STRESS FRACTURES
Ross Hauser, M.D.

Stress fractures most commonly occur in the lower extremities, but also occur in non-weight-bearing bones, including the ribs, upper extremities, and the pelvis. The most common sites are the tibia, metatarsals, and fibula. A recent study demonstrated a high incidence of tarsal navicular stress fractures, which may be the most common site in certain groups such as sprinters and hurdlers. Sports associated with specific stress fractures include rowing and golf (ribs), baseball pitching (humerus), and gymnastics (spine).

Recent studies have shown that the incidence of stress fractures in athletes is higher than previously thought. The most frequent sport associated with stress fractures is running. One prospective study of 95 track and field athletes showed an annual incidence of approximately 20 percent. (Bennell, K. The incidence and distribution of stress fractures in competitive track and field athletes: a twelve-month prospective study. American Journal of Sports Medicine. 1996; 24:211-217.)

The mainstay traditional treatment for stress fractures is rest. The theory behind this is that the bone is breaking down faster than it can be built up (because of the running), therefore rest is needed. A better approach is to view stress fractures as a connective tissue deficiency of the bone and to determine why that exact area is weakened.

Women reportedly have a higher rate of stress fractures than men. (Bennell, K. A prospective study of risk factors for stress injury in female athletes (abstract). In Medicine and science in sports and exercise: American College of Sports Medicine Annual Meeting Supplement. 1995; 27:S196.) It has been found that many female runners who sustain stress fractures have a significantly later age of menarche (onset of menstruation), less menses per year, lower bone mineral density at the spine, and less lower-rib lean mass.

In addition, female distance runners are known to have a high incidence of eating disorders, which itself may lead to amenorrhea or nutritional deficiencies. In one prospective study, females with lower bone density, history of menstrual disturbance, less lean mass in the lower limbs, a discrepancy in leg length, and who consume a very low fat diet were at a significant risk for stress fractures. No significant risk factors were identified in men; however, there was a strong trend toward low bone density, signifying that stress fractures are a connective tissue deficiency problem in both men and women since the mineral content of the bone was decreased. It is generally accepted, even in traditional medicine circles, that low mineral content in bone is often due to a deficiency in anabolic hormone production. (Lloyd, T. Women athletes with menstrual irregularity have increased musculoskeletal injuries. Med. Sci. Sports Exerc. 1986; 18:374-379. * Bennell, K. Risk factors for stress fractures in track and field athletes: a twelve-month prospective study. American Journal of Sports Medicine. 1996;24:810-818.)

Part of healing stress fractures, even in young athletes, is making sure the endocrine (hormonal) system is working properly. This is part of the connective tissue proliferation (collagen-rebuilding) program at our office in Oak Park, Illinois.

Females are fortunate because they have a monthly guide to assess their nutritional status, the menstrual cycle. A women who has a normal menstrual cycle without PMS or cramping, is generally hormonally and nutritional healthy. Unfortunately, most female athletes who walk through the doors of Caring Medical are not typically in good hormonal or nutritional shape. Many of them are already on oral contraceptive pills (birth control pills) to regulate their cycles. This is not a wise move for many reasons. First and foremost, regulating a woman's cycle is extremely easy using dietary and nutritional supplementation. Second, taking birth control pills to cover up the underlying menstrual problem is as bad as taking anti-inflammatory medications to cover up pain. Menstrual irregularities indicate that something in the patient's nutritional and/or hormonal milieu is wrong. Athletes are notorious for covering up problems.

Oral contraceptive pills have side effects including increasing a woman's risk for stroke and blood clot formation. More importantly, taking birth control pills covers up what is really going on with the woman's menstrual cycle. For this reason the menstrual cycle cannot be used as a marker of the woman's overall health. In our opinion, if the female athlete truly desires to excel in her sport, then the birth control pill must be eliminated.

Often when female athletes are undergoing Diet Typing, we find that the fat content in their blood is dangerously low or that they require more fat in their diets than they are currently eating. This is a key factor in helping them heal better. Supplementing with cod liver oil and flaxseed oil, as well as increasing the amounts of fresh fish, nuts, and seeds in the diet, corrects the essential fatty acid deficiency in their bodies. Once this occurs, the hormones become more balanced and the menstrual cycle irregularies cease in many cases.