Potential Foot Stress Fracture Lower Leg 1.1.2.9.1.2.1.2

Potential Foot Stress Fracture

When someone experiences pain within the outside of their lower leg, along with a history in a change of activity, pain when they hop, and pain with prolonged standing or walking, there may be an underlying stress fracture. You also mentioned you have a number of predisposing factors making you more likely to suffer a stress reaction or stress fracture compared to someone who did not have this number of predisposing factors.
A stress fracture is when the bone undergoes a load greater to which it can tolerate causing tiny little micro fractures. There are certain areas in the body where you are more likely to suffer a stress reaction and the lower leg in your fibula is one of them. Although this is not a load bearing bone, stress fractures can be caused by the muscle attachments in the area and the load they exert on the bone. It is a relatively common injury after somebody has either had an increased intensity in activity such as changing the frequency or duration of their chosen sport, or perhaps introduced a new weight bearing activity they don't normally do, or even a change in the surface they are performing their activity on.

It is quite typical to see a stress fracture after somebody has either had an increased intensity in activity such as changing the frequency or duration of their chosen sport, or perhaps introduced a new weight bearing activity they don't normally do, or even a change in the surface they are performing their activity on. Over time if this demand continues it can lead to a stress reaction which is where the bone starts showing signs of changes in it's structure, until eventually leading to stress fractures.

The first step is to understand if there is a stress fracture at the site. One thing to bear in mind is that you may also have what is known as a 'stress reaction'. A 'stress reaction' is the precursor before a stress fracture and shows that there are changes within the bone already occurring but without fractures being seen. The management for both are very similar so no need to complicate things. You should contact your family doctor or physiotherapist to arrange an assessment and from there a referral for an MRI scan. An MRI scan if the gold standard versus an X-ray, as it shows up a stress fracture earlier. If there is a suspicion of a stress fracture the initial treatment would be to unload the affected area, which simply means taking the weight off it. This can be done by using crutches to reduce the weight bearing on the affected leg. After the results of the MRI it may be advised through the clinical team looking after your care, to use a specific protective boot for a period of time. During this initial unloaded phase you want to follow the guidance of what rehab exercises you can and cannot do, and how long you need to follow this advice. Use this time to reflect on the weeks leading up to this point so you can understand what caused this injury, so that you don't repeat the same mistake in the future. As we have mentioned already these injuries are typically caused by a change or increase of activity, so reviewing what you have been doing will help you understand the likely trigger.

Once you move from this phase, after a number of weeks, you will want to start progressively loading the affected area. This will initially be done by some basic strength exercises and over time as you get stronger a return to your normal activities can occur. The key element with returning to activity from a stress fracture is to be patient and to build up slowly, ensuring you don't repeat the same mistakes which caused this in the first place.

Use the period of rest to reflect on the weeks leading up to this point so you can understand what caused this injury, and that you don't repeat the same mistake in the future. As we have mentioned already these injuries are typically caused by a change or increase of activity, so reviewing what you have been doing will help you understand the likely trigger. The key element with returning to activity from a stress fracture is to be patient and to build up slowly, ensuring you don't repeat the same mistakes which caused this in the first place.

Phase 1

Phase 2

Phase 3

Phase 4

This phase is normally the first 24-72 hours after the symptoms start and its aim is to settle any swelling and pain you have.

RICE

RICE stands for Rest, Ice, Compression and Elevation. These steps are helpful for when you have an injury in the acute phase to help reduce pain and also with the healing process.

Rest: You need to reduce the activity level you are performing and let your body have time to heal. The aim here is to pace your activities throughout the day and cut back on anything unnecessary or that particular increases your symptoms. For this condition you would expect running to be particularly irritable and any prolonged walking.

Ice: This can help reduce the pain you are experiencing and also reduce some of the swelling if you have any. Using some frozen peas wrapped in a damp cloth for 20 minutes will work well here and do this every couple of hours if possible. Do not apply the ice directly to your skin, make sure you have a barrier which is preferably damp, and keep an eye out for any ice burns onto the skin. If you notice this stop immediately.

What can be helpful here is having a specifically designed ice pack you can reuse over and over again. You may still need to have that damp cloth as a barrier with these packs as well.

Compression: This relates to the use of the ice being compressed onto the lower leg. This can be achieved by simply wrapping a cloth around your joint, but more bespoke equipment offers this ability which would be more comfortable and effective, such as this ankle ice pack. You may find that this aspect does not offer relief as the compression is discomforting, and in which case you should stop. Be conscious of any change in sensation in your foot or toes as a sign that this isn’t appropriate for you at this time.

Elevation: Having your foot rested on an object which is raised above your hips, whilst you are laying down, will reduce the amount of swelling in the area. This may help reduce some of the symptoms you are experiencing. Aim here for a similar time frame as applying ice and go for up to 20 minutes. Do not compress and elevate at the same time, as the volume of fluid returning towards your heart may put too much pressure on it.

Family Doctor or Physiotherapist

In this period you may benefit from a review with your family doctor or physiotherapist. They will be able to assess if there is any potential for a stress fracture given the pain when you hop. During this appointment they will be able to assess whether there is a need at this stage for further imaging such as an MRI. If they suspect you have a stress fracture they will require you to reduce the load going through your foot, by the use of crutches, and potentially after the MRI scan there may be a requirement to wear a moonboot to help offer support. You should follow the advice of the clinical team if the MRI scan shows a stress fracture as they will be able to guide specifics on your care. If there is a stress fracture you should follow the advice given and only join this programme when appropriate.

Medication

In the initial phase the use of over the counter medication may be an option. Medications such as paracetamol may allow this acute phase to be more manageable. Please consult your GP if you have any concerns with this impacting your current medication, or if any medical history may be impacted by the option of including this medication.

Exercises

In this acute phase you should generally adopt the approach to reduce the level of activity you are doing, especially strenuous exercises such as running. Stress fractures are often associated with strenuous activity and so it is important you reduce the load through your foot.

The main focus of these two simple exercises in this acute phase is to encourage blood flow to the area and to reduce any tightness on the muscles. Both of these exercises will be appropriate to do if you were referred for an MRI and are waiting for the result as they should not increase your symptoms any further.

Exercise		Frequency
Ankle pumps	30-60 seconds x 2 sets	3 x daily
Ankle Circumduction	30 - 60 seconds x 2 sets	3 x daily

Some things to consider with the exercises:

The duration, sets and frequency you perform these is not set in stone, the important point to remember is to do these little and often throughout the day. This is better than doing them for one big chunk as doing them frequently for a shorter period will mean that the benefits are felt more frequently throughout the day.
Neither exercise should be painful.
Check you can continue these exercises if you have a stress fracture whilst you are using the protective boot once you have your MRI result back.
You can continue these exercises throughout the entire programme as they may bring some relief of discomfort.

This would be roughly the first 4 weeks of your recovery either after you have stopped using the protective boot, or after the initial first few days and the MRI result showed no stress fracture. Remember if you had any imaging which confirmed a stress fracture to follow the advice of the clinical team looking after your care.

Education

The aim of phase 2 is to reintroduce some low level strength work, continue with the mobility exercises from phase 1, and apply some other treatment options which may alleviate your symptoms.

Stress fractures are normally caused by an increase in the type of activity we do, an introduction of new activity, simply changing the type of surface we perform this activity on, and even a change in footwear. Like most injuries without addressing the underlying cause which triggered the symptoms, if you simply return to activity after a period of rest there is a good chance that the painful symptoms will also return. It is important you try and correct any tightness or weakness in the area with some basic strength and stretching exercises, along with ensuring you have a structured and progressive build up back to activity.

Any weakness in a certain muscle group may lead to another muscle group having to compensate and work harder. This extra load may contribute to the stress fracture so by ensuring that all muscle groups in your lower leg are addressed you can hopefully address that fault. We also need to consider that because of this period of reduced load throughout the entire lower leg as we rest the affected area, there will be general weakness of the muscles in that area which will need to be improved upon as we reintroduce more weight bearing activity later in the programme.

Returning from a stress fracture a flexible and patient approach is best.

Exercises

The aim of these exercises is to introduce some basic strength work and to add to the mobility and stretching exercises from Phase 1. Remember to continue the exercises from Phase 1, start off easy and only increase the intensity each week once the symptoms have settled.

Exercise		Frequency
Double leg calf raise raise	12-15 reps x 2 sets	2 x daily
Single leg balance	30 - 60 seconds x 2 sets	2 x daily
Resisted inversion and eversion with a band	30 - 60 seconds x 2 sets	2 x daily

Some things to consider with the exercises:

Start with 30 seconds or 12 reps for the exercises before increasing the duration. Aim to complete a minimum of 2 consecutive days at each duration before increasing the length of time or reps, but ideally a weekly increase may be best. This will ensure you are slowly progressing the load instead of increasing it too quickly.
You may find it helpful to do these exercises in a circuit type fashion, where you do exercise 1 for 1 set, followed by exercise 2 for 1 set, then exercise 3 for 1 set, and then restarting
Remember that any day-to-day activity, such as walking, will use the lower leg muscles as well. So if you went for a particularly long walk and tried to do the exercises, it may be too irritable.

Footwear and Orthotics

A topic which you will want to start being aware of is the impact footwear and potentially orthotics can have.

If your stress fracture was triggered by an increase in intensity of your chosen activity, or by a change of training surface, then you may benefit from a review in your footwear. It is unlikely that repeating the same intensity change of exercise that led to the stress fracture but this time with different shoes will change the outcome, but it can offer some benefit used alongside the other information in this programme.

Generally speaking if you have more supportive and cushioned footwear your tendons and bones in your lower leg and feet will have less demand placed on them, and more absorption on any shock in the area. Both of these elements will help with your return to your chosen activity, and perhaps reduce the likelihood of a stress fracture occurring in the future. Remember that a change in footwear does not give you free reign to return to sport and activity as you did prior to the injury, and that the most important aspect of this rehab programme is to re-introduce load slowly and progressively.

In a similar fashion the use of inserting certain orthotics into your shoe can help support your foot and also reduce excessive load on certain muscle groups or specific bones depending on your foot type. Using orthotics offers a cheaper option than buying a new pair of shoes and can have similar benefits.

The evidence and correlation between footwear causing stress fractures is poor as the overriding cause in general is an increase in activity, however for some people this is an important aspect to correct which can have good improvements. Equally the evidence to suggest that if you use orthotics your pain will reduce simply does not exist, however similar to footwear there are some people where using orthotics can be helpful, and alongside some of the other treatment options used it can help reduce symptoms further.

This is a challenging area to tackle on your own and our advice here would be to speak to your local running shop, podiatrist or even physiotherapist. They will be able to tailor advice on which product may be suitable to your specific foot type and your specific activity.

Something else to consider for balance here is the idea of ‘barefoot’ movements. This idea is that we shouldn’t be using excessively supportive footwear for orthotics long term, and we should instead train our bodies to move around in a more natural barefoot manner, so we are in theory not reliant on shoes or orthotics for our wellbeing. In basic principle this makes sense. The downfall people generally have when they start adopting this lifestyle is they try to make the change too quickly and cause irritation in their lower leg muscles and bones. Going down this rabbit hole of the discussion of barefoot versus non-barefoot is huge, and most likely the solution that will work for you is probably somewhere in the middle. Similar to a number of the treatment options in this programme there may be a case of trial and error of what is appropriate for you as an individual, and a general sweeping statement of what will work for everyone simply does not exist. Again speaking with a podiatrist or physiotherapist they will be able to tailor the information specifically for you here.

For a simple plan, if you normally have a neutral shoe moving to one with more cushion may be helpful, but a cheaper option could be to trial using a supportive orthotic inside your neutral shoe to see if this alleviates symptoms. If the orthotic does reduce pain it then gives you confidence to purchase some shoes which have more support, rather than buying the shoes first not knowing what effect they may have.

Acupuncture

The use of Western acupuncture in stress fractures aims at improving the blood flow to the affected area and therefore increase the speed of healing. Unfortunately the evidence is poor for the use of acupuncture on improving the outcome of stress fractures. You can simply get a similar benefit of blood flow to the area by doing basic non-strenuous exercises. There is some evidence on acupuncture as a general treatment modality for reducing pain, so there may be some benefit to you for that.

Similar to the other non-exercise based treatments, it is unlikely going to resolve your stress fracture by using acupuncture, but it may offer some short term relief, and used alongside other treatments help you on your rehab journey.

Medication

You should expect to see the usage of medication reduced as you move through this phase. If you always require medication after you perform your exercises or throughout the day it may be the case that the intensity of the exercises and activity is too much and may need to be reduced.

Symptoms

During this phase you should start noticing more times in the day when you are pain free, however it is not uncommon for there to be sharp spikes in pain if you are doing a specific activity. This will improve and the activities which cause irritation should become less. If you continue to perform activities which consistently aggravate your foot, it will continue to cause you pain and perhaps be affecting the healing. You may need to alter the activities in some manner that are causing irritation until you have moved further along in your healing.

Lifestyle Choices

In this phase you need to also consider other contributing factors which may have led to you developing a stress fracture. If you are overweight this will increase the load through your bones and put you more at risk. Reducing your weight will reduce the likelihood in the future of this occurring again. If you smoke, this will delay the healing time and cause your return to be slower on average than those who do not smoke. A general poor diet will also impact your body's ability to heal and repair. Making sure you have a balanced and healthy selection of food will improve the overall ability to repair itself and keep the body strong.

In this phase we are looking at between 4 to 12 weeks following the start of your rehab either after you have stopped using the protective boot, or after the initial first few days and the MRI result showed no stress fracture.

Remember if you had any imaging which confirmed a stress fracture to follow the advice of the clinical team looking after your care.

Education

Similar to Phase 2 the timelines here are merely a guideline and may vary. You may find that you are able to start this phase before 4 weeks if the symptoms have settled and you are no longer challenged by the exercises in Phase 2.

The aim of Phase 3 is to increase the intensity of the rehab and introduce some movement to the exercises. Similar to the advice in Phase 2 we are aiming to progressively load the lower leg. During this phase you will find you can perform more day-to-day activities with ease, and towards the end of this stage you may be looking to return to running and sport.

You should at this stage be able to perform the exercises from Phase 2 with ease, and not reliant on any pain medication to perform tasks.

If you decided not to get a review by your family doctor or physiotherapist at the start of your rehab, and towards the end of this phase, you are still struggling and finding that your symptoms are not settling, it may be helpful to explore further investigations to rule out any stress reaction. The most accurate way to assess whether you have a stress reaction is by having an MRI scan as they pick up stress fractures before an X-Ray.

Exercises

You may also find that you want to continue the single leg balance exercise from Phase 2 as it will still offer benefits. It can be used as a warm up before these new exercises.

Exercise		Frequency
Single Leg Calf Raise	15-20 reps x 4 sets	1 x daily
Resisted Dorsiflexion with Resistance Band	15-20 reps x 4 sets	1 x daily
Sit to Stand or Squats	8-12 reps x 4 sets	1 x daily

Some things to consider with the exercises:

Similar to the previous phase, start with the lower rep count and complete two days at that level before progressing up. Remember as well to have that 1 minute rest between sets.
Aim for full range of movement with exercise 1 and 2.
The final exercise is aiming to make sure your general lower leg strength is maintained. If you can easily perform 12 reps on this exercise it may be helpful to add some weight to this exercise to make it a little harder.
Any discomfort you experience from these exercises should settle within 30 minutes of completing the exercises.
You may find it helpful to do these exercises in a circuit type fashion, where you do exercise 1 for 1 set, followed by exercise 2 for 1 set, then exercise 3 for 1 set, and then restarting.

This will be roughly 12 weeks onwards following the start of your rehab either after you have stopped using the protective boot, or after the initial first few days and the MRI result showed no stress fracture.

Education

Some people may not need to progress to this phase and the exercises and advice from Phase 3 may be enough for what they need.

If you have a desire to return to running or sport then you should continue with this phase.

Here we focus on performing exercises that are more dynamic and to mimic the demands of running. As we introduce impact work into the rehab programme you need to be conservative in these sessions and build up slowly. For the first week performing these exercises follow the rule that you want to leave each session wanting to do more. You do not want to finish the session and be in pain thinking that you have ‘now worked hard enough’. Starting impact work is a big step and generally what most people find the hardest. You want to be patient and not rush things, undoing all of the good work you have done up until this point.

At this stage you should be able to perform the exercises from Phase 3 with ease, have no discomfort with daily activities, and have stopped any medication to alleviate symptoms.

Exercises

Exercises

You may want to do some of the exercises from Phase 2 and 3 before these as a warm up. As we reintroduce some low level impact work into the programme be patient with any build up and conscious of any symptoms of discomfort which may develop.

Exercise		Frequency
Hopping on the spot	30-60 seconds x 4 sets	3-4 x weekly
Walking Lunges	15-20 reps x 4 sets	3-4 x weekly
Side to Side hopping	30-60 seconds x 4 sets	3-4 x weekly

Some things to consider with the exercises:

Similar to the previous phase, start with the lower rep count or duration, and complete two days at that level before progressing up. Remember as well to have that 1 minute rest between sets.
You don’t want to perform these on consecutive days, have a rest day between so you can allow time for your body to get used to the extra demand. .
You may find it helpful to do these exercises in a circuit type fashion, where you do exercise 1 for 1 set, followed by exercise 2 for 1 set, then exercise 3 for 1 set, and then restarting.
If you intend to return to running, complete at least 2 weeks of these exercises and then follow our run/walk programme alongside these exercises as you progressively build up.

Return to Sport or Activity

As a general rule, try and aim for two pain-free sessions at a reduced duration or intensity before increasing.

For example, if you normally play 60 minutes of tennis, aim to play for 30 minutes in a non-competitive environment for two non-consecutive days.

Having a day's rest between sessions allows you to have appropriate rest and for your body to repair and become stronger.

Once you have found a duration or intensity you can tolerate with no flare up, aim to increase the next session by 10%. This can seem like a slow and conservative process however the research has shown this is the optimum level of increase to avoid an overuse injury. Increasing duration or intensity by more than 10% significantly increases your chance of injury. As you will have been away from your sport for a number of months, you will have lost some of your fitness conditioning in this time and will need to build this up slowly.

Over time you will be able to slowly return to your pre-injury level of activity without regressing back to any acute flare-up.

Pacing

At this stage you should find you can do more day-to-day activities pain free. The temptation here is to go a bit overboard. A nice reminder to pace activities so that you don’t over do it, and that you spread these activities out as much as possible throughout the day.