Stress Fractures of the Lower Extremities

An Overview of Stress Fractures of the Lower Extremities

The interesting crystalline material structure of bone is the underpinning for the development of stress fractures. Fatigue fractures of a long bone are not uncommon under significant repeated load. It makes us realize that long bones are just like any brittle structure that can be overstressed. This goes back to the stress/strain curves in materials management in physics. This condition even occurs in the spine (see pars fractures and isthmic spondylolisthesis).

Bone, like any crystalline structure, has an absolute fatigue point for gross failure (a fall from a height breaking the leg). There is however the possibility of cumulative stress from constant impact that does not break the bone fully. Tiny fractures in the substance of the bone can occur that do not individually reach the gross failure point.

These stresses accumulate over time with repeated loads. This is a time and stress related function. Stress fractures overwhelm the ability of the bone to heal without rest (time).

An analogy would be taking a wire coat hanger and bending it continuously until it breaks. No one individual bend causes failure but the accumulation of bends breaks the wire. It is remarkable that bone has a self-healing process and can recover from these less than full structural failure injuries given time and rest.

Groups at Risk for Stress Fractures
of the Lower Extremities

Two groups that have the greatest risk of stress fractures of the lower extremities are the athletic and the military populations. In either population, prolonged impact activities (running, weight lifting and calisthenics) set the stage for these overuse fractures.

Insufficiency fractures due to inferior bone stock generally found in the elderly due to osteoporosis are also at high risk. These fractures also occur in the thoracic and lumbar vertebra.

Location of Lower Extremity Fractures

The typical location of these lower extremity fractures is generally found in long tubular bones. Tibial stress fractures, the most common are at 50% of all stress fractures. Metatarsal stress fractures (foot) occur under 20% of the time and femoral shaft and neck fractures exist at about a 10% occurrence rate.

There are potential risks and different healing outcomes for fractures in different locations. As would be expected, fractures with reduced vascularity due to location and anatomy (the anterior tibia and navicular bone in the foot) had poorer outcomes due to this relative lack of blood supply. If a fracture of the femoral neck is allowed to develop and then displace, the chance of avascular necrosis (bone death) to the femoral head is very high due to the retrograde vascularity of the femoral head.

(Click to Enlarge Figure A)

(Click to Enlarge Figure B) Figure A & B – Note the white signal in the tibia (lower bone in the picture) and compare this with the black signal in the higher up femur. The white signal is fluid within the bone due to the small stress fractures of the small inside bones (trabecula). The arrow points to a full black fracture line in the tibia that occurred after enough stress fractures accumulated to allow this obvious full fracture to propagate.

Are you suffering from symptoms of a lower extremity fracture?

Would you like to consult with Dr. Corenman about your condition?
You can set up a long distance consultation to discuss your
current X-rays and/or MRIs for a clinical case review.

REQUEST A SECOND OPINION

(Please keep reading below for more information on this condition.)

Symptoms of Stress Fractures of the Lower Extremities

Symptoms of stress fractures of the lower extremities include localized pain with impact activities that increase in intensity and with prolonged impact or stress exposure. If the fracture develops further, localized swelling and tenderness are noted. Day to day pain with normal activities is an indicator of a progressive fracture.

Risk factors are identified with a thorough history and physical examination. These factors include female status, menstrual irregularities and less muscle mass in the lower extremities. In fact, females who had five or less menses per year had almost double the risk of stress fractures compared to those who had a normal menstrual cycle. Interestingly, oral contraceptives reduced the chances of developing stress fractures.

Diagnosis of Stress Fractures of the Lower Extremities

This potential diagnosis has to be on the practitioner’s radar screen to be able to make the diagnosis and prevent serious sequelae. Complications of a missed diagnosis include a complete fracture of the tibia or even the need for a hip replacement due to avascular necrosis of the femoral head.

Uncommon questions such as how many menses the female has had in the last year are important to know. Practitioners need to understand the significance of this question (among others) with a young athletic female who complains of leg pain. Sir William Osler’s famous quote, “You find what you know and you see what you look for” applies here (as well as in most circumstances in medicine).

Other than the history, there are few physical examination findings that can lead to a diagnosis. Local tenderness can be a clue to the presence of a lower extremity fracture. If there is swelling at the site, this indicates a more substantial and progressive stress fracture.

The MRI is the leading tool for confirming diagnosis after a suspicion of stress fracture is considered. Prior to the development of MRI technology, bone scan and CT scan were utilized but had a much lower sensitivity for this injury. Now, with the ability to visualize the interstitial fluid within the bony matrix from the fractures of the trabecula and laminar layers of the cortical bone, identification can occur much earlier. This is especially noted with STIR images.

Clinical Relevance

Unexplained lower extremity localized pain in athletic or military personnel should be potentially considered a stress fracture with the resultant work-up necessary to diagnose this disorder. MRI of the painful region is required to determine the presence of a stress fracture.

Lower extremity insufficiency fractures due to osteoporosis are more common than we estimate. The alert practitioner needs to be especially careful to identify and treat these patients. A positive log roll test of the hip may be an early warning sign of a femoral neck stress fracture. Any unexplained lower extremity pain that increases with loading has to be considered a possible fatigue fracture in an elderly patient.

For additional information on stress fractures of the lower extremities, please contact the office of Dr. Donald Corenman, spine specialist and back doctor offering diagnostic and surgical second opinions to patients in the USA and around the world.

Related Content

Donald Corenman, MD, DC

Average rating:

81 reviews

Eric S

Sep 26, 2021

by Eric S on Donald Corenman, MD, DC

Successful pars repair at 46 years old

Back in November of 2018 (at 46 years old) I came from Vancouver BC to have a pars repair done with Dr. Donald Corenman at the Steadman Clinic in Vail Colorado. I'm finally posting this review nearly three years later in late 2021. The reason I waited so long was I wanted to know the final result before I posted my review. Unfortunately in that time Dr. Corenman has retired. Nevertheless, I want to post this review of Dr. Corenman and his staff at the Steadman Clinic in their excellent treatment of my L5 pars interarticularis.

I fractured my pars at age 42 back in 2014 when rolling on the gym floor, and was denied treatment by the Canadian healthcare system, probably due to my age. First my GP told me there was no surgical option for a pars defect, which was quite incorrect! I tried to live with it, but the symptoms worsened (periodic random spine slippage and weeks of resultant pain after just bending over to tie my shoe, so I eventually learned to mostly squat and hardly bend). When I finally consulted with Canadian spine surgeons, I was told they believed my pars defect had been congenital (since birth). This was absurd, considering I had done extreme martial arts (including jiu jitsu) for years prior, as well as 5 years of reinforcing steel full time in my 20s, probably the hardest job on the back you can find. No pars defect like mine would possibly have allowed this--ergo it was impossible that I had had the defect since birth. I did however have an asymptomatic congenital spina bifida occulta that made me more susceptible to a pars fracture. In 2014 in one instant, I went from having the strongest back people I knew said they'd ever seen, to being unable to safely bend over and tie my shoe without a non-negligible risk of my spine slipping randomly (which would lead to weeks of pain after each occurrence). This was due to the unilateral L5 pars defect, otherwise known as spondylolysis. It was when lying in pain on the floor 4 years later after maybe the 6th spine slippage event post injury, that I had had enough, and resolved to have surgery. If Canada's "universal health care" said no, I would make lemonade from lemons, and find the very best surgeon in the world at pars repairs. That was Dr. Donald Corenman. Dr. Corenman back in 2018 ran a website https://neckandback.com/ that dedicated many pages to the science of every aspect of pars repairs, from eligibility (good discs on MRI), to best surgical techniques (minimal open compared to minimally invasive), best imaging to use (i.e., O-Arm with Stealth imaging vs. older fluoroscopy), the ideal amount of BMP to use and why not use too much or too little, and much more, all to do with pars repairs, pages upon pages of his site just on the pars, with scientific references and his own extensive expert opinion. As a health research statistician, I was very impressed with this. It was in stark contrast to the websites of other spine surgeons which barely gave the pars a word or two, focusing almost exclusively on fusions. I had found the best surgeon in the world for pars repairs, and so after Dr. Corenman personally screened my MRI to ensure my discs were healthy, I booked the surgery.

Being 46 years old at the time of surgery in 2018, with a 4-year-old pars fracture from 2014 combined with a congenital SBO meant my pars fragment was somewhat atrophied, but it was "very solid", said Dr. Corenman in the operative report. Nevertheless, it was challenging with two things to fix, the pars and SBO, and OR time was around 4 hours. Recovery over the following months was guided by a very clear "Spine binder" from the Steadman Clinic with strict rules of "no BLT" (no bending, lifting or twisting), and illustrated physiotherapy guidelines. They even warned patients to avoid fish oil supplements, which could excessively dampen inflammation and hence slow bone healing. They answered many questions I had during months of recovery, with responses coming from the very supportive Lori Fugate (then director of Dr. Corenman's practice), and Ehrich Bean (then physician's assistant at the practice), as well as a couple calls with Dr. Corenman himself after two of the CT scans. Ehrich Bean offered great advice for taking the spine binder conservatively due to the nature of pars repairs vs. fusions. The final post-op CT scan I had was a couple weeks ago at 34 months post-op, and Dr. Corenman had retired, but I got a very positive and informative call from Eric Strauch (current PA at the Steadman Clinic under Dr. Corenman's replacement there, and who had also worked with Dr. Corenman previously). The staff at the Steadman Clinic were extremely supportive all the way through the process. I should mention, the local Canadian spine surgeon did offer me very good post-operative support including antibiotics as needed to deal with a mild surface incision-site infection early on, booking numerous x-rays when I felt something was amiss, as well as booking all four of my post-op CT scans. I am very grateful for that support also.

My final result shows plenty of solid bone across the pars and a healed SBO, with my vertebral body now a solid bone ring instead of being broken at two places as it was pre-op. Does my spine hold up in the real world? You bet! I have recently dug and moved several yards of dirt and sand and gravel by myself (shovel and wheelbarrow!) to fix our water main, pulled roots from the yard, moved several "portable" (these are HUGE) air conditioners up several flights of stairs my myself, and lifted weights. I now run 2 miles (3.2 KM) several times weekly with a hard 100 meter dash in the middle. I bend deeply before each run I go on, with no spine slippage. My spine feels amazing. I can bend over to do exercise, or real word tasks, with no risk of spine slippage.

My sincere thanks to God, Dr. Donald Corenman, Lori Fugate, Ehrich Bean, Eric Strauch, and the Steadman Clinic, as well as the Canadian spine surgeon who offered me excellent post-operative care back in Canada. You have all given me a new lease on life.

Sincerely,
Eric S

Robert S

May 11, 2021

by Robert S on Donald Corenman, MD, DC

Back Fusion Surgery

I had my entire lumbar spine fused in November of 2018. I had scoliosis , with pinched nerves that were so painful I could hardly walk - and standing for more than a few minutes was impossible. Even sitting was painful.
The fusion surgery produced immediate relief! And the recovery was much easier than I expected.
To this day I can do all the activities I love from hiking, to standing in a stream fly fishing to riding my bike long distances - or just walking down the street with my wife.
Kudos to Dr. Corenman and his staff, (including the two Erics) for taking such good care of me!

Leslie R

Jul 9, 2020

by Leslie R on Donald Corenman, MD, DC

TLIF

I had my TLIF surgery on 6/24/2020 by Dr. Corenman, I can not say enough good things about the Dr or his staff. I was always treated with respect and explained everything throughly, that made it easy for everyone to understand. I highly recommend Dr. Corenman and the Steadman Clinic.

Submit your review
First Name, Last Initial:
Email:
Review Title:
Rating:	1 2 3 4 5
Review:

Check this box to confirm you are human.
Submit Cancel