Strategies for Preventing Stress Fractures in Sports
By Marie Spano, MS, RD, CSCS, CSSD
Stress fractures are common sports injuries that hurt an athlete physically and mentally. In addition to hampering their training program, a situation that could lead to detraining, a variety of emotions can come into play as the athlete sits on the sidelines. Yet sports dietitians can help their clients take steps toward prevention through proper nutrition and facilitate physical and emotional recovery after a stress fracture has occurred.
Stress Fractures Defined and Risk Factors
Stress fractures are tiny cracks in bones resulting from overuse.1 “Rapid increases in the frequency, volume, or intensity of repetitive impact activities, like running or jumping, lead to an accumulation of bony microtrauma that may manifest as a stress fracture if the athlete is overtrained or lacks ample recuperation stimuli,” says Michael Roncarati, PT, DPT, CSCS, director of rehabilitation for the Atlanta Hawks of the National Basketball Association. Muscles help dissipate ground reaction forces upon impact and therefore, “overtraining can lead to muscle fatigue to the point where bones will be subjected to bear a greater brunt of the impact,” Roncarati says.
Previous history of stress fractures and female gender are primary risks factors.2 Low bone mass and strength, which are more common in females than in males, also increase risk.3,4 Low calorie intake, low body weight, and menstrual irregularities—all part of the female athlete triad—contribute to the greater risk in females because the combination creates an “unfavorable environment for healthy bone remodeling,” Roncarati says. “An inability to form strong, resilient bone may lead to development of bony injury and stress fractures. Female athletes in court sports, running, or gymnastics seem to be at higher risk of stress fractures than their male counterparts.”
Nutrition plays a role in the development of stress fractures, with most studies showing that lower calcium intake, low serum vitamin D, and a vegetarian diet are linked to greater risk.2 However, “Most diet-stress fracture studies have to be interpreted cautiously because researchers link an athlete's recall of their diet to their injury history, and these can sometimes be unreliable,” says Emma Laing, PhD, RDN, associate research scientist and director of communications in the department of foods and nutrition at the University of Georgia. “The best way to get to this answer is by conducting large, long-term studies that closely examine athletes' dietary intake and the number and timing of stress fractures. Researchers also can assess training patterns and other factors in these studies that are at play in the development of stress fractures,” Laing says.
The first thing dietitians can do to help clients prevent stress fractures is begin with an assessment. “Assessing a female athlete with a history of stress fractures is a critical skill for sports dietitians,” says Roberta Anding, MS, RD/LD, CSSD, CDE, FAND. Anding suggests dietitians assess clients for relative energy deficiency in sport, a condition characterized by low energy availability that can lead to various health consequences such as menstrual irregularities and impaired bone health.
In addition, RDs can ensure clients get proper nutrition by determining their overall energy needs as well as macronutrient and micronutrient requirements for building, maintaining, and repairing lean body mass based on training frequency and intensity. “Making sure an athlete is replete in protein, calcium, and vitamin D, in particular, will help in maintaining musculoskeletal health,” Laing says. “Though it may seem straightforward to determine an athlete’s energy needs, newer calculations exist to determine energy availability and may be challenging for clinical sports RDs. The limitations of these equations are twofold. An accurate assessment of dietary intake and calories expended is essential. [And] athletes with disordered eating may overreport intake and underreport exercise outside of sport.”
Sports dietitians also can suggest clients modify training frequency, volume, and intensity when necessary to help prevent stress fractures.
Though some athletes and coaches may want to continually overload the body, “It is not realistic to expect the body to be able to train at very high intensities for extended periods of time without recourse,” Roncarati says. “Giving the body a break from intense sprinting, running, and cutting can go a long way in reducing the risk of stress fractures and orthopedic injuries in general.”
Roncarati also recommends athletes cross-train during the early offseason, during competition when time allows, and doing workouts on softer surfaces like grass, turf, sand, or the track as opposed to concrete or hardwood. In addition, the offseason is a critical time when athletes should engage in variable training exercises instead of sports-specific activities. “Resistance training, jump training, and gradual running progressions support the building of general qualities across the training spectrum while simultaneously unloading the body of the repetitious, arduous sports-specific demands the athletes are regularly exposed to in season,” Roncarati says.
Strategies for Counseling Clients
While it’s important to know how nutrition science and training may impact the development of stress fractures, practicing sound counseling strategies is key for building rapport with athletes and delivering nutrition messages. Kensa Gunter, PsyD, CC-AASP, a clinical sport psychologist, recommends showing genuine concern by acknowledging what athletes are going through and allowing them to feel and work through their sadness, frustration, or disappointment. "Although you don't want them to stay in this place, validating their feelings can go a long way toward communicating you care, and this can help athletes feel supported as they begin their rehab process,” Gunter says, adding that if athletes experience emotions that are more severe, intense, or prolonged, dietitians should refer them to an outside mental health professional for further assessment.
If a referral isn’t needed, sports dietitians should keep in mind that nutrition counseling not only can facilitate a faster recovery from a stress fracture but also help improve an athlete’s mental state. Information is powerful and “can increase their sense of control and their feeling of being an active participant in the rehab process, which can boost positive feelings including confidence and motivation,” Gunter says.
Gunter also recommends helping [athletes] reframe their rehab as part of their training regimen as opposed to something that's keeping them away from sports training. “This can also increase motivation. Furthermore, this can increase their buy-in to the rehab process and allow them to see it as an opportunity to enhance some of the basics (eg, strength and fine motor skills) as they prepare to return to competition."
Stress fractures can take an unexpected physical and mental toll on athletes. Low bone mass and strength and a variety of training factors contribute to these overuse injuries. Sports dietitians may want to pay particular attention to females and those with a previous history of stress fractures and help them stick with a nutrition plan that includes sufficient calories, macronutrients, and micronutrients to match training frequency and intensity. By acknowledging athletes’ feelings and framing their rehab program and nutrition plan as part of their training program, sports dietitians can help empower them and gain buy-in, which may facilitate faster recovery and a more positive emotional state.
— Marie Spano, MS, RD, CSCS, CSSD, is a nutrition communication’s specialist and one of the country’s leading sports nutritionists. She’s the sports nutritionist for the Atlanta Hawks, Atlanta Braves, and Atlanta Falcons and has worked with a wide variety of athletes. Spano has appeared on CNN as well as NBC, ABC, Fox, and CBS affiliates throughout the nation, and has authored hundreds of trade publication and magazine articles. She’s the lead author of Nutrition for Sport, Exercise and Health (Human Kinetics Publishers, Fall 2017) and coeditor of Human Kinetics Publishers’ NSCA’s Guide to Sport and Exercise Nutrition.
1. Stress fractures. American Academy of Orthopaedic Surgeons website. http://orthoinfo.aaos.org/topic.cfm?topic=a00112. Updated October 2007.
2. Wright AA, Taylor JB, Ford KR, Siska L, Smoliga JM. Risk factors associated with lower extremity stress fractures in runners: a systematic review with meta-analysis. Br J Sports Med. 2015;49(23):1517-1523.
3. Schnackenburg KE, Macdonald HM, Ferber R, Wiley JP, Boyd SK. Bone quality and muscle strength in female athletes with lower limb stress fractures. Med Sci Sports Exerc. 2011;43(11):2110-2119.
4. Chen YT, Tenforde AS, Fredericson M. Update on stress fractures in female athletes: epidemiology, treatment, and prevention. Curr Rev Musculoskelet Med. 2013;6(2):173-181.