Stress Fractures

If your child or teen has developed a stress fracture, it will comfort you to know that Children’s Hospital Boston’s Orthopedic Center has a tremendous amount of experience treating this injury, developing therapies for healing and conducting research that leads to better care.

What are stress fractures, and why do they occur?

Stress fractures are an overuse injury caused by repetitive stress—usually to the shin bone (tibia) or foot bones but also to the hip (femoral neck)—over a period of time without enough rest to give the bone enough time to heal.

Muscles adapt to stress—that’s how they become stronger. But they also need to rest and rebuild between the episodes of stress. When a muscle gets repeatedly overtaxed with the stress of impact (running, quick cutting, pivoting), it can transfer that stress to the bones of the foot or lower leg.

What factors can contribute to young people getting stress fractures?

Stress fractures can occur if a runner or athlete:

• is experienced but is overtraining (often occurs late in the sports season)
• resumes hard training too soon after a lay-off
• increases the duration or intensity of training too quickly
• trains on hills
• is a novice who begins training too hard before she’s conditioned
• runs on surfaces that are too hard or uneven
• runs in improper or outworn footwear
• has flat feet (fallen arches), which unevenly distribute the stress from impact
• has poor running mechanics
• has tight muscles
• is an anorexic girl, whose bones are already deprived of nutrients, brittle and vulnerable to injury; this profile occurs often in runners and gymnasts

What are the symptoms of stress fractures?

Pain and/or inflammation in the foot or lower leg can be symptoms of stress fractures. The pain tends to intensify in stages:

• At first, the injury may hurt mildly when the child plays her sport.
• As more trauma occurs, the child will experience constant pain when she’s playing.
• At the end stage, the child has constant pain in her foot or lower leg, even when she’s not playing. At that point, the affected area will have sustained a significant amount of damage.

How are stress fractures diagnosed?

Your child’s doctor will do a physical examination, and may use diagnostic tests—including x-rays, an MRI (magnetic resonance imaging) or CT scan and, rarely, a bone scan—to get detailed images of the injury to determine if there’s a stress fracture.

How are stress fractures treated?

The primary therapy for most stress fractures is simply to rest the injured foot or leg—restricting weight-bearing actions and all activities that involve stressing the injured area for a period of weeks or months. Your child’s doctor may also recommend a cast or walking boot in order to:

• relax the stress on the leg
• protect the leg from further damage
• force the athlete to rest

For a more severe stress fracture, treatment options may include:

• temporary use of crutches or a wheelchair
• physical therapy to stretch and strengthen the injured muscles and tendons
• surgery (less common, but is sometimes needed)  

Why are girl athletes more vulnerable to a stress injury?

Occasionally, an adolescent girl runner or gymnast (or other athlete) might have an eating disorder, which will result in a cascade of problems. An anorexic or bulimic girl can lose her period (amenorrhea) and suffer bone density loss (osteopenia or osteoporosis). Her bones can become brittle and thus vulnerable to injury and fracture. It’s important for teenage girl athletes to maintain healthy, vitamin D- and calcium-rich diets.

Why is there an increase in overuse injuries in kids these days?

Youth and teen participation in organized sports has grown to about 35 to 40 million kids across the United States. Not surprisingly, the incidence of sports injuries has also grown—and statistics suggest that 30 to 60 percent of student athletes will have an overuse injury at some point in time. In one Sports Medicine practice at Children’s, for example, at least half of the young patients have an overuse injury.

Aren’t organized sports supposed to be good for kids?

Organized sports are very important and help kids—not just in the sports themselves, but in academics and social situations—and they’re good for children’s overall development and growth. The downside is that “overuse syndrome,” where the kids repeat the same drill over and over, causes overuse injuries.

How can parents and coaches help kids avoid stress fractures and other overuse injuries?

Parents and coaches have a great deal of influence—for better or for worse. Parents and coaches should emphasize moderation in training and should restrain the zeal with which they push youth and teens.

Coaches should:

• become certified
• learn and use proper training techniques
• avoid assigning too many repetitive drills—the overwhelming cause of overuse injuries
• teach proper running mechanics and other sport-specific motion techniques

Physical education departments should make sure that the surfaces of tracks and fields are in good shape, and that proper equipment, footwear and protective gear are used for each sport.

Our Sports Medicine specialists advise:

• warming up and stretching before practice
• resting at least one day a week
• cross-training/alternating sports: It is usually unwise for a child or teen to specialize in just one sport. Multi-sport athletes tend to get fewer overuse injuries than those who specialize in just one sport.
• alternating exercises during practice: By alternating exercises, the athlete is less likely to experience an injury—and over the long term, her muscle memory will actually improve.

Are there other guidelines and resources for injury prevention and safer training?

The American Academy of Orthopaedic Surgeons (AAOS) has issued comprehensive guidelines for helping to prevent sports injuries. Below is an excerpt from the AAOS recommendations:

• Use proper equipment.
  • Replace athletic shoes as they wear out.
  • Wear loose-fitting clothes that are light enough to release body heat.
  • In cold weather, dress in removable layers.

• Warm up.
  • Warm up to prepare to exercise, even before stretching.
  • Run in place for a few minutes.
  • Breathe slowly and deeply, or gently rehearse the motions of the exercise to follow.

• Stretch.
  • Stretch slowly to the point of muscle tension.
  • Hold each stretch for 10 to 20 seconds, then slowly release.
  • Inhale before each stretch, exhale on release.
  • Do each stretch only once.
  • Never bounce on a fully stretched muscle.

• Drink water.
  • Drink enough water to prevent dehydration, heat exhaustion and heat stroke.
  • Drink 16 ounces (one pint) of water 15 minutes before exercising, another 16 ounces after cool-down.
  • Drink water every 20 minutes or so while exercising.

• Cool down.
  • Cool down for twice as long as warm-up.
  • Slow down motion and lessen intensity for at least 10 minutes before stopping completely.

• Rest.
  • Schedule regular days off from exercise, and rest when tired.
  • Fatigue, soreness and pain are good reasons to not exercise.

Who at Children’s will be caring for my child if she develops a stress fracture? Members of our orthopedic team will provide expert care and support for your child. Our staff includes 10 primary care sports medicine specialists, 24 orthopedic surgeons, two podiatrists, a nutritionist, a sports psychologist, eight physician assistants, 14 nurses and four certified athletic trainers.

What is the Orthopedic Center at Children’s doing to encourage injury prevention and safer training?

To support our goal of dramatically reducing overuse injuries in youth sports, members of our team often travel to local and regional schools, youth groups and sports clubs to teach leg strengthening and other techniques. We also conduct frequent safe training programs and clinics for coaches. Call 617-355-3501 for details.

FAQ

Q: What are stress fractures?
A: Stress fractures are sports-related microtraumas (small injuries) that result from repetitively using the same parts of the body, usually the foot or lower leg and often from running or gymnastics. A stress fracture results when fatigued muscles can’t absorb the shock (stress) of impact and transfer the stress load to a bone.

Q: How do stress fractures happen?
A: Muscles adapt to stress—that’s how they become stronger. But they also need to rest and rebuild between the episodes of stress. When a muscle gets repeatedly overtaxed with the stress of impact (running, quick cutting, pivoting), it can transfer that stress to a bone in the foot or lower leg, which can crack. Repetitive or overly-rigorous training (usually running) can result in the pain and inflammation of a stress fracture.

Q: What are the signs and symptoms of a stress fracture?
A: Pain and/or inflammation in the foot or lower leg can be signs and symptoms of stress fractures or shin splints, so a proper diagnosis is important. The pain tends to intensify in stages—from occasional and mild to constant and severe.

Q: What should we do before we see the doctor for a diagnosis?

A: If you suspect that your child has a stress fracture, home care before your child gets to the doctor should include:

• rest:Make sure she doesn’t exert in any way that involves the injured area; she can use crutches or a cane, if it helps.
• ice:Wrap a towel around ice cubes, or use a bag of frozen vegetables, to ice the area at two-hour intervals, for 20 minutes each time.
• compression:Wrap a bandage or soft brace (from the drugstore) around her injury.
• elevation:Your child should remain seated or reclining, with her leg elevated, as much as possible before seeing the doctor.

Q: How are stress fractures usually diagnosed?
A: Your child’s doctor will do a physical examination, and may use diagnostic tests—including x-rays, an MRI (magnetic resonance imaging) or CT scan and, rarely, a bone scan—to get detailed images of the injury to determine if there’s a stress fracture.

Q: How does Children’s treat a stress fracture?
A: The most important therapy for a stress fracture is simply to rest the injured area—restricting weight-bearing actions and all activities that involve using the injured bone—for a period of weeks or months. Your child’s doctor may also recommend a cast or boot to protect the shin or foot from further injury. A severe case can require surgery.

Q: Will my child be OK?

A: Most kids with stress fracture can return to sports and regular activities after several weeks or months of rest and healing time. Your child’s doctor will give you guidance about how long your child’s foot or leg should be rested in order for it to heal.

During the healing period, it’s important to support your young athlete’s resolve to rest her injured bone, since she may feel disappointed and frustrated at not being able to play her sport.

Q: How long will it take for my child to recover from a stress fracture?
A: Children usually heal faster and better than adults. Your child should heal from a stress fracture in a period of weeks or months, depending on the severity of the injury.

Q: If my child has been injured playing sports, should she go back to sports?

A:If your child’s doctor has cleared her to go back to sports, the many benefits and life lessons she’ll gain from playing greatly outweigh the risks of injury. These benefits include:

•  physical fitness
• teamwork, competitive prowess, accomplishment
• improved body composition—less risk of obesity
• reduced risk of heart disease and diabetes
• stronger immune system
• academic fitness—kids who play sports often academically outperform kids who don’t
• emotional and psychological fitness—improved self-esteem, self-concept, self-confidence, empowerment and perception of competence

Q: What is Children’s experience in orthopedics?

A: At Children’s Orthopedic Center we’re known for our clinical innovations, research and leadership. Ranked among the top three in orthopedics for 2012-13 by U.S.News & World Report, we provide the most advanced diagnostics and treatments, several of which were pioneered and developed by Children’s researchers and clinicians—including platelet-rich plasma (PRP) treatment for tendon repair and physeal-sparing ACL procedures for children whose growth plates are still open.

Causes

As more and more kids play organized sports, there’s been a rise in the number of stress fractures and other overuse injuries (microtraumas to bones, tendons, ligaments or muscles) among adolescents and children, largely from repetitively using the same parts of the body. Stress fractures are often seen in runners and gymnasts—possibly because of overtraining, running with improper footwear or training too hard while still a beginner.

Signs and symptoms

Pain and/or inflammation in the foot or shin bone can be symptoms of a stress fracture. The pain tends to intensify in stages:

• At first, the injury may hurt mildly when the child plays her sport.
• As more trauma occurs, the child will experience constant pain when she’s playing.
• At the end stage, the child will have constant pain in her lower leg, even when she’s not playing. At that point, the affected area will have sustained a significant amount of damage.

When to seek medical advice

Consult your child’s doctor if her lower leg is painful or inflamed. Tell the doctor if your child:

• has been training very hard (usually running or aerobics)
• has changed her exercise routine
• has been running on hard surfaces
• has been running with improper footwear
• has an eating disorder or has been diagnosed with osteopenia or osteoporosis

Questions to ask your doctor

You and your family are key players in your child’s medical care. It’s important that you share your observations and ideas with your child’s health care provider and that you understand your provider’s recommendations.

You probably already have some ideas and questions on your mind, but it can be easy to forget the questions you wanted to ask when you’re talking to your child’s doctor. It’s often helpful to jot them down ahead of time to make sure that all your concerns have been addressed. You may also suggest to your child that she writes down questions to ask her health care provider, too. Some of the questions you may want to ask include:

• What has happened to my child’s foot or leg, and why?
• Is a stress fracture a serious injury? Will it do any permanent damage?
• What tests will you perform to diagnose my child?
• What actions might you take after you reach a diagnosis?
• Will my child be OK if she has a stress fracture?
• Will there be restrictions on my child’s activities? If so, for how long?
• What should we do at home?
• How can we help her understand that she needs to rest the injury?

Who’s at risk

• runners, gymnasts
• runners who
  • run on surfaces that are too hard or uneven
  • have recently changed their training routine or started running hard up steep hills
  • are using outworn footwear
  • have had prior stress fractures
  • are not conditioned, yet are suddenly training rigorously
  • have flat feet or rigid arches
• athletes whose sports involve quick cutting and side-to-side motions, such as basketball

Complications

Complications after proper treatment for a stress fracture are uncommon, but can occur. These can include:

• failure to respond to treatment or to heal properly
• vulnerability of the area to re-injury
• a re-injury resulting in chronic problems

For teens

Many teens who have stress fractures are not only high-performing, determined athletes, but also high-performing, determined students. If you approach your rest and healing period with that same spirit of determination, you should be back to sports and your active lifestyle within a few weeks or months, depending on how severe your injury was in the first place.

The most important thing you can do to get back into your sport is to give your foot or leg a total rest. But even though you know the importance of rest and recovery, you still could find this to be a tough time. If you feel frustrated, depressed or angry during this important time, speak to your doctor, parent or counselor—they’re all on your team, and they all want to help.

For parents

If your teen is like many young athletes who have an overuse injury, she’s not only a high-performing, determined athlete—she’s also a high-performing, determined student. Encourage her to approach her rest and recovery period with the same spirit of determination that she applies to other areas of her life. With patience and perseverance, she’ll probably be back to sports and her active lifestyle within a few weeks or months.

Even though you and your teen know the importance of resting her foot or leg, you both might experience her healing period as a difficult time. Parents who identify with their children’s success can feel frustrated or depressed along with their children, so speak to your doctor or counselor if you need help.

Prevention

Our Sports Medicine specialists advise young athletes to:

• warm up and stretch before practice
• rest at least one day a week
• cross-train/alternate sports: It’s usually unwise for a child or teen to specialize in just one sport. Multi-sport athletes tend not to sustain as many overuse injuries as those who just specialize in one sport.
• alternate exercises during practice: By alternating exercises, an athlete is less likely to experience an injury—and over the long term, her muscle memory actually improves.

Stress fractures glossary

• cast or walking boot: custom-made protections worn around the lower leg while shin splints heal

• diagnosis, diagnostics: identifying disease or injury through examination, testing and observation

• microtrauma: a small injury to the body, such as microtears to muscle fibers, stress to the tendon, bruising of the bone; can occur to bone, muscle, tendon or ligament. If not allowed rest in order to heal, accumulated microtraumas can lead to overuse injuries, such as stress fractures.

• MRI (magnetic resonance imaging): produces detailed images of organs and structures within the body; shows the amount of damage from an injury

• non-surgical (non-operative) treatments: alternatives to surgery; most treatments for overuse injury are non-surgical

• orthopedics: the medical specialty concerned with diagnosing, treating, rehabilitating and preventing disorders and injuries to the spine, skeletal system and associated muscles, joints and ligaments

• orthopedist/orthopedic surgeon: a physician concerned with diagnosing, treating, rehabilitating and preventing disorders and injuries to the spine, skeletal system and associated muscles, joints and ligaments

• osteopenia: less bone mineral density than normal, a precursor to osteoporosis

• osteoporosis: loss of bone density

• overuse injuries: sports-related microtraumas that result from repetitively using the same parts of the body, usually by overtraining; can occur to muscle, tendon, ligament or bone

• physical therapy: a rehabilitative health specialty that uses therapeutic exercises and equipment to help patients improve or regain muscle strength, mobility and other physical capabilities
   
• stress fractures: tiny overuse fractures, usually to a bone in the foot or the shin bone (tibia),causing pain and inflammation

• tibia: shin bone