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Stress Fractures: Relationship to RED-S

Stress fractures of the lower limbs are surprisingly common injuries which often present in elite and recreational athletes such as long-distance runners, dancers (specifically ballet and contemporary dance), athletics and sports involving running or jumping. It is often the repetitive physiological stress that the body goes through that can be concentrated on certain areas of the body. There are many factors to consider beyond someone’s volume of exercise. However, when identified as your diagnosis certain activities may be off the cards for a short while. At LDN PHYSIO we understand that a stop to your exercise regime may be the last thing you would consider; however we can turn this set-back into an opportunity. Returning from stress fractures with us will be the chance to set new achievements, raise your performance and return a fitter, stronger, LDNer.

Common areas of stress fractures of the lower body are the shin, ankles, metatarsals (mid-foot), pelvis, hip and spine (here are other less common areas in the upper body which can be affected if you participate in sports involving throwing or other repetitive actions). These areas can have excessive forces transmitted through them due to poor biomechanics, strength or control. It can also be caused by a sudden spike in exercise above and beyond your usual routine. A recent example of this we’ve seen is the rapid increase in running during the UK lockdown earlier this year. Rest and recovery are crucial parts of training that are often over-looked. Unknowingly, with the personal drive for fitness and performance, and the sudden desired ‘health-kick’, we can sometimes over-do when exercise is over-due. These behaviours with exercise can tip the healthy balance of what our bodies are currently capable of and you may start to experience deep aching bone pain in those common areas, as mentioned above, which can be a sign of a stress fractures. The errors in training are common. We can all have the best intentions but perhaps with the wrong methodology things start to go awry.

Symptoms of stress fracture can vary somewhat from each person to the next. The first sign of a stress fracture you may be aware of is pain. It normally intensifies during activity, especially impact training, running or jumping and then reduces during rest. However, this sounds very similar to how many muscle, tendon and joint pains start as well. Other symptoms may be local swelling without a known injury, a deep and dull pain if around your back and hips or perhaps a specific tender spot on your bones if more towards your shins or feet. A comprehensive assessment at our clinic will go into detail to ensure a confident and precise diagnosis to identify which body part or tissue structure your pain is originating from and to explain the diagnosis, expectations, treatment plan and support you along the way.

Management of these conditions begin with our specialist Physiotherapy team diagnosing and identifying the causes of your pain. There are ‘risk factors’ that may mean someone is at a higher chance of developing stress fractures and an in-depth assessment can identify these. Do you need a scan to diagnose this? If your Doctor or Physiotherapist has diagnosed you with a stress fracture it is not always necessary to have a further investigation. This is because between 40-80% of stress fractures are not present on an X-ray. A clinical diagnosis is one based on as assessment of detail, expertise, and awareness to identify the root cause and body part that there is a problem with. According to research, a clinic assessment by an experienced senior Physiotherapist or Sports Medicine Consultant is often a more reliable way than a scan to diagnose in most instance of aches and pains. However, with pressures to return to professional sports or performance, an MRI can help to identify the severity of the diagnosis. This can help with planning a timely return to your sport.

Treatment of a stress fracture is predominantly rest. Not so much that you put your feet up for weeks on end as this can also have a negative effect on your bone health and cause them to weaken over time. Stopping all activities that cause pain is crucial. The severity of the stress fracture and the location will have an impact on how long you will need to rest for. The average duration will range from 4 – 12 weeks. Our LDN Physiotherapists will advise you on your personal rest period and develop an individualised treatment plan to maintain the highest levels of strength and performance despite your injury. Sometimes a referral to a specialist Orthopaedic doctor is necessary for further scans and very occasionally surgery. Therefore, it is incredibly important to make sure you follow the advice of your Physio instead of thinking you can just push through the pain – it is the number one thing not to do for this condition.

Strength based exercises can improve your bone density during your rehabilitation and in the long-term to help protect against future stress fractures. Our LDN Physiotherapists are best-placed to guide you through your individualised treatment plan. Again, pain will be your guide so 'listen to your body and don't exercise beyond what is comfortable at any point'. Don’t false start as it can set you back to square-one. By identifying areas of physiological stress and impact, either by an in-depth assessment (see our Body MOT clinic), a Physiotherapy initial consultation or an assessment in our Running Clinic to identify impact zones, hotspots of foot contact, full biomechanics assessment and observing metrics ( such as over-pronation of your foot) will help to develop a strategy so you return to your strongest.

Diet and nutritional advice are other important parts of reducing the risk and improving the recovery from stress fractures. Without exercising as you normally would do, there may be an inclination to reduce your calorie intake. In fact, there is a strong possibility that a mismatch of energy consumption is exceeded by the energy you expend where exercising could be a contributing factor of your stress fracture. This can lead to a condition call RED-S (Relative Energy Deficiency in Sport). Other symptoms are fatigue, amenorrhea (irregular periods), weight loss, stomach problems, difficulties fighting off infections, stress and anxiety and problems concentrating (the list goes on). At LDN PHYSIO we are unique that we are the only specialist RED-S clinics in the country with a dedicated Sports Medicine Doctor, Clinical Health Psychologist, Specialist Physiotherapists and Nutritional experts. For more information about this look at our RED-S clinic webpage, look out for out blogs coming soon or contact us directly to discuss your problem.

Supplementation is one way of trying to ensure you are getting the necessary amino acids and proteins for the building blocks of repair and recovery. A recommended time to consider a protein and carbohydrate shake or bar would be immediately after exercise. Increasing evidence is pointing towards an adequate amount of immediate nutrition as a key indicator of recovery and performance. A protein supplement may be just what you need if you are like some of us and find eating a big and nutritious meal soon after exercise quite sickening.

Vitamin D and calcium supplements are also important and can be found from most supermarkets or health shops. Alternatively, for vitamin D getting outside for 30-60 minutes in the midday sun is also a great way to ensure you have the right levels. There are occasions that your levels may be too low and you may require a blood test to assess this. Ethnicity also plays a part in vitamin D levels. The darker the pigmentation of your skin then the more difficult your skin finds it to synthesising vitamin D after it has been absorbed from sun light.

Stopping smoking is another lifestyle factor we all know about as something that we shouldn’t do. It is a lot easier to give up smoking with support and we can help by finding your local services. Smoking will have a big impact on your recovery and often will delay your recovery by at least a couple of weeks. As a minimum, we advise you try to cut back during your recovery.

If you are suffering from any suspected joint, muscle, tendon, ligament pain, sprain or strain then our dedicated and experienced team are your best step to diagnosing and treating the condition. Booking in could not be easier, visit or contact us directly at on via WhatsApp on our home page.

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