracture of the foot. Further investigations such as an X-ray, MRI, CT scan or bone scan are usually required to confirm diagnosis and determine the severity of injury.

Prognosis of a stress fracture of the foot

With appropriate management, most patients with a stress fracture of the foot can make a full recovery (return to sport or full activities) in a period of 3 - 9 months. In more severe cases, recovery may take 1 year, or longer, depending on the intervention required and a range of other factors. In rare cases, some patients may experience ongoing symptoms or complications which may require further management.

Treatment for a stress fracture of the foot

Most patients with a stress fracture of the foot heal well with an appropriate rehabilitation program. The success rate of treatment is largely dictated by patient compliance. One of the key components is that the patient rests sufficiently from any activity that increases their pain until they are symptom free. This typically involves an initial period of rest from weight bearing activity and may involve a period of non-weight-bearing immobilization in a plaster cast, the use of crutches or a protective boot for a number of weeks.

Activities placing large amounts of stress through the foot should also be minimised particularly excessive weight bearing activity such as running, jumping or prolonged walking or standing. Rest from aggravating activities ensures the body can begin the healing process in the absence of further tissue damage. Once the treating practitioner has indicated it is safe to do so, and, the patient can perform these activities pain free, a gradual return to these activities, weight bearing activity in general and exercise can usually occur as tolerated, provided symptoms do not increase. This should take place over a period of weeks to months with direction from the treating practitioner and will vary depending on the severity of the injury and how well the contributing factors have been addressed.

Ignoring symptoms or adopting a 'no pain, no gain' attitude is likely to cause further damage and may slow healing or prevent healing of the stress fracture altogether. Immediate, appropriate treatment is essential to ensure a speedy recovery.

Manual "hands-on" therapy such as massage, trigger point release techniques, dry needling, joint mobilisation, stretches, and electrotherapy can assist with hastening healing, improving range of movement, pain and function and correcting factors that have contributed to the development of the stress fracture. This can generally commence once the specialist, G.P. or physiotherapist has indicated it is safe to do so.

Patients with a stress fracture of the foot should also perform specific pain free flexibility and strengthening exercises (following the initial period of immobilization) as part of their rehabilitation to ensure an optimal outcome. In addition, alternative activities which place minimal weight bearing forces through the affected bone should also be performed to maintain fitness (such as swimming, water running and, in some cases, cycling). The treating physiotherapist can advise which exercises and activities are most appropriate for the patient and when they should be commenced.

Careful assessment by the physiotherapist to determine which factors have contributed to the development of the condition, with subsequent correction of these factors is also important to ensure an optimal outcome. A review with a podiatrist may be required for the prescription of orthotics and footwear advice, particularly in those patients whose foot posture and lower limb biomechanics have contributed to the development of the condition.

In the final stages of rehabilitation for a stress fracture of the foot, a gradual return to activity or sport can occur as guided by the treating practitioner provided symptoms do not increase. This may involve a gradual return to running program to recondition the affected bone to running in a safe and effective manner.

Contributing factors to the development of a stress fracture of the foot

There are several factors which may contribute to the development of a stress fracture of the foot. These need to be assessed and corrected with direction from the treating physiotherapist. Some of these factors include:

  • inappropriate or excessive training (particularly on hard or uneven surfaces)
  • poor foot posture (especially flat feet or high arches)
  • poor biomechanics
  • muscle weakness (particularly of the gluteals, quadriceps, calf and core stabilisers)
  • muscle fatigue
  • poor balance
  • poor flexibility (particularly of the calf muscles)
  • joint stiffness (particularly of the ankle, heel or foot)
  • inappropriate footwear
  • poor running technique
  • inadequate diet
  • leg length discrepancies
  • being overweight
  • menstrual disturbances

Physiotherapy for a stress fracture of the foot

Physiotherapy treatment for patients with this condition is vital to hasten healing, prevent injury recurrence and ensure an optimal outcome. Treatment may comprise:

  • soft tissue massage
  • joint mobilization
  • joint manipulation
  • electrotherapy (e.g. ultrasound)
  • dry needling
  • the use of crutches
  • the use of a protective boot or brace
  • activity modification advice
  • foot taping
  • biomechanical correction (e.g. the use of orthotics)
  • technique correction
  • footwear advice
  • exercises to improve strength, balance, flexibility and core stability
  • education
  • a gradual return to running / activity plan

Other intervention for a stress fracture of the foot

Despite appropriate physiotherapy management, some patients with a stress fracture of the foot do not improve and require other intervention to ensure an optimal outcome. The treating physiotherapist or doctor can advise on the best course of management when this is the case. This may include further investigations such as X-rays, CT scan, MRI or bone scan, extended periods of plaster cast immobilization, use of crutches or protective boot, review with a podiatrist for possible orthotics or referral to appropriate medical authorities who can advise on any intervention that may be appropriate to improve the stress fracture of the foot. Occasionally, patients with this condition may require surgery to stabilize the stress fracture and aid healing.

Exercises for a stress fracture of the foot

The following exercises are commonly prescribed to patients with a stress fracture of the foot following the initial period of immobilisation. You should discuss the suitability of these exercises with your physiotherapist prior to beginning them. Generally, they should be performed 2 - 3 times daily once the physiotherapist has indicated it is safe to do so and only provided they do not cause or increase symptoms.

Your physiotherapist can advise when it is appropriate to begin the initial exercises and eventually progress to the intermediate and advanced exercises. As a general rule, addition of exercises or progression to more advanced exercises should take place provided there is no increase in symptoms

Initial Exercises

Foot & Ankle Up & Down

Move your foot and ankle up and down as far as possible and comfortable without pain (figure 2). Repeat 10 - 20 times provided there is no increase in symptoms.

Exercises for a Stress Fracture of the Foot - Foot & Ankle Up & Down

Figure 2 Foot & Ankle Up & Down (left foot)

Foot & Ankle In & Out

Move your foot and ankle in and out as far as possible and comfortable without pain (figure 3). Repeat 10 - 20 times provided there is no increase in symptoms.

Exercises for a Stress Fracture of the Foot - Foot & Ankle In & Out

Figure 3 Foot & Ankle In & Out (right foot)

Foot and Ankle Circles

Move your foot and ankle in a circle as large as possible and comfortable without pain (figure 4). Repeat 10 - 20 times in both clockwise and anticlockwise directions provided there is no increase in symptoms.

Exercises for a Stress Fracture of the Foot - Foot & Ankle Circles

Figure 4 - Foot & Ankle Circles

Intermediate Exercises

Single Leg Balance

Always begin this exercise in a safe environment in case you lose your balance and to prevent falls (e.g. practise next to a bench or with a spotter). Standing on one leg, maintain your balance (figure 5). Try to hold for 1 minute. Once this exercise is too easy progress to eyes closed. This exercise can be performed for 1 5 minutes or longer provided the exercise is pain free and safe.

Exercises for a Stress Fracture of the Foot - Single Leg Balance

Figure 5 Single Leg Balance (right side)

Lunge Stretch

With your hands against the wall, place your leg to be stretched in front of you as demonstrated (figure 6). Keep your heel down. Gently move your knee forward over your toes until you feel a stretch in the back of your calf or Achilles tendon. Hold for 15 seconds and repeat 4 times at a mild to moderate stretch provided the exercise is pain free.

Exercises for a Stress Fracture of the Foot - Lunge Stretch

Figure 6 - Lunge Stretch

Squat with Swiss Ball

Begin this exercise in standing with your feet shoulder width apart and your feet facing forwards. A Swiss ball can be placed between a wall and your lower back to improve your technique (figure 7). Slowly perform a squat, keeping your back straight. Your knees should be in line with your middle toes and should not move forward past your toes. Perform 10 - 30 repetitions provided the exercise is pain free.

Exercises for a Stress Fracture of the Foot - Squat with Swiss Ball

Figure 7 Squat with Swiss Ball

Calf Raises

Begin this exercise standing at a bench or chair for balance (figure 8). Keep your feet shoulder width apart and facing forwards. Slowly move up onto your toes, raising your heels as far as possible and comfortable without pain. Perform 10 30 repetitions provided the exercise is pain free.

Exercises for a Stress Fracture of the Foot - Calf Raises

Figure 8 Calf Raises

Advanced Exercises

Calf Stretch

With your hands against the wall, place your leg to be stretched behind you as demonstrated (figure 9). Keep your heel down, knee straight and feet pointing forwards. Gently lunge forwards until you feel a stretch in the back of your calf / knee. Hold for 15 seconds and repeat 4 times at a mild to moderate stretch provided the exercise is pain free.

Exercises for a Stress Fracture of the Foot - Calf Stretch

Figure 9 - Calf Stretch

Single Leg Squat with Swiss Ball

Begin this exercise in standing on one leg with your foot facing forwards. A Swiss ball can be placed between a wall and your lower back to improve your technique (figure 10). Slowly perform a squat, keeping your back straight. Your knee should not bend beyond right angles and should be in line with your middle toe. Your knee also should not move forward past your toes. Perform 10 30 repetitions provided the exercise is pain free.

Exercises for a Stress Fracture of the Foot - Single Leg Squat with Swiss Ball

Figure 10 Single Leg Squat with Swiss Ball.

Single Leg Calf Raises

Begin this exercise standing on one leg at a bench or chair for balance (figure 11). Keeping your foot facing forwards, slowly move up onto your toes, raising your heel as far as possible and comfortable without pain. Perform 10 30 repetitions provided the exercise is pain free.

Exercises for a Stress Fracture of the Foot - Single Leg Heel Raises

Figure 11 Single Leg Calf Raises

Wobbleboard Balance Exercises

Always begin this exercise in a safe environment in case you lose your balance and to prevent falls (e.g. practise next to a bench or with a spotter). Standing on a wobbleboard with both feet, maintain your balance and try not to let the rim touch the ground (figure 12). Progress the exercise by doing circles with the rim touching the ground clockwise and then anticlockwise. Once this is too easy you can try these balance exercises with your eyes closed and, eventually, with only one leg eyes open and eyes closed. Practise these exercises for 1 5 minutes per day provided they are safe and pain free.

Exercises for a Stress Fracture of the Foot - Wobbleboard Balance

Figure 12 Wobbleboard Balance Exercises

Rehabilitation Protocol for a stress fracture of the foot

The following is a general rehabilitation protocol for patients with a stress fracture of the foot. This needs to be tailored to each individual and should be discussed with your treating practitioner prior to commencing. Progression through this program can vary from weeks to months depending on the severity of injury, injury duration and quality of treatment:

  • See your physiotherapist or general practitioner as soon as possible to confirm diagnosis, establish the likely prognosis, identify the contributing factors to injury and begin appropriate treatment.
  • Review with a podiatrist may be indicated for footwear advice and possible orthotics in patients who have poor foot biomechanics. (For more information view Do I Need Orthotics?)
  • Rest from any activity that increases pain. If walking is painful or causing a limp, crutches are usually required for a period of time (often 2 6 weeks) and should be discussed with your physiotherapist.
  • If using crutches, walk normally, but take enough weight off the injured leg so walking is pain free and limp free. If you are unable to place some weight through the injured leg without pain and limp, no weight should be placed through the affected leg for a period of time (usually 2 6 weeks). A gradual increase in weight bearing forces through the injured side can occur provided there is no increase in pain or limp and should take place over a period of weeks to months. This should be progressed until you are eventually walking without crutches, pain free.
  • Aim for pain free rehabilitation (i.e. gradually increase strength, flexibility and activity, provided there is no increase in symptoms during activity or upon rest following activity. This should take place over weeks to months).
  • Begin "Initial Exercises" 72 hours following injury provided there is no increase in symptoms. These should be continued until the exercises can be performed on the injured leg to the same extent and through the same range of motion as the good leg.
  • Low impact exercise may be performed to maintain cardiovascular fitness such as swimming, water running or cycling provided there is no increase in symptoms during activity or upon rest following activity.
  • Increase walking distance, and eventually speed, gradually, and, provided there is no increase in pain or limp (this should take place over weeks to months). Aim to increase activity levels by no more than 10% per week.
  • Add the "Intermediate Exercises" once the "Initial Exercises" can be performed pain free for a few days consecutively and provided walking without crutches is pain free. Ensure all new exercises do not cause or increase symptoms.
  • Add the "Advanced Exercises" once the "Intermediate Exercises" become too easy and can be performed pain free for at least a few days consecutively. Ensure all new exercises do not cause or increase symptoms.
  • A gradual Return to Running Program should be implemented for individuals who aim to return to running following injury provided there is no increase in symptoms. Your physiotherapist can advise when it is safe to do so.
  • A gradual return to sport and activity can occur provided there is no increase in symptoms. Your physiotherapist can advise when it is safe to do so.
  • Ensure your physiotherapist has identified the contributing factors to your injury and appropriate intervention has taken place to address these issues to minimize the likelihood of injury recurrence.

Find a Physio

Find a physiotherapist in your local area who can treat a stress fracture of the foot.

 

Physiotherapy products for a stress fracture of the foot

Some commonly recommended products by physiotherapists for patients with a stress fracture of the foot include:

  1. Crutches
  2. Protective Boots
  3. Ice Packs and Heat Packs
  4. Sports Tape
  5. Wobbleboards and Duradiscs for Balance Exercises

To purchase physiotherapy products for a stress fracture of the foot click on one of the above links or visit the PhysioAdvisor Shop.

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Relevant Anatomy for a Stress Fracture of the Foot

 

Figure 1 - Relevant Anatomy for a Stress Fracture of the Foot

 

Wheat Heat Pack

 

Crutches Ad

 

Foam Rollers

 

Spikey Massage Balls

 

Sports Tape 38mm

 

Wobble Boards

 

Dura Discs

 

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