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Football Physio Newcastle

Stress Fractures In Football

As we move towards selection for next year’s club football sides there is a tendency for players to push harder to prove themselves. More training, higher intensity, less rest / recovery time plus there can be school soccer games added in there, not to mention lunchtime playground fun. One consequence of an imbalance in load versus rest time is stress fractures. The earlier the problem is diagnosed the better the outcome and given that stress fractures can unfortunately lead to prolonged periods of lost game time, it is an important topic in football health and wellbeing. We have previously published a blog regarding stress fractures in runners, which includes a detailed explanation of the cause, biological process, diagnosis and management which you can read about here.

This blog will focus on some common causative factors and the division of the “high risk” versus “low risk” types of stress fractures, as these are managed very differently. The risk relates to the specific location within a given bone rather than the likelihood of developing that type of stress fracture.

Stress fractures almost always occur in one of the following scenarios, or a combination of these.

Increase in load on a region of the body in a given (often too short) time period
Decrease in recovery time relative to loading time
Decrease in the bone’s ability to repair / remodel following exposure to load.

Therefore, when volume of load increases the risk is higher, such as progressing to a higher competitive level of play, a busy period in the season with extra games and training sessions, an increase in training load such as during pre-season fitness training or even a change in training surface or footwear relative to the amount of loading. Conversely if the athlete’s load remains unchanged but they have a change in diet, energy input, illness or nutritional balance this can lead to an increased risk of injury.

High risk stress fractures generally involve a bony area where there is critical blood supply or an ossification centre (where the bone grows from). An example of these are the Femoral neck (hip), Navicular bone (midfoot), base of the 5^th metatarsal (outside of foot) and the medial malleolus (inside of the ankle). These are considered high risk due to the possibility of a full fracture disrupting the only blood supply to this part of the bone, which can lead to ongoing problems. The high risk stress fractures are often managed initially with complete unloading / non-weight bearing and then closely monitored during the periods of activity reduction / relative rest including repeated imaging studies to track bony healing. In more severe cases these can require surgical management. High risk stress fractures often require orthopaedic specialist involvement in early management. Regardless of severity if a stress fracture is diagnosed we recommend assessment and advice regarding management with a sports physician specialist.

Low risk stress fractures are located in areas with good blood supply which are known to heal well with relative rest and progressive rehabilitation. These are more common in soccer and mostly found in the postero-medial tibia (lower inside of the shin) and in the metatarsals (the forefoot). This type of stress fracture can usually be diagnosed clinically but usually require imaging (MRI / Xray) to confirm type and severity.

Effective management of these injuries in soccer players requires good communication between the physiotherapist, sports physician, coaches and player, especially given the potentially longer period of recovery than most soft tissue injuries. It is important not to continue to play if a stress fracture is a possibility.

If you have any questions on the information in this blog or need assistance in diagnosis or rehab relating to soccer injuries, contact us on admin@numovesphysiotherapy.com.au or 49216879.

Newcastle physiotherapy for groin and adductor pain in football The NU Moves Physio team has recently completed a masterclass debating the best approach to manage and treat adductor pain and tendon problems with footballers. Journal articles were found and discussed relative to the NU Moves approach to diagnosis and treatment.

The following is a summary of the NU Moves masterclass. The current best approach to assist a footballer with pain in the groin or adductor region:

Diagnosis is essential: There are many different possible sources of pain into the groin / hip area. Identifying the likelihood of each of these (e.g. osteitis pubis, stress fractures, avulsion fractures, bursitis, tendon strain, hernia, arthritis, lower back referral) via a thorough assessment is essential. Subsequently investigations (Xray, CT scan, MRI, Ultrasound) to confirm or negate are considered. The timing of investigations depends on the risks of the problems and whether treatment is altered because of the investigation findings.

Treatment of adductor tendon pathology:
- Note that this requires consideration and exclusion of all the other potential causes of hip pain.
- Don’t stretch the adductor muscle area – the right type of strength and functional return to sport exercises will assist recovery of flexibility and stretching is more likely to irritate the problem.
- Stability is essential – becoming core stable in the pelvis by focussing on strengthening the gluteal and abdominal muscles in sport specific positions (i.e. one leg stand) is the starting point and can often be done very quickly after injury occurs.
- Strengthening the adductor tendons – when commenced at the correct time after the injury, adductor strength exercise is useful in improving long term outcomes of full pain free return to sport. This could be a ball squeeze between the ankles / knees in lying or a band or cable resistance exercise in standing (as long as the pelvic stability stage has been achieved).
- Graded return to running: graded return to jogging then running then change of direction exercises is essential. Once the tendon can cope with it and the pelvic / core stability is adequate then a terrific way to strengthen the area for running is to start jogging. The problem is when you go too hard too soon and create a flare-up of pain that lasts several days. Flare-ups are a set back to the eventual goal of return to playing again.
- Sport specific exercise: kicking / striking / passing the ball in football can all be done lightly and gradually increased in a comparable way to jogging and running. Similarly, once pelvic / core stability and sufficient local strength of adductors is achieved, these are a great way to strength load the area for sport. Again, be wary of flare-ups by progressing too quickly.

The adductor tendon strain is a frequent problem in sport and particularly in football. The best advice is to get an accurate diagnosis first then an active exercise program including 3 parts: the pelvic / core stability, the adductor tendons themselves, and a sport specific program. Getting the right level of loads on the area during each phase of recovery is essential to the process. That is where we help the best.

If you want the best diagnosis and treatment then call us at NU Moves if you have groin pain or a known adductor problem. If you have a friend or family member needing advice to get back to sport then recommend us.