Stress fractures represent a common overuse injury in the metatarsals, tarsals, tibia and fibula caused by repetitive sub-maximal stress placed on the lower extremity during athletic activities.
This leads to accumulation of micro-damage in the region which gradually disrupts bone homogeneity and results in fractures.
The pathophysiology of bone response to stress was outlined by McCormick et al. who describe the process as an osteoclast/osteoblast imbalance resulting from osteoclastic activity outstripping osteoblastic activity.
This occurs when the bone is subjected to repeated stress without appropriate rest leading to micro-fractures that can gradually progress to a true cortical break.
The early identification and treatment of stress fractures are essential to reduce the significant loss of training time; with return to full activity taking anywhere between weeks to months, the injured athlete will require complete healing before making a comeback or risk further complications.
Stress fractures of the foot and ankle are normally categorised as low- or high-risk depending upon their propensity to heal without causing complications.
As stated by Mayer et al. in their study on the subject, low-risk stress fractures have a better prognosis and can often be diagnosed clinically and treated with activity modification unlike high-risk fractures which often need more advanced imaging, periods of non-weightbearing and possibly surgical fixation.
Intrinsic and extrinsic factors such as bone health, training, nutrition and foot biomechanics serve as reliable predictors of the risk of stress fractures in adults, helping clinicians formulate preventative strategies accordingly.
Biomechanical factors such as cavus feet, leg length discrepancy and a history of tibial stress fractures can predispose an individual to stress fractures, with studies having shown increased peak hip adduction and rearfoot eversion angles in runners with previous tibial stress fractures.
Gait retraining has been recommended as a measure to alter loading mechanics and reduce lower extremity loading during initial contact; a study by Crowell and Davis demonstrated that subjects were able to run with reduced tibial acceleration and vertical force loading immediately following the completion of a gait retraining programme, reducing their risk of stress fractures.
In addition to this, the use of customised foot orthotics such as MASS4D® should help reduce any excessive pressure on the site of injury by promoting an optimal distribution of plantar pressure and enforcing the optimal functioning of the foot and ankle complex.
MASS4D® foot orthotics can be used as a prophylactic device to help minimise any biomechanical discrepancies that increase the likelihood of an individual developing stress fractures and to further provide protection from the onset of a number of lower extremity pathologies.
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Repetitive plantarflexion can lead to pain and mechanical limitation in the posterior ankle joint which is known as posterior ankle impingement syndrome. This pathology commonly occurs in ballet dancers and football players.