Stress fractures usually occur in major weight bearing bones such as those of the foot or leg. Repetitive stress weakens the bone and begins to break it down. Many researchers think that this overuse injury starts out as a microscopic fracture. As such, it is difficult to diagnose right away because the injury does not immediately show up on X-ray. When it does show up it is already starting to heal.

In soccer players the most common stress fractures are found in:

• Second and fifth metatarsals and femur (older soccer players).
• Tibia and fibula (younger soccer players).

Mechanism of Injury

Stress fractures typically result from one or more of the following:

• Hypermobile, pronated (flat) feet or high arched feet.
• Initiating a new soccer activity or exercise too vigorously.
• An increase in training intensity.
• Overtraining.
• A change in activity surfaces (i.e. hard or soft ground, turf).
• A return from a previous injury too quickly.
• An abrupt change of footwear, often with poor design (i.e. from soccer cleats to soccer turf shoes).

Signs and Symptoms

• Pain is usually more prominent at the end of soccer practices or games rather than during either.
• Diagnosis is often difficult, and is usually based on history and physical examination (that may or may not include a bone scan).
• There is usually specific point tenderness and pain focused directly over the site of the injury when palpating from both sides of the bone.
• Bone percussion (gentle tapping directly over affected bone to elicit pain) can distinguish it from soft tissue injury.

On-Site Management

P.R.I.C.E. PROTECT the area by addressing equipment (i.e. soccer cleats, turf shoes and insoles) and technique of activity (biomechanics of soccer kicking, running and cutting). REST does not imply halting all activity, and the injured player can be running in deep water, light cycling, etc. to maintain and/or increase fitness. ICE the area for 10-20 minutes to reduce inflammation. COMPRESSION is NOT recommended. ELEVATE the area after a long workout to increase circulation to the heart.

Refer for a Correct Diagnosis. It is important, as with all overuse injuries, that a correct diagnosis be determined before the cycle of pain becomes established. A sports medicine practitioner will take a history of the injury, conduct a physical examination of the injured area, and undertake a biomechanical assessment of the athlete's lower extremity (looking for anatomical abnormalities). If warranted, selected diagnostic tests may be ordered such as X-rays, bone scans, etc. A dietician can also help to assure adequate nutrition, especially calcium intake.

Rehabilitation

Promote Healing. Invariably with overuse injuries, when the soccer player's pain is relieved, s/he prematurely returns to activity and is re-injured. It is important, not to attempt to "play through" the pain or place continual pressure on a stress fracture, as a complete fracture of the weakened bone may result. Caution against weight bearing during severe pain. Healing occurs with rest and a combination of progressive site-specific strength and conditioning exercises and overall body conditioning. Cross train with low-impact exercises, including swimming, cycling, deep-water running, and the elliptical to maintain conditioning.

Control Abuse. The potential for tissue overload must be adequately controlled prior to returning the athlete to activity. Some effective methods for tibial stress include:

• supportive footwear
• improving soccer kicking, running and cutting technique
• addressing training errors (frequency, intensity, duration)
• paying attention to playing or training surfaces

Return to Activity. Return to activity is often mishandled; there can be an endless cycle of rest-run-pain-rest-run-pain. A very gradual return to playing must be adhered to once stretching and strengthening exercises have been undertaken. The soccer player should not return until pain-free for 2 weeks and receives a doctor's OK.

Prevention

• Adequate warm-up, including stretching before any activity.
• Pre-season soccer specific strengthening and stretching.
• Appropriate corrective footwear (i.e. new soccer cleats or turf shoes) or orthotics for pronation if it is a lower leg stress fracture.

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