A stress fracture is a small crack in a bone caused by repetitive stress or force. It commonly occurs in the weight bearing bones of the lower leg and foot in athletes who participate in running sports like track and field, soccer, and basketball. Rest is the most important part of treating a stress fracture to allow the bone to heal.
What is a stress fracture?
A stress fracture is a tiny crack in a bone that occurs due to repeated stress or force. It typically develops in the weight bearing bones of the lower body like the femur, tibia, metatarsals, and navicular.
Stress fractures are commonly seen in runners, gymnasts, dancers, and other athletes who participate in high impact activities that place repeated stress on the bones of the legs and feet. They can also occur in non-athletes who have underlying conditions that weaken the bones like osteoporosis.
When stress is continually placed on a bone, it can cause tiny cracks or fractures to form. If the stress continues, the cracks will gradually deepen until a complete fracture occurs. That’s why it’s crucial to treat stress fractures early before they progress to a more serious break.
Signs and symptoms
The most common symptoms of a stress fracture include:
– Localized pain that increases with activity and decreases with rest
– Swelling around the affected bone
– Tenderness to touch directly over the fracture site
– Pain that develops gradually over time, sometimes described as an aching or soreness
In more severe cases, complete fractures may cause sudden onset of sharp, severe pain along with swelling and bruising around the fracture.
Causes
There are several factors that can increase an athlete’s risk of developing a stress fracture:
– High intensity training – Dramatically increasing mileage, intensity, or frequency of workouts
– Improper footwear – Worn out or ill-fitting shoes that don’t provide enough cushion and support
– Muscle inflexibility or imbalance
– Poor running form and biomechanics
– Hard or uneven training surfaces like concrete
– Nutritional deficiencies – Low calcium or vitamin D levels weaken bones
– Underlying medical conditions – Such as metabolic bone disease or eating disorders
Diagnosis
If a stress fracture is suspected, the doctor will perform a physical exam to pinpoint the site of pain and look for any swelling or tenderness. They may order imaging tests such as:
– X-ray – Can detect fractures 2-3 weeks after onset of pain
– Bone scan – More sensitive than x-ray in finding early bone damage
– CT scan – Provides detailed images of bone
– MRI – Most accurate for viewing early stress fractures
How long does it take a stress fracture to heal?
The length of time it takes a stress fracture to heal can vary greatly depending on the severity, location, and how early it is treated. Here is a general timeline:
– Grade 1 (mild) – Healing takes 2-4 weeks
– Grade 2 (moderate) – Healing takes 4-8 weeks
– Grade 3 (more severe) – Healing can take 3 months or longer
Other factors that affect healing time include which bone is involved and if the person follows the recommended treatment plan.
For example, stress fractures of the tarsal bones in the foot often take longer to heal compared to fractures of the tibia in the leg. And failure to stop the offending activity and rest can prolong the healing process.
Early stages – 1-2 weeks
In the early stages when pain and symptoms first begin, immediate and complete rest from the aggravating activity is critical. This could mean using crutches to avoid placing weight on the leg or refraining from all impact exercise.
The goal is to modify activity to reduce repetitive stress on the injured bone and prevent the fracture from worsening. RICE (rest, ice, compression, elevation) can also help alleviate pain and inflammation.
Proliferative phase – 2-6 weeks
After 2-3 weeks, a callus starts to form around the stress fracture as the bone begins to repair itself. Some new bone formation occurs.
The athlete can gradually return to exercise as long as it doesn’t cause pain at the fracture. Low impact, non-weight bearing activities like swimming, upper body lifting, or cycling are encouraged.
Remodeling phase – 6-12 weeks
From 6-12 weeks, the bone continues to remodel and rebuild around the fracture site. Impact activities like running or jumping can slowly be incorporated if they don’t cause any discomfort.
By the end of the remodeling phase around 12 weeks, the bone should be mostly healed and able to withstand high intensity forces again.
Return to activity phase – 3-6 months
Once the fracture has fully healed, the athlete can gradually transition back to their sport over the course of 3-6 months. This helps adapt the bone to the stresses and prevent re-injury.
Activities are progressed slowly from walking to jogging to running. Sport-specific drills and skills can be incorporated. The timeline for return to competition depends on the severity of the original fracture.
How long should you rest for specific stress fracture locations?
The recommended rest period can range significantly depending on the location of the stress fracture.
Tibia and fibula
– Non-displaced fracture: 6-8 weeks rest
– Displaced fracture: 8-12 weeks rest
Metatarsals
– 1st or 5th metatarsal: 4-6 weeks rest
– 2nd, 3rd, or 4th metatarsal: 6-8 weeks rest
Calcaneus
– Non-displaced: 6-8 weeks rest
– Displaced: 12+ weeks rest, may require surgery
Navicular
– Mild fracture: 6 weeks rest
– Moderate fracture: 3 months rest
– Severe fracture: 6+ months rest, may require surgery
Sesamoids
– 3-6 weeks rest while wearing rigid-sole shoe
Femur
– Mild stress reaction: 4 weeks rest
– Stress fracture: 3 months rest
The more delicate bones of the feet like the navicular and sesamoids typically require longer non-weight bearing rest. Fractures that are displaced also lengthen the healing timeline.
Treatment
The primary treatments for a stress fracture are rest, activity modification, and bone stimulation:
Rest
The most critical part of treatment is reducing or stopping the repetitive impact activity that caused the stress fracture. This resting period allows the bone tissue to regenerate and heal.
Depending on the location, a period of non-weight bearing rest may be required (no walking). Crutches, walking boot, or wheelchair will be used to avoid standing or putting weight on the leg.
Activity modification
Low impact cross-training activities will be incorporated to maintain fitness without overly stressing the healing bone. This includes swimming, upper body strength training, and bicycling.
The athlete can gradually return to higher impact exercise over time as symptoms allow.
Bone stimulation
Bone stimulators deliver a small electrical current or ultrasound waves to the fracture site, which stimulates the growth of new bone tissue.
This non-invasive therapy can be used along with rest to accelerate the body’s natural healing process.
Other treatments
– Pain relievers – To help manage discomfort during the recovery period
– Calcium & vitamin D – Supplements support bone health and healing
– Weight management – May need to reduce weight-bearing activities
– Orthotics – Custom shoe inserts help correct poor biomechanics
Surgery
Surgery is rarely needed but may be required for fractures that fail to heal or are severely displaced. The surgeon can stabilize the bones with screws, plates, or rods.
What are the risks of not resting a stress fracture properly?
It’s extremely important to adhere to the recommended rest period when recovering from a stress fracture. If normal training is resumed too soon, there are several risks including:
– Delayed union or nonunion – The fracture won’t heal properly
– Malunion – Healing in a misaligned position
– Progression to complete fracture – Developing a full break across the bone
– Chronic pain – Long-standing achiness in the bone
– Stress reaction in nearby bones – Early bone damage spreads to other sites
– Premature osteoarthritis – Increased risk of degenerative joint disease
Stress fractures left untreated can progress to complete breaks, which may require surgery and lengthy casting or immobilization of the bone.
Even once the fracture has healed, the bone may remain weaker and more prone to re-injury if not given adequate rest. Rushing return to activity can greatly prolong recovery or interrupt healing.
How can you prevent stress fractures?
There are several things athletes can do to help prevent stress fractures from developing:
Increase training gradually
Ramp up any increases in mileage, pace, or duration slowly over time. A general rule is no more than 10% increase per week.
Cross-train
Incorporate low or non-impact activities like cycling, swimming, rowing, and strength training to give bones a break from repetitive impact.
Wear proper shoes
Running shoes should be replaced every 300-500 miles. Worn out or poorly fitting shoes can contribute to stress fractures.
Address biomechanics
See a physical therapist or podiatrist for an evaluation to correct any imbalances, improper form, overpronation, or high arches. Custom orthotics can help improve alignment.
Take calcium & vitamin D
Supplement with calcium and vitamin D to support bone health, especially if you are deficient.
Maintain healthy nutrition
Eat a balanced diet rich in bone-building nutrients like calcium, vitamin D, protein, fruits, and vegetables. Maintain a healthy body weight.
Rest and recovery
Take 1-2 rest or easy days between high intensity workouts. Periodically take a recovery week of reduced training every 6-8 weeks.
Can you run with a stress fracture?
Attempting to run through the pain of a stress fracture is never recommended. Running applies significant repetitive impact forces that can further displace the fracture, resulting in a more serious and prolonged injury.
Even jogging or walking can potentially worsen a stress fracture in the early stages of healing. That’s why an initial period of non-weight bearing rest is often prescribed.
However, once the pain and inflammation have subsided after a few weeks of rest, some modified running may be incorporated gradually. This might involve:
– Running only every 2-3 days to allow for bone recovery
– Decreasing overall weekly mileage
– Avoiding hills, uneven terrain, or hard surfaces
– Wearing a boot or orthotic for extra support
– Pool running or deep water running to remove impact
– Cycling or elliptical in between run days
The key is to avoid impact that causes any pain at the fracture site. Stop immediately if you feel any discomfort while running and consult your doctor. Progress slowly over several weeks to prevent re-injury.
When can you start running again after a stress fracture?
It’s important not to resume running until the stress fracture has had sufficient time to begin healing, typically at least 2-3 weeks for mild cases. Here are general return to running timelines:
Grade 1 (mild) stress fracture
– Rest completely for 2-3 weeks
– Begin running after 2-3 weeks if pain-free
– Progress back to normal running over 4-6 weeks
Grade 2 (moderate) stress fracture
– Rest completely for 3-4 weeks
– Begin running after 4-6 weeks if pain-free
– Progress back to normal running over 6-8 weeks
Grade 3 (severe) stress fracture
– Rest completely for 8-12 weeks
– Begin running after 12 weeks if pain-free
– Progress back very gradually over 3-4 months
These timelines assume appropriate rest and treatment were followed. Attempting to run too soon can substantially prolong recovery. Always consult your doctor before returning to running after a stress fracture.
How long until full recovery from a stress fracture?
Full recovery to high level sports can take many months following a serious stress fracture. A gradual progression of activities is crucial to adapt the bone and prevent re-injury.
Here are general timelines for full recovery:
Grade 1 stress fracture
– Sports-specific training after 6 weeks
– Full practices after 8 weeks
– Full competition after 12 weeks
Grade 2 stress fracture
– Sports-specific training after 8-12 weeks
– Full practices after 12 weeks
– Full competition after 16 weeks
Grade 3 stress fracture
– Sports-specific training after 4-6 months
– Full practices after 6 months
– Full competition after 9-12 months
Recovery also depends on the specific bone involved and the demands of the sport. More aggressive, high impact sports require longer recovery. Rehabilitation focuses on correcting any imbalances or biomechanics issues that contributed as well.
Conclusion
Treating a stress fracture properly requires an extended period of rest from the offending activity, typically anywhere from 2-12 weeks depending on severity. Attempting to return to running or impact exercise too soon can greatly prolong healing or lead to more serious injury.
With appropriate rest and activity modification, most mild to moderate stress fractures heal within 8-12 weeks. More severe injuries can take 3-6 months for the bone to fully remodel and be ready for the demands of competitive sports. Gradual progression under the guidance of a physical therapist is key to ensure full recovery and prevent future stress fractures.