Stress Fractures

Stress fractures usually occur in major weight bearing bones such as those of the foot or leg. Repetitive stress weakens the bone and begins to break it down. Many researchers think that this overuse injury starts out as a microscopic fracture. As such, it is difficult to diagnose right away because the injury does not immediately show up on X-ray. Stress fractures typically result from one or more of the following:

  • Hypermobile, pronated (flat) feet or high arched feet.
  • Initiating a new activity too vigorously.
  • An increase in training intensity.
  • A change in activity surfaces.
  • A return from a previous injury too quickly.
  • An abrupt change of footwear.

Signs and Symptoms

  • Pain is usually more prominent at the end of the activity rather than during the activity.
  • Diagnosis is often difficult, and is usually based on history and physical examination (that may or may not include a bone scan).
  • There is usually specific point tenderness and pain focused directly over the site of the injury when palpating from both sides of tibia.
  • Bone percussion (gentle tapping directly over affected bone to elicit pain) can distinguish it from soft tissue injury.

On-Site Management

P.R.I.C.E. PROTECT the area by addressing equipment (i.e. shoes) and technique of activity (biomechanics of running). REST does not imply halting all activity, and the injured athlete can be running in deep water, light cycling, etc. to maintain and/or increase fitness. ICE the area to reduce inflammationl. COMPRESSION is NOT recommended. ELEVATE the area after a long workout to increase circulation to the heart.

Refer for a Correct Diagnosis. It is important, as with all overuse injuries, that a correct diagnosis be determined before the cycle of pain becomes established. A sports medicine practitioner will take a history of the injury, conduct a physical examination of the injured area, and undertake a biomechanical assessment of the athlete's lower extremity (looking for anatomical abnormalities). If warranted, selected diagnostic tests may be ordered such as X-rays, bone scans, etc.


Promote Healing. Invariably with overuse injuries, when the athlete's pain is relieved, s/he prematurely returns to activity and is re-injured. It is important, not to attempt to "run through" the pain or place continual pressure on a stress fracture, as a complete fracture of the weakened bone may result. Caution against weight bearing during severe pain. Healing occurs with rest and a combination of progressive site-specific strength and conditioning exercises and overall body conditioning. Cross train with low-impact exercises, including swimming, cycling, deep-water running, and elliptical to maintain conditioning.

Control Abuse. The potential for tissue overload must be adequately controlled prior to returning the athlete to activity. Some effective methods for tibial stress include: supportive footwear, improving running technique, addressing training errors (frequency, intensity, duration), and paying attention to playing or training surfaces.

Return to Activity. Return to activity is often mishandled. There can often be an endless cycle of rest-run-pain-rest-run-pain. A very gradual return to running must be adhered to once stretching and strengthening exercises have been undertaken. The athlete should not return until pain-free for 2 weeks and receives a doctor's OK.


  • Adequate warm-up, including stretching before activity.
  • Pre-season strengthening and stretching.
  • Appropriate corrective footwear for pronation if it is a lower leg stress fracture.

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