Stress Fractures of the Foot

A stress fracture is described as a small crack in the bone which occurs from an overuse injury of a bone. It commonly develops in the weight bearing bones of the lower leg and foot. When the muscles of the foot are overworked or stressed, they are unable to absorb the stress and when this happens the muscles transfer the stress to the bone which results in stress fracture.

Stress fractures are caused by a rapid increase in the intensity of exercise. They can also be caused by impact on a hard surface, improper footwear, and increased physical activity. Athletes participating in certain sports such as basketball, tennis or gymnastics are at a greater risk of developing stress fractures. During these sports the repetitive stress of the foot strike on a hard surface causing trauma and muscle fatigue. An athlete with inadequate rest between workouts can also develop stress fracture.

Females are at a greater risk of developing stress fracture than males, and may be related to a condition referred to as “female athlete triad”. It is a combination of eating disorders, amenorrhea (irregular menstrual cycle), and osteoporosis (thinning of the bones). The risk of developing stress fracture increases in females if the bone weight decreases.

The most common symptom is pain in the foot which usually gets worse during exercises and decreases upon resting. Swelling, bruising, and tenderness may also occur at a specific point.

Your doctor will diagnosis the condition after discussing symptoms and risk factors and examines the foot and ankle. Some of the diagnostic tests such as X-ray, MRI scan or bone scan may be required to confirm the fracture.

Treatment

Stress fractures can be treated by non-surgical approach which includes rest and limiting the physical activities that involves foot and ankle. If children return too quickly to the activity that has caused stress fracture, it may lead to chronic problems such as harder-to-heal stress fractures. Re-injury can also occur without allowing the stress fracture to completely heal.

Protective footwear may be recommended which helps to reduce stress on the foot. Your doctor may apply cast to the foot to immobilize the leg which also helps to remove the stress. Crutches may be used to prevent the weight of the foot until the stress fracture is healed completely.

Surgery may be required if the fracture is not healed completely by non-surgical treatment. Your doctor makes an incision on the foot and uses internal fixators such as wires, pins, or plates to attach the broken bones of the foot together until healing happens after which these fixators can be removed or may be permanently left inside the body.

Some of the following measures may help to prevent stress fractures:

• Ensure to start any new sport activity slowly and progress gradually
• Cross-training: You may use more than one exercise with the same intention to prevent injury. For example you may run on even days and ride a bike on odd days, instead of running every day to reduce the risk of injury from overuse. This limits the stress occurring on specific muscles as different activities use muscles in different ways.
• Ensure to maintain a healthy diet and include calcium and vitamin D-rich foods in your diet
• Ensure that your child uses proper footwear or shoes for any sports activity and avoid using old or worn out shoes
• If your child complains of pain and swelling then immediately stop the activities and make sure that your child rests for few days

The plantar fascia is a long, thin ligament present along the bottom of the foot that creates the arch of the foot. It extends from the heel bone, and then splits and fans out to attach itself to the toes.

Plantar fasciitis is a condition where the plantar fascia becomes inflamed from overstretching or overuse, causing pain in the heel and bottom of the foot. It can occur in one or both feet due to excessive standing and is one of the most common orthopedic complaints, especially in active men between 40 and 70 years of age.

Causes

Plantar fasciitis occurs when you strain or irritate the plantar fascia ligament. Repeated strain can result in tiny tears in the ligament, leading to pain and swelling, which can make walking difficult.

Strains Can Occur Due To :

• High or low foot arch
• Obesity or sudden weight gain
• Tight Achilles tendon which connects the calf muscles to the heel
• Starting a new activity or increasing the intensity of an activity
• Wearing improper shoes with soles that are too soft, do not fit well or offer poor arch support

Symptoms

The major complaint of plantar fasciitis is pain and stiffness in the heel and foot. The pain associated with this condition becomes more intense:

• In the morning when you step out of bed
• Walking after sitting or standing for some time
• Climbing stairs
• After exercise

Diagnosis

Your doctor diagnoses plantar fasciitis after reviewing your medical history and conducting a physical examination of the foot to check for tenderness, stiffness or redness of the sole. Your doctor may watch how you stand and walk, and evaluate related conditions such as high arches.

X-rays of the foot can be taken if your doctor suspects a stress fracture, a hairline fracture in the bone, or other related conditions such as a heel spur, which is extra calcium deposit on the heel bone.

Treatment

Treatment involves conservative measures to resolve the condition. Conservative treatment measures include:

• Rest: Rest is the first step that is considered for reducing pain and preventing further damage to the ligament.
• Ice: Rolling your foot over ice can be very effective in reducing swelling, and is recommended for 20 minutes, 3-4 times a day
• Medications: NSAIDs (non-steroidal anti-inflammatory drugs) may be prescribed for relief of pain and inflammation
• Exercise: calf stretches and plantar fascia stretches are effective in relieving pain
• A steroid injection may be administered into the plantar fascia for reducing pain and inflammation
• Supportive shoes and orthotics may also be recommended to reduce the pain while walking or standing
• Night splints can be suggested by your doctor to help stretch the plantar fascia while sleeping
• Physical therapy may be recommended for instruction on stretching exercises, massage and ice treatments
• PT may use extracorporeal shockwave therapy (ESWT), which uses high-energy shockwave impulses to stimulate healing of the damaged plantar fascia tissues

Surgery

Surgical treatment is considered only if conservative therapy does not provide effective relief after 12 months. There are two surgeries your surgeon may perform and will depend on your particular situation.

• Gastrocnemius Recession – Tight calf muscles or gastrocnemius muscles can strain the plantar fascia. To release this stress, your surgeon will surgically lengthen the calf muscle, and increase the motion of the ankle. The surgery can be performed by open incision or endoscopically through a small incision by using an endoscope, which is a long instrument with a small camera attached.
• Plantar Fascia Release – If you have normal range of ankle motion, but continue to have heel pain, a partial release procedure is recommended. Your surgeon will partially cut the plantar fascia ligament to relieve the tension. The surgery can be performed endoscopically but open incision is easier to perform and is associated with lower risk of nerve damage.

Risks & Complications

Complications are rare following surgery to treat plantar fasciitis, but as with any surgical procedure, they can occur. Some complications include:

• Infection
• Nerve Damage
• Unresolved Pain