What are Stress Fractures?
Stress fractures are tiny cracks that form in a bone after repetitive stress. As a type of overuse injury, stress fractures are common in athletes of all levels, particularly with a sudden increase in training volume or intensity.
Stress fractures occur most commonly in the bones of the foot and lower leg.
- Tibial stress fractures (stress fractures of the shin bone): the most common fracture; often occurs in runners of all levels (3). Most tibial stress fractures occur in the lower portion of the bone, closer to the foot.
- Fibular stress fractures: another common stress fracture of the lower leg. The fibula bone is located on the outside of your lower leg and forms the outside of the ankle.
- Calcaneal (heel) stress fractures: are most commonly found in long-distance runners and endurance athletes.
- Metatarsal stress fractures: occur in the long, thin metatarsal bones of the front of the foot. Fractures often occur in the second and third metatarsal bones as they bear more relative force in activities like running.
- Navicular stress fractures (fractures of a bone in the arch of your foot): often occur with activities that involve explosive or lateral (side-to-side) movement.
Symptoms of Stress Fractures:
While the most common symptom of a stress fracture is focal pain at the site of the fracture, other symptoms may include:
- Tenderness to the touch
- Localized swelling over the area of injury
- Pain with everyday activities that subsides with rest
- Unexplained pain at night or at rest
Symptoms can vary in intensity between individuals, and there may be periods of time where symptoms are more intense than others.
Risk factors for Foot Stress Fractures include:
While stress fractures can affect a wide variety of people, there are several risk factors associated with developing them:
- Gender differences – Stress fractures are seen more often in female patients than males. While the literature is mixed as to why this is, some suggest that in females, the increase in the Q-angle at the hips increases the load on the lower leg and foot, increasing the risk for stress fractures (4).
- High-impact activities – Activities that place a large amount of stress on the bones and tissues of the foot and lower limb can contribute to the development of stress fractures. Running, basketball, tennis, and soccer are all high-impact activities that can cause stress fractures in the feet (4).
- Poor nutrition – Nutritional deficiencies, particularly in vitamin D and calcium, have been linked to a reduction in bone density. Loss of bone density increases the risk for stress fractures, as the bones become weakened (4).
- Poor shock absorption – A more rigid, higher-arched foot is less able to absorb shock and, as a result, will transfer more shock through the bones of the foot or up through the tibia (shin). This increase in shock transfer can increase the risk of a stress fracture in the foot and lower leg (4).
- Overpronation – Excessive pronation (collapse of the arch) can place an excessive amount of torsion on the tibia (shin bone). Repetitive torsion of the tibia can lead to stress fractures in this bone (4).
Treatment for Stress Fractures
Treatment for stress fractures depends on the severity and location of the fracture. Most stress fractures take six to eight weeks to heal completely.
Your primary care provider is the best initial resource for this injury. They will be able to recommend lifestyle or activity modifications or medications as well as order any necessary imaging or diagnostic tests. Your doctor may recommend using crutches or a removable cast walker to keep weight off the affected foot/leg.
Physiotherapists and kinesiologists can help with activity modifications and training changes to help manage your pain while remaining active.
A pedorthist can help control excessive movements at the foot that impact the alignment and movement at the knee. Your pedorthist may recommend a specific shoe or incorporate orthotics for stress fractures to correct these movements and realign the lower limb.
More severe stress fractures may require surgery to heal completely. In these cases, the surgeon will use pins, screws, or plates to hold the bones in place while they heal.
Physiotherapists can help with strengthening, stretching, and alignment issues that are impacting your pain. They may also be able to provide taping or other modalities to control pain and symptoms.
Kinesiologists can help you modify your activity or training to reduce your pain. After recovery, they can assist you in developing safe, gradual training programs to avoid future injury.
Staying active with a plan
The best therapy for healing a stress fracture, particularly in the lower leg or foot, is to abstain from all weight bearing activity. Some substitutions for weight-bearing activities might include:
- Resistance training
1. Patel D S, Roth M & Kapil N. Stress Fractures: Diagnosis, Treatment and Prevention. American Family Physician. 2011;83(1):39-46
2. Baxter M L, Baycroft C, & Baxter G D. Lower limb injuries in soldiers: Feasibility of reduction through implementation of a novel orthotic screening protocol. Military Medicine, 2011;176(3):291-296
3. Heaslet M W & Kanda-Mehtani S L. Return-to-activity level in 96 athletes with stress fractures of the foot, ankle and leg. Sports Medicine of the Lower Extermity 2007;97(1):81-84
4. Bennell K, Matheson G, Meeuwisse W, Brukner P. Risk Factors for Stress Fractures. Sports Med 1999;28(2):91-122