What is a stress fracture?

Bones are living tissues that continually remodel in response to the loads placed upon them.

When you exercise, small amounts of bone damage occur naturally. Normally, the body repairs this damage and the bone adapts to become better able to tolerate the activity.

A stress fracture can develop when the rate of bone damage exceeds the body's ability to repair it.

This can happen following:

• A sudden increase in running

• Increased training intensity

• More hill running

• Increased jumping

• A change in training surface

• Returning to exercise after a period of inactivity

• Increased walking or standing

• Inadequate recovery

Stress injuries exist on a spectrum, from an early bone stress reaction through to a more established stress fracture.

Stress Fracture vs Stress Reaction

A bone stress injury can develop progressively.

Early bone stress may cause pain without a clear fracture line. This is sometimes described as a stress reaction.

If repetitive loading continues without adequate recovery, the injury can progress and eventually develop into a stress fracture.

Recognising symptoms early is therefore important.

Continuing to train through progressively worsening bone pain can increase the risk of the injury becoming more significant.

Where Do Stress Fractures Occur?

Stress fractures can occur in many bones, but common locations include:

Shin

Stress injuries of the tibia are common in runners.

Pain is usually felt in a specific area of the shin rather than diffusely throughout the lower leg.

Foot

Stress fractures can occur in several bones of the foot, including the metatarsals.

They may cause pain during walking or running and can sometimes be associated with swelling.

Ankle

Stress injuries can affect bones around the ankle, including the tibia and fibula.

Hip and pelvis

Stress fractures of the femoral neck and pelvis are less common but potentially more serious.

Persistent hip or groin pain in a runner should not automatically be assumed to be a muscle injury.

What Causes Stress Fractures?

Stress fractures usually develop when repetitive loading increases faster than the bone can adapt.

Common triggers include:

• Increasing weekly running mileage

• Suddenly introducing longer runs

• Increasing running speed

• Adding hill sessions

• Increasing jumping or plyometric training

• Changing training surfaces

• Returning to running after time away

• Increasing training frequency

• Rapid increases in walking or physical activity

Other factors can also affect bone health and recovery, including inadequate nutrition, low energy availability, previous stress fractures and reduced bone density.

Symptoms of a Stress Fracture

Symptoms vary depending on the location and severity of the injury.

Common symptoms include:

• Localised pain during exercise

• Pain that becomes progressively worse with activity

• Pain in a very specific area of bone

• Pain that initially settles with rest

• Pain that eventually occurs during normal walking

• Tenderness when pressing over the affected bone

• Swelling in some cases

• Pain that returns when activity is increased

A particularly important feature is localised bony tenderness.

Unlike some muscle injuries, stress fracture pain is often very specific to one area.

Can You Run With a Stress Fracture?

If a stress fracture is suspected or diagnosed, you should not simply continue running through the pain.

Continuing to repeatedly load the affected bone can delay healing and potentially allow a stress injury to progress.

The appropriate level of weight-bearing and activity depends on the location and severity of the injury.

Your doctor, sports medicine specialist or physiotherapist can help determine what activity is currently appropriate.

How Are Stress Fractures Diagnosed?

Diagnosis involves consideration of your symptoms, activity history and physical examination.

X-ray

X-rays are often used initially but can be normal during the early stages of a stress fracture.

A normal X-ray therefore does not necessarily rule out a stress fracture.

MRI

MRI is often the most useful imaging investigation when a stress fracture or bone stress injury is suspected.

It can identify bone marrow changes associated with bone stress before changes become visible on an X-ray.

Bone scan

Bone scans can also identify areas of increased bone activity, although MRI is often preferred when available.

Stress Fracture Treatment

Treatment depends on the location and severity of the stress fracture.

The primary principle is to reduce the load on the affected bone sufficiently to allow healing.

This may involve:

• Temporarily stopping running

• Reducing weight-bearing

• Using a walking boot

• Using crutches

• Cross-training with appropriate low-impact exercise

• Gradually returning to weight-bearing

• Progressive strengthening

• A structured return-to-running programme

The rehabilitation approach should be individualised according to the affected bone and medical guidance.

High-Risk and Low-Risk Stress Fractures

Not all stress fractures have the same risk profile.

Some stress fractures have a relatively good prognosis with appropriate load management.

Others occur in locations where there is a greater risk of delayed healing, displacement or complications.

Examples of potentially higher-risk locations include:

• Femoral neck

• Anterior tibia

• Navicular

• Certain areas of the fifth metatarsal

These injuries may require more cautious management and specialist orthopaedic or sports medicine input.

If a high-risk stress fracture is suspected, it is important to obtain appropriate medical assessment before returning to exercise.

Rehabilitation Following a Stress Fracture

Rehabilitation should not simply begin when pain disappears.

The aim is to gradually rebuild the capacity required for your normal activities.

Maintaining fitness

Depending on the location and severity of the injury, alternative forms of exercise may be possible during recovery.

These might include:

• Swimming

• Pool running

• Cycling

• Upper-body conditioning

However, the appropriate activity depends on the specific fracture. Exercises that continue to load the affected bone should be avoided if they aggravate the injury.

Strength training

A period of reduced activity can lead to significant loss of strength.

Once medically appropriate, rehabilitation may include:

• Calf strengthening

• Quadriceps strengthening

• Hamstring strengthening

• Glute strengthening

• Single-leg exercises

• Functional strength exercises

Strength should be progressively rebuilt before high-impact activity is reintroduced.

Return to Running After a Stress Fracture

Returning to running too quickly is one of the main concerns following a stress fracture.

Before returning to running, you should generally have:

• Minimal or no pain with normal daily activities

• Appropriate strength

• Good single-leg control

• Tolerance to weight-bearing

• Appropriate functional capacity

• Medical clearance where indicated

Running should then be introduced gradually.

A typical progression may involve:

Walking → brisk walking → walk/jog → continuous easy running → increased duration → increased mileage → hills → faster running

The exact progression depends on the location and severity of the stress fracture.

How Long Does a Stress Fracture Take to Heal?

Recovery varies substantially.

Some stress fractures heal within several weeks, while others require several months before full return to running or sport.

Factors that influence recovery include:

• Location of the fracture

• Severity of the bone stress injury

• Whether the fracture is high or low risk

• How early it was identified

• Weight-bearing requirements

• Overall bone health

• Nutrition

• Training load

• Previous stress fractures

Importantly, pain disappearing does not necessarily mean the bone is immediately ready for high-impact activity.

Why Do Stress Fractures Happen?

A stress fracture is rarely caused by one factor alone.

Training load is often an important contributor, but other factors can influence the ability of bone to adapt.

These may include:

• Rapid changes in training

• Inadequate recovery

• Poor sleep

• Insufficient energy intake

• Low calcium or vitamin D intake

• Low energy availability

• Previous stress fracture

• Reduced bone density

• Menstrual or hormonal factors

• Certain medications or medical conditions

If you have experienced a stress fracture, particularly more than once, it may be appropriate to investigate why your bone is struggling to tolerate your current level of loading.

Preventing Stress Fractures

There is no guaranteed way to prevent stress fractures, but several strategies can reduce risk.

Gradually increase training

Avoid large sudden increases in running distance, intensity or frequency.

Include recovery

Bone needs time to adapt to training loads.

Rest days and easier training sessions can help manage overall load.

Maintain strength

Resistance training can help improve the capacity of the muscles and bones to tolerate loading.

Fuel appropriately

Adequate energy and nutritional intake are important for maintaining healthy bone and supporting recovery.

Progress high-impact activity gradually

If returning to running after a period away, gradually increase impact exposure rather than immediately returning to your previous mileage.

Stress Fracture Physiotherapy

Physiotherapy can be useful during and after recovery from a stress fracture.

Your physiotherapist can help with:

• Managing activity levels

• Maintaining fitness

• Restoring strength

• Identifying training errors

• Addressing contributing factors

• Planning your return to running

• Progressing impact loading

• Reducing the risk of future injury

Physiotherapy does not replace medical assessment when a stress fracture is suspected.

When Should I See a Physiotherapist?

Consider an assessment if you have:

• Persistent localised pain during running

• Pain that is becoming progressively worse

• Pain that returns every time you increase activity

• Localised tenderness over a bone

• Pain that is beginning to occur during walking

• A history of stress fractures

• Difficulty returning to running following a stress fracture

If a stress fracture is suspected, you may require medical assessment and imaging before beginning a normal exercise programme.

Frequently Asked Questions

Can a stress fracture heal on its own?

Many stress fractures can heal with appropriate load modification and time.

However, the management required depends on the location and severity of the injury. Some stress fractures require specialist assessment or more significant restrictions on weight-bearing.

Should I stop running if I think I have a stress fracture?

If you have localised bone pain that is worsening with running and you suspect a stress fracture, it is sensible to stop the aggravating activity and seek appropriate assessment.

Continuing to repeatedly load the bone could allow the injury to progress.

Can I cycle with a stress fracture?

It depends on the location and severity of the stress fracture.

Cycling may be suitable for some injuries but inappropriate for others. Your medical or physiotherapy team can advise whether cycling is safe for your specific injury.

Does a stress fracture show on an X-ray?

Not necessarily.

Early stress fractures can have a normal X-ray. MRI is often more sensitive for identifying bone stress injuries during the early stages.

How do I know if shin pain is a stress fracture?

Stress fracture pain is often localised to a specific area of the bone and becomes worse with impact.

However, other conditions such as medial tibial stress syndrome can cause similar symptoms.

If pain is persistent, localised or progressively worsening, it should be assessed.

How long should I wait before running after a stress fracture?

There is no universal timeframe.

Return to running depends on the location and severity of the injury and whether you have regained sufficient pain-free weight-bearing capacity and strength.

Can you get another stress fracture?

Yes.

A previous stress fracture increases the risk of another, particularly if the underlying training, nutritional or bone-health factors have not been addressed.

Why do I keep getting stress fractures?

Recurrent stress fractures may be associated with rapid changes in training, inadequate recovery, low energy availability, nutritional deficiencies, reduced bone density or other health factors.

If you have recurrent stress fractures, further medical assessment may be appropriate.

What exercises can I do with a stress fracture?

This depends on the location and severity of the injury.

During the early stages, exercises that load the affected bone may need to be avoided. As healing progresses, strengthening can gradually be introduced.

Do I need an MRI for a suspected stress fracture?

Not every case requires an MRI, but it is often considered when clinical suspicion is high and an X-ray is normal or inconclusive.

Your doctor or sports medicine clinician can determine whether imaging is appropriate.

Stress Fracture Physiotherapy in Newcastle

At NE Physio, we provide rehabilitation for people recovering from stress fractures and help runners and athletes safely return to activity.

We can help you understand how your training load, strength and recovery may have contributed to the injury and develop a progressive programme to rebuild your capacity.

Whether your goal is to return to running, get back to sport or safely increase your activity, rehabilitation will be tailored to your individual requirements.

Book Your Assessment

If you are recovering from a stress fracture or experiencing persistent bone-related pain, book an assessment with NE Physio in Newcastle.