Bone Care For Athletes

By John W. Kosty, MD of UTMB’s South Shore Harbour Clinic, 281-334-0620

The development of “stress” or fatigue fractures is a common disabling condition of athletes, and in particular, long distance runners.  Although stress fractures can occur at any age and at any level of conditioning, they are more likely to occur in poorly conditioned individuals training too rapidly, or in elite athletes who have simply overused the limb to the point of injury.  Medical studies also indicate a higher incidence of stress fractures in women than men at all ages. The exact explanation of this, however, is still unclear.  Hormonal factors such as stress-induced amenorrhea, the post-menopausal years, or nutritional factors such as inadequate calcium and vitamin D, intake inadequate exposure to sunlight or poor nutrition in general may all be causes.

The root cause of stress fractures is repetitive “loading” of the skeleton, especially in the lower extremities. Cyclic loading of a weight-bearing bone can cause microfractures which, though painful, may not be immediately obvious on x-ray examination.  

Weight-bearing stress fractures of the lower extremities most often  involve the tibia, fibula, or foot bones  Occasionally the femur, especially at the hip, can also be affected.  Children or young adults who participate in sports involving repetitive back “extension”, such as gymnastics, horseback riding, and contact sports can develop stress fractures in the lower back.  In contrast, stress fractures are extremely rare in the upper limbs or hands

Whenever an athlete begins to experience insidious onset of pain in a distinct area such as the ball of the foot, the heel, the mid leg, or lateral knee, stress reaction, or fracture, should be considered, especially if the area is tender to the touch and worsened by the athletic activity.   Though the diagnosis can usually be made by physical exam and x-ray, sometimes more advanced imaging such as a bone scan or CT scan are necessary.

Although most stress fractures will heal given an adequate period of rest (typically eight weeks), some may become troublesome. These include certain lateral foot fractures, and fractures of the posterior elements in the lower back.  Aggravation of the fracture by too early return to the activity increases the risk of prolonging the problem.

It is important to note that rest does not necessarily mean total avoidance of athletic activity, but rather, avoiding the specific activity that caused the stress fracture.  So, cross training via another pain-free, aerobic activity (such as bicycling or spinning, swimming, aqua-jogging, cross-country skiing machines or similar exercise equipment) are good alternatives. 

Here are several tips you can follow to help avoid these types of injuries:

1) When beginning a new activity, set reasonable goals.  If running, leave at least a day of rest or cross training between exercise sessions if you are increasing your mileage.

2) Use high-quality equipment.  Avoid old or worn shoes.

3) Maintain good nutrition.

4) If symptoms do occur, stop the activity immediately.  Seek medical assistance if the symptoms last more than a few days.