21 Jun Rest or not to rest – Stress fractures
Written By Megan Hunter
It is important to highlight the difference between traumatic fracture healing and stress fracture healing, as these two processes have different considerations when it comes to rest. Stress fractures develop over a period of time rather than being due to one acute traumatic impact and can present as a continuum from a bony stress reaction to a fully visible fracture on scans.
Bony stress occurs when the load which the bone has encountered causes “micro-strain” within the bone and creates a cellular response. Micro-strain is a perfectly natural response to load and we need this as a part of the process in making healthy, strong bones. In most situations, when left to it, the body will then strengthen the bone to ensure that it can stand up to even more load next time BUT if not given enough time and the bone is loaded in a way that stimulates a further cellular response, then that area of the bone can fall into the cycle of “breaking down” rather than being allowed to “build up”.
Initially this imbalance can result in pain but no change in the continuity of bone, however, will eventually become a visible fracture line if inappropriate load is continued. While stress fractures can occur just as a result of inappropriate load, it is also important to note that they may also occur if there is a biological deficit in the bodies ability to “build up” bone. If a stress fracture has occurred it should be co-managed with a medical professional who will oversee the healing of the bone but also screen for intrinsic causes (e.g. genetics, nutrition, vitamin deficiencies etc).
It is these factors, the location and the amount bony stress present that determines how strict rest may need to be. Stress reactions deemed to be “low-risk” are usually managed with avoiding specific activities e.g. running/jumping and/or particular positions that may load the area of stress, but allowing pain to guide most other activities to maintain activity and even strengthen the area while the bone is allowed to heal. Stress fractures or “high-risk” stress reactions will often be managed with a period of bracing/immobilisation.
So initially, some rest may be best for stress, but in most low-risk cases this is not complete rest. Even if the bone stress is more complex or high risk and there is a time where complete immobilisation is needed, the bone will not be fully healed until it is eventually loaded.
Resources/ Further Reading:
Hughes, Julie M, Popp, Kristin L, Yanovich, Ran, Bouxsein, Mary L, & Matheny, Ronald W. (2017). The role of adaptive bone formation in the etiology of stress fracture. Experimental Biology and Medicine (Maywood, N.J.), 242(9), 897-906.
While this article was written by Megan Hunter using academic resources, further information can be found at https://patient.info/doctor/stress-fractures