Some repeated sporting gestures or in particular biomechanical conditions, can subject the skeleton to “stress” by functional overload, which muscles are not always able to “absorb”, thus giving rise to a particular type of fracture, defined precisely as “stress fracture”. Marathoners, jumpers and basketball players, as well as gymnasts and dancers, in addition to canoeists (at coastal level) are among the sportsmen most exposed to the risk of stress fractures. The same can sometimes be said for soldiers who march along long routes wearing reinforced footwear. The same risk exists for individuals who do not practice sport and lead a sedentary life, but who, due to genetic conformation or trauma outcomes, are affected by structural alterations of the lower limbs, even if not striking, but which can create the same functional overload as above.
What can be done to prevent them, recognize them early and intervene with appropriate treatment? The word goes to Dr. Maria Cristina D’Agostino, orthopedic specialist and head of the Center for Therapy and Research of Shock Waves of Humanitas.
“The fracture from stress – explains Dr. Agostino – is not (at least in the early stages) a real fracture from acute trauma, but a kind of “fissure”, due to an accumulation of repeated “micro lesions”, which the bone tries to repair, but, since the rhythm is accelerated and exceeds its physiological capacities, it is as if the system went into tilt, a sort of “short-circuit”. The word “stress” gives a very good idea of a critical situation. Slowly therefore, if not recognized, it can also give rise to a fracture in the strict sense of the word, with the possible formation of a restorative bone callus, or a sort of “sleeve” that can weld the stressed part of the bone”.
Sometimes, if not recognized in the very early stages, also because the painful symptomatology is relatively more tolerable than a real fracture, the stress fracture is diagnosed only as an “outcome”, or when the bone callus is recognized on the X-ray, as a testimony of the repair. Classically, the most affected sites are the bones of the lower limbs and feet: running for many kilometers or jumping repeatedly on rigid surfaces, especially in the presence of morphological alterations of the foot or in any case of the lower limbs, as well as suddenly intensifying one’s routine of physical activity are all possible risk factors for a stress fracture. In professional dancers, dedicated to dancing “on the tips”, the localization of the fractures from stress is typical, just because of the movements made.
When should I go to my doctor?
The warning sign is usually a persistent bone pain, relatively well localized, in the absence of a greater direct trauma, very often related to physical activity, but in more advanced phases, however, may not give peace even at rest.
Prevention: Sport is the key
It is very important to consider all possible risk factors, generally related to skeletal conformation and the type of repetitive activity (sporting, but not limited to) to which the skeletal segment is subjected. It is therefore important to practice sport sensibly, possibly choosing the discipline best suited to ones’ physical constitution, and, if necessary, to increase physical activity, this should be tackled gradually. It is also essential to wear suitable footwear, equip yourself with sports equipment that suits your abilities and try to alternate higher-impact forms of physical activity with others that are less so.
Although in many cases of stress fractures related to sports activity, the risk factor “osteoporosis” is not concerned in the first instance, it is certainly to be considered for some categories of patients “at risk”, including women in menopause or individuals with endocrine-metabolic disorders that can alter the good health of the bone, weakening it.
“Prevention is very important,” the specialist continued, “as is the early recognition of this type of injury, since early treatment can shorten recovery times, reduce discomfort for the patient, and bring about a quicker return to sport. Since the stress fracture is generally not recognizable with common X-rays in its earliest stages (however symptomatic for the patient), it is indicated, in case of strong diagnostic suspicion, to proceed with magnetic resonance examination, which offers a dual advantage: does not expose the patient to ionizing radiation, and allows the recognition of bone alterations from the earliest stages (not visible with a simple X-ray), before a structural alteration of the bone also forms”.
What to do once a stress fracture has been diagnosed? If certain types of fractures (e.g. at the neck of the femur) are excluded, for which surgical intervention is indicated (stabilization by means of metallic synthesis), the treatment is generally “conservative”. “First of all, rest and, if a segment of the lower limb is involved, obviously the “unloading” of the weight, using crutches – said Maria Cristina D’Agostino – is indispensable. For healing and complete recovery, a few weeks are generally expected, averaging from 4 to 6. Variability is mainly linked to the fact that not all stress fractures are diagnosed in the same phase, sometimes when they are already in the healing phase. However, we have the possibility of accelerating the reparative processes, applying the so-called “regenerative biophysical therapies” (magnetotherapy and shock waves). Even though they are different in nature, they are both physical stimulations that can induce beneficial effects at the cellular level”.
In particular, shock waves are mechanical stimulations, which have no detrimental effect on living tissue, but accelerate the metabolic activity of bone cells, as well as the production of growth factors and the growth of new small blood vessels. Already used for many years for the treatment of pseudarthrosis and consolidation delays, they can currently represent, in many cases, the treatment of choice for the treatment of stress fractures, as, in addition to stimulating bone repair, they would also be able to normalize the proper remodeling of bone tissue, literally “stressed” by altered biomechanical or endocrine-metabolic conditions. In summary: prevention, early recognition of the disease and prescription of appropriate therapy, for which shock waves and other biophysical stimulations are a valuable resource, represent the winning strategy to deal with the “stress” of the bone.