Stress fractures 101!

By. Dr Sean Delanghe BSc (Hons), DC

There’s nothing worse than hearing you have a stress fracture as a runner (maybe)! This 2024 review of systematic review will help to arm you with the information you need to avoid them and catch them early!

What This Study Is About
Stress fractures are overuse injuries that develop when repeated mechanical loading exceeds the bone’s ability to recover. The paper explores how frequently these injuries occur, where they are most likely to happen, what contributes to their development, and how they are best diagnosed and treated.

How the Research Was Done
The authors reviewed evidence from major databases – primarily systematic reviews. Around 90 studies were initially identified, with approximately 57 included in the final analysis. This is the best of the best!

Where Stress Fractures Happen Most
Stress fractures occur predominantly in the lower extremities due to repetitive loading during running. In long-distance runners, the tibia is the most commonly affected bone, followed by the metatarsals. In contrast, sprinters tend to experience more stress fractures in the toe bones, likely due to the higher forces and forefoot loading associated with sprinting mechanics.

Why Stress Fractures Develop
Stress fractures are multifactorial and typically result from a combination of biological, nutritional, mechanical, and psychological factors.

Key factors include:

• female sex
• reduced bone density
• nutritional factors such as low energy availability and deficiencies in calcium or vitamin
• Training-related issues, particularly rapid increases in workload
• In addition, psychological factors like high stress levels, perfectionism, and fear of failure may indirectly increase injury risk by influencing training behaviours and recovery.

How They Are Diagnosed
Diagnosis begins with a detailed clinical history and physical examination, but imaging is often required for confirmation.

• MRI is considered the most sensitive and preferred method for detecting stress fractures, especially in the early stages.
• X-rays are commonly used but may not detect early bone stress injuries, which can delay diagnosis if relied upon alone.
• Bone scans are the fastest and most sensitive option for most of us in Canada.

What Treatment Looks Like
Treatment primarily involves reducing or temporarily stopping the activity that caused the injury, allowing the bone time to heal. A gradual return to running is introduced once symptoms improve. Importantly, treatment should also address the underlying factors that contributed to the injury- see above!

How to Reduce Your Risk
Preventing stress fractures requires a proactive approach that includes maintaining adequate nutrition and energy availability, progressing training loads gradually, and addressing any biomechanical inefficiencies. Screening for conditions such as RED-S or the Female Athlete Triad may also be important in certain populations. Psychological stress should not be overlooked, as it can influence both training habits and recovery- are you doing the right thing for your training, or are you responding to anxiety that is telling you to illogically ramp up?

Practical applications:

• Most stress fractures occur in the lower extremities
• Tibia is the most common site in long-distance runners
• Metatarsals are the second most common
• Sprinters more commonly experience stress fractures in the toes
• Risk factors include biological, nutritional, mechanical, and psychological components
• MRI is the most sensitive diagnostic tool, bone scan is probably our best choice in Canada
• Treatment focuses on rest, gradual return, and addressing underlying causes
• Prevention requires proper training progression, nutrition, and overall load management
• Managing anxiety related to training and racing is a huge factor for most competitive runners!

If you have any questions about any of your injures for our Waterloo based chiropractors, physios or RMTs- feel free to contact us or book online HERE.

Does Dry Needling help with Plantar Fasciitis?

This article examined whether dry needling (DN) is effective for treating plantar fasciitis (PF), a common cause of heel pain. Dry needling involves inserting thin needles into muscle trigger points wth a goal reduce pain and improve movement.

This is not meant to replace more important strategies like load management, strengthening/ rehab etc. But is it actually a useful adjunct to these better supported potions?

Methods

The authors conducted a systematic review and meta-analysis of previously published research.

Major research databases were searched (PubMed, Embase, Web of Science, etc.), and only randomized controlled trials (RCTs) were included.

Study sample

• 12 RCTs
• 781 total participants
• Comparisons included:
  • Dry needling plus routine care (stretching, massage, exercise)
  • Dry needling alone
  • Other conservative treatments without dry needling

Key Findings

Pain Reduction

Dry needling combined with routine treatment resulted in significantly lower heel pain compared to routine treatment alone. Pain was measured using standard tools such as the Visual Analog Scale (VAS) and Numeric Pain Rating Scale (NPRS).

Mean pain score reduction ranged from −1.76 to −2.12 points, which represents a moderate to large clinically meaningful improvement.

Dry needling alone was not consistently superior to other conservative treatments for pain relief- so you still have to do the other stuff!

Functional Improvement

Dry needling combined with routine care led to significant improvements in foot function (measured with the Foot Function Index), and dry needling alone also showed better functional outcomes than other conservative treatments. This suggests dry needling may improve a patient’s ability to walk, stand, and perform daily activities, even when pain reduction is limited.

Timing of Benefits

Improvements were more consistent after one month. Short-term results (less than one month) were mixed, suggesting dry needling is more effective as a medium-term intervention rather than an immediate solution.

Safety and Side Effects

About 50% of the included studies reported minor side effects, most commonly temporary soreness, mild bruising, or minor bleeding at the needle site. No serious adverse events were reported.

Overall Conclusion

Dry needling appears to be a safe and effective treatment option for plantar fasciitis, particularly when combined with routine conservative care, used for at least one month, and aimed at improving both pain and foot function. However, the authors note that study quality varied, sample sizes were relatively small, and more high-quality randomized controlled trials are needed before strong clinical recommendations can be made.

If you have more questions about this therapy, or would like to try it, please contact us or book online HERE!

Manipulation for acute neck pain- does it work?

Does spinal manipulation actually help with acute neck pain? A recent systematic review and meta-analysis took a look HERE.

Acute neck pain , meaning neck pain that lasts less than three months, is very common and can lead to disability or persistent problems. The authors wanted to investigate how effective and safe SMT is specifically for acute neck pain, since previous reviews often mixed acute, sub-acute, and chronic cases, which makes interpretation difficult.

Methods
The researchers searched several major databases (PubMed, Embase, Web of Science, PEDro, Cochrane) up to March 20, 2023, for randomized controlled trials (RCTs) involving SMT versus control in adults with acute neck pain lasting less than 3 months. Outcomes of interest were pain intensity, cervical range of motion, and disability. They included 8 RCTs, with a total of 965 patients.

Key Findings

• Pain: SMT significantly reduced pain compared to controls (mean difference 1.53 points lower on the pain scale, 95% CI 0.83 to 2.22)
• Cervical range of motion: SMT improved neck movement in all directions (flexion, extension, rotation, lateral flexion). Flexion improved by a mean of 11 degrees (95% CI 9.10 to 12.93)
• Disability: Patients receiving SMT had lower disability scores than controls (mean difference 6.20, 95% CI 2.59 to 9.81)
• Safety: No serious adverse events were reported. One patient had a mild, transient arm sensation episode after SMT

Clinical Implications
Despite limitations (small sample sizes in some cases, dose/response not established), the review suggests SMT can be an effective and safe option for acute neck pain: it reduces pain, improves neck movement, and lowers disability in the short term. SMT is best considered alongside other treatments, such as exercise and education.

This study is a good start, but more research is required to determine which patients benefit most, how much and how often it should be performed, and which SMT techniques work best.

If you suffer from neck pain, or have more questions about this study, feel free to contact us HERE.

WANTED: PHYSIOTHERAPIST

Our awesome physio, Sayaka, is expecting her second child and needs help keeping her patients strong and healthy!

Sayaka works with a diversity of patients ranging from Parkinson’s rehab, surgical rehab all the way to strength training for athletes. We are looking for somebody who works with a strong emphasis on strength work/ rehab- we want to put that gym space to use!

Some general facts about the job:

• Flexible hours
• Expected duration: 1 year
• Part-time or full time- we will take what we can get if the practitioner is a good fit!
• Your own treatment room and access to gym space
• Jane practice software
• Patient- focused, evidence-based work environment
• Plenty of parking with store front entrance into the clinic
• Reception coverage for 40 hours/week with the option to work outside of those hours

There’s always the option to work beyond the locum if it makes sense for all, but for now the focus would be on maintaining Sayaka’s patients and other new physio patients that come into the clinic.

E-mail seandelanghe@gmail.com if you want to learn more!

Stretch or Strengthen a “stiff” muscle?

By: Sayaka Thiessen, Waterloo Physiotherapist

I am sure most of use have experienced a muscle that feels tight and stiff. Most people immediately think to stretch the affected area, but is that always the solution? 

If you have stretched to the ends of the earth but you still feel tight, it might be time to change the approach and try to strengthen it. The sensation of “tightness” doesn’t always mean a short muscle. It could, in fact, mean that the muscle is weak or that a joint lacks motor control and needs to be trained. 

Getting assessed by a healthcare professional, like a physiotherapist, you can determine if stretching, or strengthening, or a combination of the two is the way forward. 

Looking for a physiotherapist in Waterloo? Sayaka might be a good fit for you, read more HERE.