The Runner’s Guide to Stress Fractures: How to Diagnose, Prevent and Recover from a Fracture

If there’s any injury that’s stops runners dead in their tracks, it’s the feared stress fracture.

Runners and Stress FracturesIn this article, you’ll learn:

  • What is a stress fracture?
  • How to know if you have a stress fracture
  • How to prevent this injury
  • How to recover from a stress fracture

Thankfully, this injury is rare compared with most running injuries.

But if you do experience a stress fracture, it can be frustrating. Unlike most other injuries, it requires a lengthy period of no running whatsoever. And you may need crutches or a “boot” to help the healing process.

Sounds like fun, right?

Most runners will never need to deal with a stress fracture. But for those who do, here are the best ways to prevent, treat, and get back to running after this type of bone injury.

What is a stress fracture?

A stress fracture is a small fracture in a bone. In runners, it typically happens in one of the legs. Wikipedia has a comprehensive definition:

A stress fracture, also known as a hairline fracture, is a fatigue-induced fracture of the bone caused by repeated stress over time.

Instead of resulting from a single severe impact, stress fractures are the result of accumulated trauma from repeated submaximal loading, such as running or jumping.

This injury is virtually unheard of in some sports like cycling, swimming, water polo, or diving because there are no impact forces.

But runners experience a tremendous amount of impact force with every step, Every foot strike loads your foot and leg with 2-5 times your body weight!

If you’re not ready for that, you could experience a stress fracture after many months of this repeated, accumulated stress causes your bones to become fatigued (they get tired, too).

There’s also an injury called a stress reaction which is not as severe. It’s essentially a low-grade stress fracture with a few differences:

  • The bone is not fractured yet (this is a good thing!)
  • There is increased bone-building activity at the reaction site

A stress reaction is the precursor to a stress fracture and if you catch it early, you’ll limit your recovery time and be able to get back to running sooner.

It’s important to note that if you have a stress fracture in your toe, that’s very different than a stress fracture in your femur. Small bones are more likely to break but if you experience a fracture in a large bone like the femur or pelvis, that could indicate some other underlying medical issue that should be addressed as soon as possible.

Thankfully, stress fractures in the large bones of the body are rare. Pay attention to the prevention measures below and you probably will never worry about a femoral fracture…

What causes stress fractures and how do you prevent them?

The main causes of stress fractures are poor training habits. If you’re training hard for a race, you could be more at risk of a fracture if…

  • weekly mileage increases too quickly
  • duration or intensity of faster workouts increases too quickly
  • there’s not enough muscular strength to support the training
  • recovery runs are too fast

Ultimately, it’s a case of doing “too much, too soon, too fast.” Bones take a lot longer to adapt to new stressors (like higher mileage) than muscles and connective tissues, so you need a longer time period to adjust.

Running is, after all, an impact sport. It’s you vs. the ground and it’s critical that your body adjust to the increasing demands of training.

Now that we know what causes fractures, we know how to prevent them.

Mileage increases (my mileage article on Competitor can help you with this) should always be conservative when you’re doing more than you have before. The same is true for the duration or intensity of your faster workouts.

Smart training must also include strength exercises and slow paces on recovery days to ensure you’re strong enough to withstand the stress of training and recovering properly.

This is exactly why one of the six pillars of injury prevention is patience in Injury Prevention for Runnerswhere I go into more detail about my “Patience Protocol” and how to know if you’re increasing too quickly or slowly.

Both injuries – stress fractures and reactions – tend to be more common in women experiencing amenorrhea due to heavy training or calorie restriction. Talk to your doctor to diagnose any other health issues that could be negatively impacting your running.

And remember, stop counting calories!

What does a stress fracture feel like?

Stress Fracture

A stress fracture feels like your bone is being squeezed by the dirty hand of Satan himself.

Kidding, of course, but it sure ain’t fun.

If you have a stress fracture, you’ll know something is very wrong. This injury presents with sharp, burning localized pain directly where the fracture is located. It may even be painful to touch.

But a stress reaction may feel different. There could be a burning or aching pain on the bone at the site of the injury. The surrounding muscle could even feel tight.

Pain from a fracture will get progressively worse as you run. And if you keep running, the pain may be present while walking or even sitting.

While an x-ray may be able to spot a big stress fracture, a bone scan or MRI is needed for most cases and certainly for stress reactions. Since there’s no fracture, a bone scan or MRI will show more bone-building at the site of the reaction.

If you suspect you have either bone injury, get to a doctor (an orthopedist is generally the best option) as soon as possible to properly diagnose the injury and get your definitive prognosis.

Stress fracture treatment

Once you have a firm diagnosis of “stress fracture”, it’s time to rest (after you stop sobbing – don’t worry, I’d cry too). The only thing you can do is rest – there’s not much else that will speed the healing process.

Depending on the severity of the fracture or stress reaction, the doctor will typically prescribe 6-12 weeks of rest. This means no running whatsoever.

It’s very important that runners listen to this advice. There’s literally a hairline fracture in the bone so any running is only going to make it worse. Do not try to run on a stress fracture.

If the fracture isn’t severe, the doctor may allow some non-impact cross-training like aqua-jogging which can help maintain fitness levels.

But other exercise can be risky even if there’s no impact, like:

  • Cycling
  • Strength training
  • Elliptical
  • Stair climber

Ask your doctor about whether it’s safe for you to enjoy these types of exercise during the recovery period. They’ll make your return to running a lot easier if they’re allowed.

Post-Injury Evaluation

During your recovery, it’s helpful to evaluate your prior training to determine what can be improved. Ask yourself:

Did my mileage jump up too quickly?

Did I run more frequent fast workouts than I was used to?

Or did I run my workouts at too fast a pace?

Is my cadence (steps per minute) over 170?

Am I getting a regular period?

Am I eating enough and getting enough high-quality nutrients (especially calcium and Vitamin D)?

Have I been doing regular strength workouts?

This is the least fun part of recovery: identifying your training mistakes so you can prevent stress fractures in the future. But it can be really valuable, just like a running “annual review.”

As you (slowly) begin running again, figuring out what aspects of your running can be improved will help you be more consistent (the “secret sauce” of successful running) long-term by staying healthy.

While most stress fractures are caused by the “3 Too’s” of poor training progression, diet plays a role as well.

Our free nutrition e-course has more detail on smart, easy recipes for runners.

Once you’re running again, it’s important to increase your mileage very gradually (the “10% Rule” is too aggressive in this scenario) and avoid faster workouts for at least a month.

You may also find it beneficial to run on softer surfaces like grass. Now could be a good time to also start trail running!

The reason is not necessarily the softer surface, but rather the irregular surface. Your foot lands and responds to the terrain in slightly different ways with each foot strike, which varies the stress your legs experience.

Once you dial in your training, pacing, and diet, most runners shouldn’t worry about stress fractures.

What other questions do you have about stress fractures? Leave it below and I’ll try to respond to every question!

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Comments

  1. Hi, and thanks for useful article..
    Re this: “it’s important to increase your mileage very gradually (the “10% Rule” is too aggressive in this scenario)”
    .. have you got any suggestions of exactly how slowly you need to build mileage back up? Like what’s a typical build-up schedule?

    I’m coming back from femoral neck SF (3.5 months ago), I’ve literally JUST been allowed to start doing 5 mins (at slower than normal pace) on treadmill every other day, while continuing with lots of strength work and all my other cardio (spinning, swimming etc) of course, but wondering how long its likely to be before I am back at my normal mileage levels (c. 30/week). Next marathon is December..

    Thanks 🙂

    • First I’d check out the mileage article I wrote for Competitor. I linked to it earlier in the article. That will give you good ideas for building up mileage in different ways than simply adding time/distance every week.

      Right after a stress fracture, here’s what I would do:

      1. Add 3-5 minutes of running to 1-2 runs per week for 4 weeks. After this period you can be more aggressive.
      2. All runs should be on soft surfaces at a VERY easy, comfortable pace.
      3. During this 4-week period, run 1-2 days less per week than you usually do.

      Good luck Cat!

  2. Mary Jane says:

    Hello Jason, this article is very useful to me as I think I’m suffering from a stress reaction or knock on wood, a stress fracture but I haven’t visited any doctor yet. I just google and self-diagnose my symptoms for now.
    3 weeks ago, just a week before my big marathon, I went on a brick training involving 10K bike-10K run-10K bike with the 10K involving mostly speedwork.
    On the mid part of my run, I suddenly felt this sharp pain on my shins that made me slow down and eventually decided to just take it easy.
    The next day, I was hobbling and unable to walk normally. My left leg was very painful that running seemed impossible.
    The pain lingered the following day, lessening a bit but still unable to run as I used to.
    I was able to do hill repeats on a bike instead. It was just running that made it unbearable.
    I tried the hop test as I read on the Internet and yes, I failed that one. It hurts to hop on the affected leg. I only noticed that one spot where I usually felt pain.
    And there was a small bruise outside.
    With only a week left for my big race, I decided to just sit back at home and rest.
    I put on a compression sleeve on the affected part and limit my movements by just walking around at home.
    That week was dreadful as I spent most of the time praying and contemplating whether to run my marathon or not as I really trained hard for it.
    You can say I was almost in the stage of depression.
    Two days before the big race, the pain on my shin noticeably lessened.
    I could hop without feeling pain (just a slight, dull discomfort on the affected shin) and my walk normalized and I felt better. I tried running a hundred meters just to test my legs and it felt fresh but then, that nagging fear at the back of my head still haunted me.
    The morning of the race came.
    I decided NOT to run the marathon and opted to sign up for the 10K instead to pace a good friend of mine on his 1st 10K race.
    The race felt good. My legs felt fresh and amazingly, 2 days after and I felt no sharp pains or whatsoever. It’s been 3 days after my 10K race and I feel no sharp pain at all BUT I can still feel this dull pain on my shins, on that very spot and a slight discomfort on my leg.
    I haven’t ran yet after that 10K and I finally decided to go off season and rest for the entire August.
    I tried doing core workout yesterday with a little bit of weight lifting and I must admit, there was a little pain and discomfort on that site again.
    Do you think this is a stress fracture or a bad case of shin splints?
    I’m planning on doing my cardio through biking instead and I just can’t stay this way at home doing no activity at all.
    By the way, my period’s irregular but I’ve been constantly taking Calcium supplements and drinking milk.
    So what’s my next step? This is just so frustrating to me as I’m not used to being inactive like this.
    Help! 🙁

    • I honestly don’t know. You can’t diagnose a stress fracture from symptoms – you could possibly have a stress reaction or just shin splints. You really need an MRI or bone scan. Good luck Mary Jane.

  3. Hello Jason, I love the work you do on all of your articles. The reason why I’m commenting today is because I have a few questions about a recovering stress fracture. I’m a 21 year old college Cross Country & Track athlete with aspirations to reach my high goals. In December I was diagnosed with a stress fracture on my left tibia and unfortunately had to miss all of my sophomore indoor & outdoor track season. After about 3 months in a boot I was able to start walk/jogging/elliptical for about a month. Now I’m back to full time running even though my mileage is still low roughly about 30-35 mi. per week is a huge difference compared to my 60-65 mi per week last summer. I’m worried I may come back down with another stress fracture. I do not feel pain during my runs, but after running I feel a bit of tenderness on top of my left tibia which is my stress fracture leg. The tenderness is one sided so only my left leg feels it. I have switched to trail running for the past 3 weeks and it has helped me stay consistent with my training. When I run on pavement the pain is more noticeable the next day, but still during my run there is no pain at all. I remember last winter the pain was so bad I almost had to stop during my runs, but thank the lord that isn’t the case now. I’m on top of nutrition and do strength training 2x per week. This is my first time recovering from a stress fracture and wanted to know if the tenderness is a regular occurrence or if it’s something I should be worried about. I would like to hear your thoughts on this.

    – Thank You
    BA

    • It could just be shin splints, but I can’t say for certain. Considering your past stress fracture, if it were me I’d get another bone scan/MRI just to confirm there’s no stress fracture/reaction.

  4. Thank you for that Jason.
    Another question. Any exercises you can recommend for us recovering from stress fracture? I’m really bummed out not moving around.
    What kind of core exercises can i do? I understand I cannot do any strengthening exercises that require weights on the affected foot. Thanks!

    Mary Jane

    • A stress fracture is more of a medical issue than a running injury. You have to check with your doctor because any advice depends on your specific stress fracture. Good luck MJ

  5. My question about stress factures is: is it possible to get a stress fracture on the bottom outer part of your foot. My foot strike is on the outer half of both feet. After about 8 miles at tempo speed I feel the discomfort on my feet. It tends to dull as I run 12 – 14 miles. I have never had a problem with feet. I have not increased my distances, actually I have cut back a few miles. I do not know what is causing the pain. No pain when walking or just run 6 miles, it seems to begin at 8-9 miles, very strange, I am just looking for cause so I can correct.

    • Sure, it’s definitely possible to get a stress fracture there, but since you can run on it sometimes with no pain my hunch is that it’s not a fracture. If it continues I’d check with your doctor though! I do not play MD on the web 🙂