You can't recall an incident where you injured your leg, but it's really aching when you run. It's not sore to the touch, but you're getting sharp pains in your shin when you go out for a long walk. You haven't missed a workout in weeks, but your leg is really hurting and you can't figure out why.

If this sounds familiar, you might have a stress fracture.

With more people hitting the roads to get in shape, the number of stress fractures is on the rise. Stress fractures are most common in the lower leg and foot. The major weight-bearing bone below the knee, the tibia (shin), is affected in the majority of cases.

The gold standard of fracture diagnosis is a bone scan. In the presence of a stress fracture, a bone scan will show increased metabolic activity — a signal that the body is trying to heal itself. It appears bright white on the film and is easily recognizable to the naked eye. Bone scans are expensive, though, so don't be surprised if your doctor orders an X-ray first.

On an X-ray, a severe stress fracture is easily seen. The bone will have a "soupy" appearance with poorly defined borders. Detection of a fracture in a mild case is clinically challenging, so a second test may need to be performed to be certain of the diagnosis.

Stress fractures can be diagnosed in a number of other ways, however. Clinical inspection can detect a fracture over 95 percent of the time using simple and safe methods that spare patients from undergoing an X-ray or a bone scan.

When bones are broken, even slightly, they are extremely sensitive to even the smallest vibration. Vibrating a tuning fork and placing it against the bone in question will often produce a sharp, painful ache, thus indicating a positive test. Other methods include using a physical therapy ultrasound unit to resonate the bone in a similar fashion. This produces an effect in the same manner as the tuning fork.

Even with a plethora of advanced, expensive clinical tests, a patient's history will always be the cornerstone of an accurate diagnosis. A complete subjective history must be taken by your health care provider — it is the most useful of all the diagnostic tools and will lead you to the most appropriate form of treatment.

Patients who report a sudden increase in exercise or a substantial change in training patterns are at a higher risk for having a stress fracture than somebody who does not participate in repetitive weight-bearing activities. Runners, cross-country skiers, military personnel and basketball players top the list of potential candidates. If this sounds like your case, talk with a physical therapist regarding how reincorporate the activities you like to do without perpetuating the injury.

Stress fractures have many different origins, and the most common cause is easily treatable with a select set of strengthening exercises and correction of your running form. Most of the aforementioned sports require substantial hip strength to prevent oblique forces from traveling into the leg. Oblique force is the number one cause of all stress fractures sustained in sports, and is quickly eliminated with just a few hours of focused muscle retraining.

I firmly caution against exercising through a stress fracture. These injuries need specific attention and plenty of rest to heal properly. Patients that attempt to run through pain could end up with compartment syndrome — a limb threatening disorder where blood pools in the leg and compresses nerve tissue creating a surgical emergency.

Rehabilitation of a stress fracture is straightforward and painless, and the recovery rate for patients who seek physical therapy is nearly perfect. Only the most difficult and severe cases are kept from a full return to sports. Schedule a visit to a therapist — we'll tune you right up.


Joe DiVincenzo is a physical therapist and clinical specialist in manual therapy. He works in the outpatient division of Beverly Hospital and writes "On the Mend" weekly.¬ Questions may be submitted to On the Mend, c/o Salem News, 32 Dunham Road, Beverly, MA 01915 or e-mail

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