Is Foot and Leg Pain Hiding Stress Fracture

On an almost daily basis I encounter patients who present to me with some form of foot or lower leg pain. Some cases have involved a traumatic episode whilst others appear to have come out of the clear blue sky. Pain is often a very good indicator that something in the body may not be quite right and will push people to seek answers. More often than not, this may be due to an overload of joints, tendons, ligaments or muscles however other factors such as arthritis, soft tissue injury or fractures may also be the cause. Of the mentioned factors, it is often stress fractures of bones that go unnoticed and misdiagnosed leading to prolonged pain and time for recovery. The following will be a brief introduction into what stress fractures are and what you need to know to help you make an informed decision of when the pain is more serious and requires an assessment.

What are stress fractures?

Stress fractures are classified as minor (or hairline) fractures in bones often due to repetitive activity which has resulted in repetitive minor trauma to the bone. Stress fractures are often seen in people who are involved in strenuous physical activity that involves sports such as running, athletics, soccer, football, basketball to name a few. While this is the case, the same type of fracture can often be seen in people who have recently undertaken a higher exercise load to get fit or have pre-existing conditions such as osteoporosis which may make them more likely to have these bone injuries. Since stress fractures are borne from overload and repetitive trauma, they can occur in virtually any leg or foot bone although the metatarsal heads are more often injured than any other due to the ongoing pressures going through the foot. If pressure is not alleviated, bone matter can only resist for so long before it breaks completely and a hairline fracture becomes a larger and potentially complete fracture which is not only even more painful, but a lot more complicated to heal.

What causes stress fractures?

As already mentioned, most stress fractures are caused by repetitive or sudden increases in forces across bony areas. Some possible causes of stress fractures includes but is not limited to:

Increasing exercise frequency (exercising more days than normal)
Increasing the duration of exercise.
Inadequate or improper footwear for physical activity. This may be insufficiency cushioning in runners or constant use of high pitched heels.
Change in exercises or physical activity surface.
Foot and lower limb biomechanics and function.
Foot posture and structure.
Pre-existing conditions such as osteoporosis.
Excessively tight muscles particularly the calf muscles.

What are some symptoms of stress fractures?

The primary symptoms of stress fractures is pain. The pain will vary in intensity depending on the level of injury however some points to keep in mind when assessing the pain:

Is the pain constant or does it diminish with physical activity. Constant or worsening pain during activities may indicate a stress fracture.
Is there bruising visible on the skin?
Is the region that is sore when you are standing still sore to touch when you are not weight bearing?
Are you struggling to stand, walk or exercise without pain?
Does the pain decrease with rest?

What are common areas of pain to look out for?

Legs

Inside region of the shins (usually susceptible to shin splints’)
Outside region of the legs (referred to as the peroneal region)
Ankle joint

Feet

Around all the borders of the heel.
Underneath the balls of the feet.
In through the instep
Along the top of the middle foot joints (referred to as the midtarsal joints)

What can you do at home?

Due to the nature of the condition, the primary response that I advise people to seek before they come in for an assessment is called RICE (Rest Ice Compression Elevation). The protocol involves attempting to reduce the inflammation associated with the injury and promote the body’s natural healing mechanisms.

Rest: Means exactly that. Take some time off to reduce the stress on the sore region. Sitting down or bed rest is a good way to do so however wearing supporting shoes or sandals is also another way of doing just that.
Ice: Ice should be applied immediately after injury and kept on the sore region for 10-20 minutes. However it is important to never apply ice directly to the skin.
Compression: Slight pressure should be applied to the region to reduce swelling.
Elevation: The foot or leg should be kept higher than the level of the heart.

When to seek help?

I advise my patients to always follow the ‘better safe than sorry’ idea. Help or advice should be sought the moment the body is in pain or feeling ‘unusual’. I will constantly tell patients that the body always tries to maintain a perfect harmony amongst all of its internal systems. Pain is in direct response of a breakdown in that system. If pain is preventing you from standing, walking, training or achieving goals you have set for yourself, it is time to see a professional for advice. A podiatrist can perform a biomechanical investigation as well as refer you on for appropriate x-ray or ultrasound imaging and then combine the two to create a unique treatment plan for your condition.

Dr Anel Kapur (Podiatrist)