Stress fractures account for 10% of all sport-related overuse injuries, with 69% percent of stress fractures occurring in runners. With an average recovery time of almost 13 weeks, developing a stress fracture is every runner’s nightmare.
What are stress fractures?
A stress fracture is a very small crack in the bone, in runners mostly occurring in the legs. Stress fractures develop gradually and occur on a spectrum; if caught early in the stress reaction stage it may not be worse than a painful bone bruise but allowing it to go untreated can lead to a full stress fracture. Prevention is always far better than treatment.
Common places for stress fractures include weight bearing bones such as shin bone or tibia or the second and third metatarsals in the foot (they are thinner and usually longer than the first metatarsal). Stress fractures can also occur in the heel, the ankle, the hip or even the lower back.
What causes stress fractures?
Stress fractures are a fairly common overuse injury. They are often caused by poor biomechanics or occur when fatigued muscles stop being able to absorb impact, transferring the overload of stress onto the bone. The injury usually develops gradually over time as the repetitive strain from the impact of running causes microscopic damage to the bone. If you start running long distances without allowing your body to adjust or you fail to give your body adequate time to rest, you run the risk of stress fractures.
Vitamin D deficiency, which is very common, is a significant risk factor in stress fractures. Vitamin D is important for bone strength and with a recent study finding Vitamin D deficiency evident throughout the European population at concerning rates, supplementation is recommended.
Osteoporosis or other conditions affecting your bone density can also increase your risk of developing a stress fracture.
Symptoms of stress fracture
The most common symptoms of a stress fracture are:
- Pain, swelling or aching at the site of the fracture
- Tenderness or sharp pain you can pinpoint on a bony area
- Pain during activity that then resolves with rest
- Pain that’s present throughout the activity and doesn’t go away after you have finished
You can help diagnose stress fractures in the feet by performing “the hop test”; carefully hop a few times on the injured foot. If it hurts when you land, it could be a stress fracture.
Note: Any pain that comes on suddenly and prevents you from moving normally may be a warning sign and you might want to see your doctor.
How to avoid stress fractures?
Stress fractures are infinitely easier to prevent than they are to heal. Begin by ensuring your diet contains enough calcium, Vitamin D and other nutrients which will help strengthen your bones and prevent the development of stress fractures.
Be patient with your training, it's easy to fall into the trap of “too much, too soon” but the accepted formula is to add no more than 10% to your running distance each week. Adding some weight training, swimming or cycling into your training will help balance the load.
It's also important to make sure your footwear fits well and supports your biomechanics. Improper footwear can lead to imbalances that contribute towards the development of stress fractures.
If you suspect you might be suffering from a stress fracture, ease off exercise and make an appointment with your doctor. X-Ray can be an unreliable diagnostic tool with stress fractures so an MRI scan would be preferable.
Denay, Keri L. MD Stress Fractures, Current Sports Medicine Reports: 1/2 2017 - Volume 16 - Issue 1 - p 7-8 doi: 10.1249/JSR.0000000000000320
Fredericson, M., Jennings, F., Beaulieu, C., & Matheson, G. O. (2006). Stress fractures in athletes. Topics in magnetic resonance imaging : TMRI, 17(5), 309–325. https://doi.org/10.1097/RMR.0b013e3180421c8c
Miller, T. L., Jamieson, M., Everson, S., & Siegel, C. (2018). Expected Time to Return to Athletic Participation After Stress Fracture in Division I Collegiate Athletes. Sports health, 10(4), 340–344. https://doi.org/10.1177/1941738117747868
Astur, D. C., Zanatta, F., Arliani, G. G., Moraes, E. R., Pochini, A., & Ejnisman, B. (2015). Stress fractures: definition, diagnosis and treatment. Revista brasileira de ortopedia, 51(1), 3–10. https://doi.org/10.1016/j.rboe.2015.12.008
Knechtle, B., Jastrzębski, Z., Hill, L., & Nikolaidis, P. T. (2021). Vitamin D and Stress Fractures in Sport: Preventive and Therapeutic Measures-A Narrative Review. Medicina (Kaunas, Lithuania), 57(3), 223. https://doi.org/10.3390/medicina57030223
Kevin D Cashman, Kirsten G Dowling, Zuzana Škrabáková, Marcela Gonzalez-Gross, Jara Valtueña, Stefaan De Henauw, Luis Moreno, Camilla T Damsgaard, Kim F Michaelsen, Christian Mølgaard, Rolf Jorde, Guri Grimnes, George Moschonis, Christina Mavrogianni, Yannis Manios, Michael Thamm, Gert BM Mensink, Martina Rabenberg, Markus A Busch, Lorna Cox, Sarah Meadows, Gail Goldberg, Ann Prentice, Jacqueline M Dekker, Giel Nijpels, Stefan Pilz, Karin M Swart, Natasja M van Schoor, Paul Lips, Gudny Eiriksdottir, Vilmundur Gudnason, Mary Frances Cotch, Seppo Koskinen, Christel Lamberg-Allardt, Ramon A Durazo-Arvizu, Christopher T Sempos, Mairead Kiely, Vitamin D deficiency in Europe: pandemic?, The American Journal of Clinical Nutrition, Volume 103, Issue 4, April 2016, Pages 1033–1044, https://doi.org/10.3945/ajcn.115.120873
Bennell, K. L., Malcolm, S. A., Thomas, S. A., Wark, J. D., & Brukner, P. D. (1996). The incidence and distribution of stress fractures in competitive track and field athletes. A twelve-month prospective study. The American journal of sports medicine, 24(2), 211–217. https://doi.org/10.1177/036354659602400217