Rehabilitation (Stress fracture of the lower leg)

The following guidelines are for information purposes only. We recommend seeking professional advice before beginning rehabilitation.

Aims of rehabilitation?

• Reduce pain and allow the injury time to heal.
• Maintain flexibility and mobility.
• Improve strength, particularly in the muscles of the lower leg and ankle.
• Gradual return to training and full fitness.

The best approach to rehabilitation of a stress fracture is to try and maintain as normal a pattern of training as possible, substituting the high impact activities with other training methods.

Rehabilitation can be divided into two phases. Phase 1, when it is healing and phase 2, when the fracture has healed.

Phase 1 - Usually about 8 weeks.

• Rest. No running, jumping or high impact activities. A particularly severe injury may require immobilizing in a cast for a short time. It is important to maintain aerobic fitness - see below.
• Identify and correct any biomechanical abnormalities of the foot and lower leg which may have increased the forces on the lower leg for example over pronating. Training errors should also be looked at. Always keep a training diary so you can look back and identify possible errors such as sudden increases, change of shoes which may not be immediately obvious.
• Progress with an aerobic training programme that includes swimming, running in a pool or cycling. Maintaining fitness will speed up the rehabilitation process post healing phase and help keep the athlete in a better frame of mind.
• An X-ray of bone scan can help identify how the healing process is progressing.
• Strengthen the lower leg muscles. All the muscles of the lower leg and ankle, particularly the calf muscles should be worked. This will maintain muscle strength which will take the stress off the bone when the athlete returns to running.
• Stretch the muscles of the lower leg, particularly the claf muscles and achilles tendon.
• Sports massage of the lower leg muscles can improve condition and accelerate rehabilitation once healing is completed.

An example of a training session during this phase might be:

• Warm up muscles by applying heat from a hot bath / hot water bottle. Gentle massage techniques may also help.
• Mobility exercises for the ankle.
• Stretching the calf muscles and front of the ankle.
• Strengthening exercises for the ankle.
• Aerobic activity (swimming / cycling).
• More stretching exercises.
• Apply ice or cold therapy.

The length of this phase is usually around 6 to 8 weeks. At this point an X-ray may indicate healing of the bone having taken place. The athlete is then ready to move to phase 2 of the rehabilitation programme. If they have maintained fitness and progressed the exercises above then the risk of recurrence is reduced.

Phase 2

• Begin a gradual return to running programme. Start running for just a few minutes and gradually build up. The previous fitness level will determine the initial duration of runs and rate at which running time increases. An example is seen below:

Day 1:	walk 4 minutes	jog 2 minutes	repeat four times
Day 2:	rest
Day 3:	walk 4 minutes	jog 3 minutes	repeat three times
Day 4:	rest
Day 5:	walk 3 minutes	jog 4 minutes	repeat 4 times
Day 6:	rest
Day 7:	walk 2 minutes	jog 6 minutes	repeat 4 times

• When normal running time has been reached, a general rule is to increase running time (or distance) by no more than 10% a week. Ensure running shoes are designed for running in and are in good condition.
• Apply heat before training sessions to warm the muscles up and ease pain.
• Apply ice or cold therapy to the shin following training sessions to help reduce inflammation.
• For athletes in sports requiring sudden changes of direction or explosive movements, these should be gradually introduced into the programme as it progresses.

An example of the structure of a training session during phase 2 might be:

• Mobility exercises for the ankle.
• Gentle jog to warm up muscles.
• Stretch muscles of the lower leg an ankle.
• Main training activities - e.g. running session.
• Stretching muscles.
• Strengthening exercises.
• Apply ice.

Prevention

• Avoid a rapid increase on training. Keep a training diary to record progress. Increase training mileage / workload by no more than 10% per week.
• Avoid a single severe training session for example the sudden urge to run 20 miles when not accustomed to that level of training.
• Ensure the muscles of the lower leg are stretched regularly, are not tight and are balanced and strong (maintain regular strengthening exercises).
• Regular sports massage can help prevent build up of tension in the muscles which will enable them to take more of the stress of running for longer, placing less stress on the bones.
• Correct footware for your running style and correct any biomechanical abnormalities with orthotic devices.