Stress fractures are a common condition experienced by runners.

Causes of stress fractures

In general, stress fractures are caused by too much load on the bone at one time. Excessive loading can be induced by increasing training intensity, volume, or frequency. Extreme pounding on inappropriate surfaces or wearing old shoes does not help. We usually see stress fractures in military personnel, active sportspeople, or elite athletes. However, anyone who increases training suddenly over a short period is at risk. Therefore, the first part of stress fracture management is determining why a person has developed the injury.

Sometimes, people might have other causes unrelated to their training. For example, the weakening of bones, also known as Osteoporosis,s can place you at increased risk. The weakening of bones can be secondary to vitamin deficiencies, hormonal imbalance, or other medications. In women, a condition known as the ‘female athletic triad,’ a combination of poor nutrition, eating disorders, and irregular periods can lead to weakened bones and an increased risk of stress fractures.

How do we diagnose stress fractures? 

Generally, pain occurs with impact activity such as walking, running, or sports. Initially, pain can be mild and vague, meaning that stress fractures may be misdiagnosed as muscle strain or joint arthritis. As the condition progresses, rest and night pain are common. Often, people with more severe stress fractures limp and have difficulty walking at any time.

Typically, a thorough examination is needed to confirm the diagnosis and exclude other causes of pain. Touching the bone is often painful, and jumping or hopping constantly reproduces pain at the fracture site.

In the early stages, an X-ray may be normal. Then, however, a bone scan or MRI is needed to see bone swelling and fracture.

Stress fracture management

Rest from impact activity is the best treatment. Taking time away from running or traditional sports often allows the bone to heal. Cross-training with non-impact activities such as swimming or cycling will keep you fit despite rest. Icing the fracture site can reduce swelling. Finally, we generally advise against medications such as ibuprofen, as anti-inflammatories have been shown to slow bone healing.

Overall, during this time of bone healing, we suggest you see your therapist to perform rehab exercises. Exercise therapy is essential to develop a more muscular pelvis and lower body to cope with the demands of running.

As the pain improves, we suggest gradually re-introducing fitness activities such as gym and walking. Rather than starting running, we recommend a slower progression using a walk/run program.

Further investigations for Osteoporosis

We sometimes recommend further investigations to check your hormonal and bone health. For example, in cases with a suspected weakening of bones, we recommend hormonal blood tests and a bone density X-ray (also called a DEXA scan). Generally, hormonal or vitamin deficiencies must be treated before returning to full activity. For example, vitamin D deficiency is common in the UK and requires high-dose supplementation over many weeks.

Other causes of Osteoporosis include diabetes, inflammatory bowel disease, inflammatory arthritis and certain medications such as cortisone and anticonvulsants.

Management of a stress fracture: how do we prevent it?

There are a few simple tips to prevent future stress fractures. First and foremost, controlling the amount you do, also known as load management, is the most critical factor. We suggest you use the 10% rule, i.e. try not to increase your load by more than 10% per week. Secondly, eat healthily and increase foods containing calcium (dairy products) and Vitamin D (eggs, fatty fish). Finally, avoid exercising through pain and seek medical advice if your musculoskeletal pain does not settle with a few days of rest.

Dr Masci discusses specific stress fractures in these blogs:

Dr. Masci is a specialist sport doctor in London. 

He specialises in muscle, tendon and joint injuries.