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Stress fractures are also known as march fractures because soldiers in boot camp performing marching drills would often get them. They are caused by repetitive trauma or stress to the feet or other weight-bearing bones. A stress fracture is a small, often microscopic, fracture or break in the bone. They are also known as “hairline” fractures because they are small and only a “hairline crack” shows in the bone on x-ray.

In the foot, the metatarsal bones (the long bones behind the toes) are the most commonly affected, however any bone in the foot could suffer a stress fracture, as could the bones in the leg, hips or spine. Long-distance runners, basketball players, volleyball players or anyone working for prolonged times on their feet — including referees, who must run a lot while officiating — are particularly susceptible to those injuries.

The main symptom is pain. Swelling and redness occur on the top of the foot when a metatarsal bone is involved. Usually there is one small point of maximal tenderness on the bone when pressing on it. However, there can be generalized swelling and vague, diffuse pain that is difficult to pinpoint in the early stages of the problem. Standing up on “tip toes” often mimics the pain, or makes the pain worse when a metatarsal bone is involved. Jumping and landing on the injured foot usually is very painful. The pain gets progressively worse as activity levels increase in duration or become more intense. Left untreated, a stress fracture will get progressively worse until the pain becomes so bad that weight-bearing physical activity becomes nearly impossible.

Based on the history and physical examination, there is usually a high index of suspicion of the problem. The initial diagnosis is usually made with an X-ray. However, early on in the injury process, an X-ray may not be sensitive enough to detect a stress fracture. In those cases, a bone scan, CT scan or MRI may be necessary to detect the problem. Long-standing stress fractures are usually readily obvious on simple X-rays, thus more involved imaging techniques usually aren’t required in long-standing stress fractures.

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The treatment is straight forward, namely reduce the stress that caused the initial injury in the first place. That may be as easy as taking a break from physical activity, or may involve using soft insoles in the shoes to relieve pressure. When treating a stress fracture in the foot, special shoes that relieve pressure on the forefoot may be utilized for a while until the injury heals. More resistant cases may require a walking or even a non-weight bearing cast with crutches for up to six weeks to allow the bone to heal. A last resort would be surgery to get the bone to heal when all other options have been exhausted.

Fortunately, stress fractures almost always heal simply by reducing the stress on the bone and almost never require surgery. A fractured bone takes four to six weeks to heal, so returning to intense physical activity too soon will usually result in a recurrence of the symptoms and recovery will be delayed.

It is particularly important to try to prevent its recurrence. Unless you modify your activity level or the conditions under which you are physically active, recurrence of the injury is possible. Modifying footwear and wearing softer soled shoes or shock-absorbing insoles can help prevent a recurrence. If you incorporate jogging or running into your training program for conditioning, wear running shoes designed to absorb pressure and try to run on grass or softer surfaces like dirt trails. Concrete is very hard, and running on concrete should be avoided if at all possible. Downhill running is very stressful on the weight bearing bones so be careful in choosing your running route to avoid a lot of downhill running if you incorporate jogging into your training regimen.

When recovering from the injury, swimming or jogging in a swimming pool is a way to maintain conditioning and reduce stress on the bones. Pool work is also a good cross-training method and a way to give the bones a rest while maintaining conditioning.

If you think you have a stress fracture, get it checked out by your health-care provider. The diagnosis and treatment is painless, easy and straight forward. Left untreated, a stress fracture will only get worse and could force you out of your officiating duties for a long time.

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