Move Forward Guide
Physical Therapist's Guide to
Lower Extremity Stress Fractures
Lower extremity stress fractures are a relatively common injury seen most often in athletes playing sports that require repetitive impacts (running and jumping). Stress fractures make up about 8% of all activity-related injuries of the lower extremities. Female athletes are about one-third more likely to develop stress fractures in the legs and feet. While athletes may be more susceptible to these types of injuries, individuals who walk, march, or spend much of their workday on hard floors are also at risk. A physical therapist can help with recovery after a stress fracture as well as identify potential risk factors for prevention of future stress fractures.
What is Lower Extremity Stress Fractures?
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 change in the normal process of bone breakdown and reformation. Stress fractures are most common in the feet and legs as these structures bear 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 up walking, running, or jumping. You may also experience aching pain in the area after activity.
Signs and Symptoms
With activity-related lower extremity stress fractures, you may experience:
- Pain during activity (walking, running, or jumping)
- Sharp pain over a specific point on the bone (point tenderness)
- Swelling without bruising at the site of pain
- Aching pain after activity
How Is It Diagnosed?
If you see your physical therapist first, the therapist will conduct a thorough evaluation that includes taking your health history. Your physical therapist may ask whether you:
- Have 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 (fall, twist, collision)
Your physical therapist also will perform special tests to help determine the likelihood that you have an activity-related lower extremity stress fracture. For instance, the therapist may repeatedly bump on the bottom of your foot (called the "bump" test or the "percussion" test), MFPT.com Editorial Board Webinar or gently push directly over the site of the injury or squeeze the bone. (You might feel some discomfort during these tests, which is normal.) Your physical therapist may use additional tests to assess possible damage to other parts of your legs.
To provide a definitive diagnosis, your physical therapist will collaborate with an orthopedic physician or other health care provider. The physician may order further tests, such as magnetic resonance imaging (MRI) or bone scan to confirm the diagnosis.
How Can a Physical Therapist Help?
Stress fractures are treated by resting the leg as much as possible. Whatever activities you are participating in that increase force in the legs (running, jumping or "cutting" in sports) must be stopped for at least 3 weeks in order for the bone to begin the healing process. 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. Your therapist can design a specific treatment program for you to follow at home to help speed your recovery. Initial treatment will focus on muscle-strengthening exercises using bands rather than heavy weights.
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 select from treatments including:
Range-of-motion exercises. Because you have been less mobile over the past few weeks, your range of motion may have decreased. A physical therapist teaches 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 full weight on your foot without pain, your physical therapist may prescribe these exercises to help you return to your normal activities. For instance, you might learn how to stand on 1 leg or stand on a wobble board, with or without your eyes closed, to challenge the muscles in your legs.
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 the therapist’s examination of your legs, your goals, and your activity level and general health.
Activity-specific training. Depending on the requirements of your job or the type of sports you play, you might need additional rehabilitation tailored for your job or sport. Your physical therapist can develop a program that takes all of these demands as well as your specific injury into account.
Can this Injury or Condition be Prevented?
While there are no guaranteed ways of preventing lower extremity stress fractures, there are a number of factors known to be associated with their occurrence. These include:
- Excessive impact physical activity (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 calorie and Vitamin D intake
Real Life Experiences
Joan is a 27-year-old runner with no history of previous bone or joint disease. She has been training for her first marathon, and recently ran her longest distance of 15 miles last Saturday. 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, and by the end it was sharp and throbbing, and the area appeared slightly swollen. The site continued to be painful to touch; Joan had difficulty walking even short distances without pain. She decided to contact her physical therapist.
On her first visit, her physical therapist took measurements of her hip, knee, and ankle strength and range of motion. He gently pushed on her lower shin and bumped the bottom of her foot. 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. During this time, her physical therapist 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 was instructed not to run or walk without the boot. After 4 weeks, the boot was discontinued and gradual weight-bearing activities were started (weight shifting, stair climbing, small hops). 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. Now, 2 months after her injury, Joan has resumed her training with more care and attention to preventing injury for her next marathon.
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 orthopedic physical therapy. This 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 their 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.
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.
Authored by D.S. Blaise Williams, PT, PhD. Reviewed by the MoveForwardPT.com editorial board.