Out of all running injuries, nothing strikes more fear into a runner’s heart than stress fractures.
But what are stress fractures and why they’re so god damn common in the running world?
Inside of this post, I’ll provide you with a full overview of stress fractures in runners.
By the end, you’ll learn:
- What is a stress fracture?
- The causes of stress fractures in runners
- The most stress fracture prone areas in runners
- How to tell that you have a stress fracture—the main symptoms to look for
- How to ease stress fractures pain
- Can you run with a stress fracture?
- How to return to running after a stress fracture
- How to know when your stress fracture is fully healed
- How to deal with phantom pain after a stress fracture
- How to prevent stress fractures while running
- Best running shoes to prevent stress fractures
- And so much more
Stress Fractures In Runners Explained
Also known as a hairline fracture, basically, a small crack or severe bruising in a bone.
Stress fractures are the classic form of overuse injury caused by the gradual build-up of trauma from repetitive submaximal loading and bad posture.
Surveys show that stress fractures may account for 20 percent of all running injuries.
Athletes who participate in high-impact sports, such as basketball, football, soccer, are also prone to this condition.
In some cases, but rarely among productive age runners, stress fractures may be blamed on inadequate bone mineral density or bone diseases, such as osteoporosis.
They can also be traced back to genetic disorders or nutritional and hormonal imbalances.
Stress Fractures Vs. Bone Break
This may surprise you, but a fractured bone and a broken are not technically the same thing.
A stress fracture, as I explained earlier, is a bone crack or break that occurs when force is applied to a bone repeatedly and over time.
This means that they develop slowly over an extended period of time.
They don’t strike overnight.
The other characteristic is, your bone stays still in the same place.
You won’t even notice anything except the ongoing pain or bruising.
Whereas, the typical bone break happens when an outside force is applied suddenly on a bone.
The key here is the discontinuation of bone structure.
Falls, car accidents, sports contacts, such as football, can often cause bone breaks.
Common Stress Fractures In Runners
A stress fracture can strike any bone, but in runners, the weight-bearing bones are most prone.
Let me explain.
The most affected area is the lower leg in the shin bone (the tibia).
Survey shows that about half of all cases of stress fractures take place in the tibia.
But stress fractures are also common in other bones.
The foot, especially the second metatarsal, is another stress fracture prone bone.
More specifically, the second and third metatarsals in the foot, according to the American Academy Of Orthopedic Surgeons.
According to surveys, roughly 25 percent of all stress fractures strike these two bones.
The condition is also pretty common in:
- The heel, what’s known the calcaneus;
- The ankle joint, more commonly in a small bone called the talus;
- The fibula, the outer bone of the ankle and lower leg; and
- The navicular, a boat-shaped bone on the top of the midfoot, specifically in the ankle between the talus and the cuneiform bones.
- The talus is a small bone located within the ankle joint
Extreme (but rare) Cases of Stress Fractures
The bigger bones in your pelvis, hips, and femur are also prone to stress fractures, but these aren’t that common among runners.
And only a few people can feel it, since it’s not the main weight-bearing.
Causes of Stress Fractures While Running
The primary cause of the condition is, of course, overuse.
If you increase your training volume and/or intensity too fast and over a short period of time, you’re setting yourself up for injury.
Other factors that may contribute to stress fractures include:
- Bad footwear. Running in improper running shoes that provide little or no shock-absorbing ability.
- Being a female runner. Research shows that female athletes are more prone than male athletes. This is blamed on the so-called “female athlete triad,” a mix eating disorders, bone density issues, and menstrual dysfunction.
- Running technique. In some cases, overstriding may contribute to tibial stress fracture as it puts more stress on this region than other footstrike types.
- Inadequate nutrition, mainly insufficient vitamin D intake, can put you at risk, according to research out of The Journal of Foot & Ankle Surgery.
- Bone conditions. Bone disease compromises bone strength and density. Osteoporosis is one example.
- Weather condition. Research shows that stress fractures are more common in the winter than any other season of the year due to a deficiency in Vitamin D.
- Foot Abnormalities. Runners with anatomical foot abnormalities, such as fallen arches, are more prone to stress fractures than runners with a neutral arch, according to research.
- Muscle tightness. Research out of the Journal of Orthopedic and Sports Physical Therapy reported that having tight calves can make you roughly five times more likely to sustain a metatarsal stress fracture.
Symptoms of a Stress Fracture
If you notice any bony tenderness that worsens during running but subsides during rest, you might be experiencing the onset of a stress fracture.
Stress fractures are characterized as achy or generalized pain in and around the affected area.
You can’t pinpoint the exact place.
This pain usually develops slowly and worsens during running or any weight-bearing activity.
Over time and miles, this pain gets worse, then it becomes highly localized to a specific “area” on the bone, which will even be painful to the touch.
Sometimes it causes bruising, but mild.
Devoid of rest, the pain becomes gradually worse—to the point where it limits your range of motion and alters your running gait.
Can you Run With a Stress Fracture?
From my experience and the stories I’ve heard, I wouldn’t risk it.
It’s actually the dumbest thing you can do as a runner.
Running through tibia, fibula, or fracture is asking for more serious injury.
It’s also painful as these bones are the major weight-bearing bones that take most of the stress and brunt of pounding the pavement.
By ignoring your stress fracture, you risk snapping the bone completely.
Here’s the logic.
The femur is one of the biggest human bones, supported by two smaller bones.
If the smaller bones are affected by any injury, the support won’t be as good.
You force your bone to pass their stretch tolerance.
What’s the next plan?
If it’s an incomplete fracture, with no misalignment, bandage, and casting might help.
But if its complete fracture with multiple breakages, knife and fixation is the only solution.
Well, six months rest.
As a rule of thumb, avoid running through a stress fracture.
What should you do in case you have a stress fracture?
If you suspect a stress fracture, stop training altogether and do what you have to do to speed up recovery.
Let me explain.
Stop High Impact Exercise
Your first step is to let the affected bone(s) recover completely following injury.
It takes at least 28 days for complete remodeling.
I’d recommend that you cross-train during your recovery period.
Choose exercises with minimum impact.
Ideal options include aqua jogging, cycling, swimming, or yoga.
As long as you avoid high-impact weight-bearing exercise, such as running, rope jumping, plyometrics, you’re good to go.
Keep it as long as you feel comfortable before you add up the intensity.
Reassess every month.
Apply ice on the affected area to keep swelling down and ease tenderness.
I’d recommend using a frozen bag of beans or ice wrapped in a towel or cloth for 15 to 20 minutes at a time, at least three times a day.
Just whatever you do, do not apply a source of cold directly on your skin.
To reduce swelling, compress the injured limb by lightly wrapping it in a soft elastic bandage.
Keep your injured limb raised up higher than your chest level.
Using a hanging traction device can help.
What should you do if home treatments don’t improve your symptoms?
Consult a doctor or podiatrist.
They will help you figure out the exact location and severity of your injury as well as what to do next to bounce back and speed up your recovery.
Left untreated, stress fractures can result in the bone breaking completely.
First of all, expect to be X-rayed.
But you may need to do more.
Often, traditional X-rays may come out looking healthy as they might not be enough to spot a stress fracture, especially when the fracture is not completely through the bone.
For this reason, I’d recommend that you consult a sports-oriented physician for a thorough bone scan.
They’ll typically recommend a nuclear bone scan, an MRI, or any other advanced imagining techniques to fully detect the condition.
The Doctors Recommended Treatment Options
Your doctor will recommend taking an NSAID—Nonsteroidal anti-inflammatory drugs— such as Ibuprofen and Paracetamol to alleviate pain and reduce swelling.
Depending on the area and the severity of the stress fracture, your doctor might also recommend a splint, a cast, or protective footwear (such as a wooden-soled sandal or a stiff-soled shoe) to immobilize the injured limb.
Crutches are also recommended to keep weight off the injured leg, at least until you pass the acute phase.
In some cases, your doctor may need to put a fracture boot on the injured limb to keep the bones in a fixed position.
This helps eliminate the stress on the leg and speed up recovery.
Expect Surgery As The Worst-Case Scenario
In extreme cases of stress fractures, surgical intervention is needed to patch up the damage, especially when the fracture line has extended completely across the bone or your bone density is really bad.
This is done by inserting a type of fastening, known as internal fixation, to support the bones of the injured area. For those who had osteoporotic, external fixation might be one of the treatment choices.
Again, it depends on the severity and alignment.
How long It Takes To Recover From A Stress Fracture
Recovery time varies from one runner to the next.
The good news is, given time and rest, most stress fractures will heal.
Some people can recover really well starts from 28 days, but most take between six weeks to six months or even longer.
That’s a wide range of time.
And the reason stress fractures are categorized into two main groups: “low risk” and “high risk.”
A stress fracture within the low-risk category often heals on its own and may not call for any aggressive treatment measures such as long rest time or the use of crutches.
This category includes fibular and tibial stress fractures as well as metatarsal stress fractures.
High-risk stress fracture, on the other hand, usually strikes a region known for healing poorly.
These regions include the low back femur, pelvis, and navicular—all of which are the body’s strongest bones.
Returning to Running After A Stress Fracture
Planning to pick running again after a stress fracture?
Here’s what to keep in mind.
Phase One – The Injury Period
Lasting between four to 12 weeks, the injury period starts at the time of the diagnosis.
This, of course, depends on the nature and severity of the stress fracture.
Prepare for the worst.
No exercise at all. Rest!
You should stay below your pain threshold throughout this stage.
You should also minimize walking as much as possible.
In some cases, you may need the help of a boot or crutches to help you immobilize and support the injured limb.
I’d also recommend that you do plenty of low-impact exercises, such as yoga and the sort.
Expect to spend two to four weeks this stage—even much longer for serious cases of the condition.
If you feel pain, that’s a sign that the level of activity is too much.
Stage Two – Return To Running
Once you feel little to no pain during low impact weight-bearing activity, it’s time to get back to training.
I cannot emphasize this enough, but you should consult your doctor again—even if you’re completely pain-free.
The visit should help you confirm whether the stress fracture has fully healed or not yet.
Once you get the green light from your doctor, go ahead and slowly return to running.
Start slow and try to increase your training load—distance than speed—gradually over the next upcoming months.
Just do it in a slow and gradual manner.
Start with very short sessions and pay attention to your body the entire time.
I’d recommend the 10 percent rule as rough guidelines to follow.
Do not increase your weekly mileage by no more than 10 percent from one week to the next.
If, during any stage, you feel pain retuning, take a few days off and drop back to the previous pain-free level.
Don’t let your ego get in the way of your success.
You should also address your biomechanical challenges during this period.
Analyze your gait, assess your running shoes, etc.
Preferable to use a cushion, paddings, or elastic bandage inside your shoes.
Running After A Stress Fracture – Phantom Pains
Keep in mind that long into your return, you may still feel some lingering pain around the affected area—even after being cleared by your doctor.
This is what’s known as phantom pains.
Phantom pains are believed to the result of calcium build-up but can also be mentally triggered by fear of a relapse.
The pain often consists of minor twinges in the region where the stress fracture occurred.
Not blown-out pain, but more likely a discomfort in the area.
Phantoms pains are common and occur where the stress fracture was, especially when trying to increase distance or speed.
When you experience these phantom pains, you may start believing that the stress fracture is coming back and that it hasn’t fully healed.
In general, if the pains are irregular and vary in location and severity, more than likely, the pains are phantom pains you shouldn’t be fretting over them.
When it’s the case, just focus on your breathing, take one step at a time, and try not to read into every little sensation.
You don’t want to be paranoid.
Just don’t confuse it with chronic pain!
Chronic pain is a continuous pain with dull characteristics, and the same intensity usually occurs after the acute phase.
Preventing Stress Fractures In Runners
The best way to deal with stress fractures is to not get injured in the first place.
Although there’s no foolproof way to prevent stress fracture—and overuse injuries—in runners, there are many steps you can right away to reduce the risk and severity of such injuries.
Let’s look at a few.
Proper diet and nutrition is key to bone health.
I cannot emphasize this enough.
As well as meeting your calorie needs and eating healthy, you should also aim to get adequate calcium each day.
When you’re calcium deficient—either through the insufficient intake or improper absorption—your body will “burrow” calcium from your bones in order to maintain balance.
This robs your bones of strength and makes them prone to injury.
Don’t take my word for it.
A two-year study out of the Clinical Research lab at Hayes Hospital in New York reported that a high intake of calcium, skim milk, and dairy products helped reduce stress fractures in athletes.
As a rule, shoot for 1300 to 1600 mg of calcium.
Supplement using daily 500-mg carbonate calcium if you’re not getting enough amounts of calcium from your diet.
Calcium is only one nutrient among many.
Your body also needs vitamin D and a bunch of minerals such as zinc, iron, potassium, and others to maintain bone health.
Analyze Your Running Program
Coming down with a stress fracture makes you more prone to re-injury.
To prevent this from re-occurring, review your running habits, and make it a goal to not repeat the same injury-causing scenarios.
Check for any sweeping changes in training volume and/or intensity in the past few months that could have led to the onset of the condition.
Don’t hit the trails if you aren’t mentally and physically ready.
If you still feel unstable even to stand on your feet, run with moderation.
I’d also recommend that you consult with a sports physician to check for any strength imbalances, flexibility issues, or biomechanical problems that might require fixing.
By adding strength and power to the muscles, you’ll improve their shock absorption ability and prevent your muscles from getting tired too quickly.
This should also help ease the load on your bones.
That’s not the whole story.
Research also shows that regular strength training can help boost up your bone density—especially the type that comes with aging, along with a host of other health benefits.
Here are some of the strength exercises for protecting you against stress fractures.
- Calf Raises
- Step Lunges
- Toe Walks
- Toe Grabs
Invest in Proper Running Shoes
Looking for the best running shoes to prevent stress fractures and avoid injury?
Sorry, it’s not that simple.
Running shoes won’t cure all of your running injuries, but getting a proper pair is a step in the right direction.
Choosing the right running shoes can help provide your feet with enough support and comfort to actually lessen overuse while making the most out of your runs,especially for your arches and knees.
Test it first before you get it.
What’s not to like!
As a rule, run in shoes that match your running style.
Go to a specialty running store to get fitted with the right pair according to your foot arch, gait type, fitness goals, personal preference, and budget.
Don’t forget to replace your shoes every 400 to 600 miles to allow for proper mid-sole cushioning.
This, of course, depends on many various factors, including training volume, your current weight, shoe durability, etc.
Start Slow, Go Slow
As I pointed out to earlier, the main cause of stress fractures—and most overuse injuries—is doing too much too soon.
The key to increasing your training volume gradually and follow a well-structured, sensible, training plan.
As a rule of thumb, do not increase your training volume by more than 10 percent from one week to the next.
You should also warm-up and cool down for a few minutes before each workout.
I’d also recommend that you periodize your training plan.
This means to increase your training over three to four weeks, then followed by a week of relative rest in which you allow your body, especially your bones, to recover.
Most experts recommend taking a week completely off or drastically reduce volume, every fourth or fifth week of intense training.
I know it’s a long time to get back on track.
But consider this as the time to treat your body after hard times.
Better 100% than sorry.
Listen to Your Body
In the end, your body knows better.
The best way to avoid a stress fracture—and getting injured in general—is to simply pay attention to your body and re-adjust your training approach accordingly. Your body does a fantastic job of telling when something goes
Pay attention to your body, and do not ignore pain—it’s there for a reason.
Pain warns you that you are doing something wrong and might need to back off a bit and allow your body the ability to head itself properly.