Out of all running injuries, nothing strikes more fear into a runner’s heart than stress fractures. They’re a painful, nagging condition that requires long weeks, even months, of recovery.
What’s more?
This notorious injury is common among runners, especially those that run long distances and/or push themselves more than they should.
So would you like to learn more about how to manage stress injuries in runners? Then you’ve come to the right place.
In this post, I’ll provide a full overview of stress fractures in runners. By the end, you’ll learn the following:
- What is a stress fracture?
- The causes of stress fractures in runners
- The most stress fracture-prone areas in runners
- The main symptoms to look for
- 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
- 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.
The typical stress fracture onsets as a stress reaction, which manifests as swelling around the bone.
Then, in case it progresses, it can develop a small crack. If this injury reaches this stage, you’ll likely have to rest the injured limb for a few weeks—even months—to let your body heal.
Surveys show that stress fractures may account for 20 percent of all running injuries.
Athletes who participate in high-impact sports like basketball, football, and 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 to genetic disorders or nutritional and hormonal imbalances.
Stress Fractures Vs. Bone Breaks
This may surprise you, but a fractured bone and a broken one aren’t technically the same.
As I explained earlier, a stress fracture 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.
The other characteristic is your bone stays still in the same place. You won’t even notice anything except the ongoing pain or bruising.
On the other hand, the typical bone break happens when an outside force is applied suddenly to a bone. The key here is the discontinuation of bone structure.
Falls, car accidents, and sports contacts like football can often cause bone breaks.
Common Stress Fractures In Runners
A stress fracture can strike any bone, but the weight-bearing bones are most prone in runners.
Let me explain.
The lower leg in the shin bone (the tibia) is the most affected area.
Survey shows that about half of all stress fractures occur 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 as 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 is 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, which aren’t 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, 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 of eating disorders, bone density issues, and menstrual dysfunction.
- Running technique. Overstriding may sometimes contribute to tibial stress fracture as it stresses the main weight-bearing bones more.
- Inadequate nutrition. For example, insufficient vitamin D intake can put you at risk, according to research from 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 in any other season of the year due to a deficiency in Vitamin D.
- Foot Abnormalities. According to research, runners with anatomical foot abnormalities, such as fallen arches, are more prone to stress fractures than those with a neutral arch.
- Muscle tightness. Research from the Journal of Orthopedic and Sports Physical Therapy reported that tight calves 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.
Pain worsens the more miles you log in. 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 is mild.
Devoid of rest, the pain gradually worsens—to the point where it limits your range of motion and alters your running gait.
How Are Stress Fractures Diagnosed
Sometimes, your doctor can diagnose a stress fracture from a medical history and physical checkup, but imaging tests are often required to confirm the condition.
Since stress fractures are thin, X-rays usually cannot spot them, especially shortly after the onset of pain. The doctor may recommend an MRI or CT scan in addition to the physical checkup.
Can you Run With a Stress Fracture?
Though you might feel tempted to run on a stress fracture, it’s never a good idea. Running through a stress fracture does nothing but delay healing and will likely cause a compensatory injury for changing your running gait.
From my experience and the stories I’ve heard, I wouldn’t risk it.
It’s the dumbest thing you can do as a runner.
Running through the tibia, fibula, or fracture requires a more serious injury. It’s also painful since these are the major weight-bearing bones that withstand a lot of the stresses of running.
What’s the next plan?
Depends.
If it’s an incomplete fracture with no misalignment, bandage, and casting might help. But if it’s a complete fracture with multiple breakages, a knife and fixation are the only solution.
Next? Six months rest.
As a rule of thumb, avoid running through a stress fracture.
What Should I Do If I Do Have A Stress Fracture?
If you suspect a stress fracture, stop training altogether and do what you must to speed up recovery.
Next, visit a physician—preferably a podiatrist or an orthopedist—to have it diagnosed.
Let me break down what you need to do.
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.
You’re good to go if you avoid high-impact weight-bearing exercises like running, rope jumping, and plyometrics.
Keep it as long as you feel comfortable before adding the intensity.
Reassess every month.
Cold Therapy
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.
Compress it
Compress the injured limb by lightly wrapping it in a soft elastic bandage to reduce swelling.
Elevate it
Keep your injured limb raised higher than your chest level.
Using a hanging traction device can help.
Severe Cases
What should you do if home treatments don’t improve your symptoms?
Simple.
Consult a doctor or podiatrist.
They will help you determine your injury’s exact location and severity and what to do next to bounce back and speed up your recovery.
Left untreated, stress fractures can result in the bone breaking completely.
Further Tests
First of all, expect to be X-rayed.
But you may need to do more.
Often, traditional X-rays may look 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 recommend you consult a sports-oriented physician for a thorough bone scan.
They’ll typically recommend a nuclear bone scan, an MRI, or other advanced imaging 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 until you’re past the acute phase.
Sometimes, your doctor may need to put a fracture boot on the injured limb to keep the bones fixed.
This helps eliminate the stress on the leg and speed up recovery.
Expect Surgery As The Worst-Case Scenario
In extreme stress fractures, surgical intervention is needed to patch up the damage, especially when the fracture line has extended completely across the bone, or you have low bone density.
This is done by inserting a type of fastening, known as internal fixation, to support the bones of the injured area. External fixation might be one of the treatment choices for osteoporotic patients.
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 that most stress fractures will heal after time and rest.
Some people can recover well, starting from 28 days, but most take six weeks to six months or even longer.
That’s a wide range.
And reason stress fractures are categorized into two main groups: “low risk” and “high risk.”
A stress fracture within the low-risk category often heals independently and may not call for aggressive treatment measures such as long rest time or crutches. This category includes fibular and tibial stress fractures as well as metatarsal stress fractures.
On the other hand, a high-risk stress fracture often occurs in areas notorious for healing poorly. Examples include stress fractures of the pelvis, navicular, and femur. If you develop fractures in any of these bones, you’ll need drastically longer times away from running and a proactive approach to resuming running again.
The only good news is that these high-risk fractures are less common in runners than in the low-risk types.
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 doing plenty of low-impact exercises, such as yoga and the sort.
Expect to spend two to four weeks at this stage—even much longer for serious cases of the condition.
If you feel pain, that’s a sign that the activity level 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 return to training.
I cannot emphasize this enough, but you should consult your doctor again. And this is the case even in the absence of pain.
The visit should help you confirm whether or not the stress fracture has fully healed.
Once you get the green light from your doctor, resume training.
Start slow and gradually increase your training load—distance than speed—over the next months.
Begin 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 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, padding, or elastic bandage inside your shoes.
Running After A Stress Fracture – Phantom Pains
Here’s the truth: you may still feel lingering pain around the affected area—even after getting the green light from your doctor.
This is what’s known as phantom pains.
Phantom pains are believed to result from calcium build-up but can also be mentally triggered by fear of a relapse. They occur where the stress fracture was, especially when trying to increase distance or speed.
The pain often consists of minor spasms in the region where the stress fracture occurred. Not blown-out pain, but more likely a discomfort in the area.
When you experience these phantom pains, you may believe the stress fracture is returning and 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’re likely okay.
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. Don’t be paranoid. And 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.
Although there’s no foolproof way to prevent stress fracture—and overuse injuries—in runners, there are many steps you can take right away to reduce injury risk.
Let’s look at a few.
Eat Well To Avoid Stress Fractures
Proper nutrition is key to bone health.
I cannot emphasize this enough.
As well as meeting your calorie needs, you should also aim to get adequate calcium daily.
When you’re calcium deficient—either through insufficient intake or improper absorption—your body will “burrow” calcium from your bones to maintain balance.
This robs your bones of strength, making 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 calcium from your diet.
Calcium is only one nutrient among many. Your body also needs vitamin D and minerals such as zinc, iron, potassium, and others to maintain bone health.
Up Your Vitamin D
Vitamin D is another key nutrient for healthier bones.
As a runner, you’re likely getting enough of it since you’re spending extended time outdoors in the sun. But it might not be the case during the winter when most days are cloudy.
Before turning to supplements, try adding the following vitamin D-rich foods to your daily menu:
- Whole milk
- Trout
- Halibut
- Yogurt
- Salmon
- Fish oil
- Mushrooms
- Fortified cereals
Want to make sure you’re doing right? Then have your Vitamin D levels analyzed, then consult a physician or registered dietician for advice on how to get enough.
Follow A Good Running Plan
Choosing a properly structured running plan is key.
As I’ve already explained, stress fractures are usually caused by running too many miles without enough recovery. This submaximal load causes, sooner or later, a crack in the bone.
For this reason, make sure to follow a well-rounded schedule.
To prevent overuse injuries, a good running plan should employ periodization. This means increasing the training load over three to four weeks, followed by a week of relative recovery to allow the bones to recover.
To make the most out of a running plan, consult a running coach to help you design a more personalized running plan that works the best for your running goals, lifestyle, and experience.
You can also contact me at david@runnersbluprint.com for help.
Analyze Your Running Program
Developing a stress fracture makes you more prone to re-injury.
To prevent this, review your running habits and avoid repeating the same injury-causing scenarios.
Check for sweeping training volume and/or intensity changes in the past few months that could have led to the condition’s onset.
If you still feel unstable even to stand on your feet, run with moderation.
What’s more?
Consult a sports physician to check for any strength imbalances, flexibility issues, or biomechanical problems that might require fixing.
Strength Train
Strengthening your muscles improves their shock absorption ability and prevents 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 your bone density—especially the type that comes with aging, along with many 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 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 lessen overuse while making the most 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. This is a wide range since it depends on various factors, including training volume, weight, shoe durability, etc.
Start Slow, Go Slow
As I pointed out earlier, the main cause of stress fractures—and most overuse injuries—is doing too much too soon.
The key is gradually increasing your training volume and following a well-structured, sensible training plan.
As a rule, 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 increasing your training over three to four weeks, followed by a week of relative rest, allowing your body, especially your bones, to recover.
Most experts recommend taking a week completely off or drastically reducing 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 properly.
Stress Fractures in Runners – The Conclusion
There you have it!
If you’re serious about learning to better manage stress fractures from running, then today’s post should get you started on the right foot.
The rest is just details.
Please feel free to leave your comments and questions in the section below.
In the meantime, thank you for dropping by.
