Nothing strikes fear in the heart of a runner like the threat of a stress fracture. Advertisement - Continue Reading Below months of rest to heal. Unlike a regular broken bone you might sustain due to an accident or a nasty fall, stress fractures can seemingly appear out of nowhere with no inciting event. Plus, they’re notoriously tricky to diagnose.
It’s tempting just to ignore persistent aches and pains and hope for the best. But denial isn’t a great strategy for dealing with potential stress fractures or bone stress injuries. These overuse injuries can worsen if left undiagnosed, especially if you continue to train as usual.
Knowledge is power when it comes to preventing, managing, and recovering from bone stress injuries and stress fractures. The best way to minimize your downtime and quickly get back to running pain-free is to understand the warning signs and when to see your medical provider. Here’s what you need to know.
Bone Stress Injuries vs. Stress Fractures
Stress fractures fall under the broader category of “bone stress injury” (BSI), which refers to accumulated microdamage in the bone that leads to pain, structural fatigue, and the inability to bear weight.
Amazing Runners World Show Nutrition - Weight Loss and, through MRI imaging, are graded on a scale of one to four, Adam Tenforde, M.D., assistant professor of physical medicine and rehabilitation at Harvard Medical School, tells Runner’s World.
“Grade one is very early bone edema [swelling] and grade four is a true stress fracture,” where a fracture line is present, he says. “A grade one injury, on average, takes four to six weeks to get back to training. A grade four injury can take anywhere from three to five months,” he says, noting that the location of the injury is also a factor in healing and recovery.
The dreaded stress fracture represents around 20 Stress Reaction vs Stress Fracture, explains Milica McDowell, D.P.T., physical therapist, exercise physiologist, and vice president of operations at Gait Happens. “Eighty percent of them are not actually cracked. It’s more like inflammation right below the outside eggshell of the bone,” she says.
However, with continued loading and stress, low-grade injuries can worsen, says William B. Workman, M.D., board-certified orthopedic surgeon and sports medicine expert at Disc Sports & Spine Center in Newport Beach, California. “This is the concept of the ‘bone stress continuum,’” he says. “At the early stage, you’ll have a bone stress reaction. If loading continues, it progresses to a stress fracture. Early rest or cross-training can reverse this before a crack forms.”
5 Stress Fracture Warning Signs
According to the experts we spoke with, BSIs can be challenging to diagnose, even with the help of imaging. But there are some telltale symptoms and warning signs to look out for so they don’t progress to that full-on fracture. If these signs persist for more than two weeks or get worse, or if they interfere with your running or walking form, it’s time to see a medical professional ASAP.
1. Pain With Activity
Feeling pain during a run or everyday weight-bearing activities, like walking and standing, is usually the first sign of a BSI. However, this pain can present differently, depending on the person and the injury.
“Some people say it’s like a deep ache in the bone. Some people say they feel throbbing, and other people are like, ‘it’s sharp,’” McDowell says.
According to Tenforde, individuals with BSIs in the hip and pelvis may feel vague groin pain or tightness in the hip. Others may find that their gait is off, as they’ve inadvertently managed their discomfort by walking and running differently. “That’s part of the ambiguity of a runner self-recognizing what’s happening,” McDowell says.
Of course, runners may feel aches from tough workouts or lots of miles, and not every pop-up in pain means you have a bone stress injury—muscle strains can also happen. But if you’re feeling it regularly over the course of a few weeks, consider it a definite sign you need to seek help.
2. Point Tenderness
If the area that’s causing you pain is also sensitive to touch, that can be an indicator of a BSI. “One of the things that is pretty hallmark from a sign and clinical exam standpoint is point tenderness,” McDowell says. “If I push on or compress the bone, or I squeeze across the arch of their foot and they yelp,” that can be a sign of BSI, she says.
“Also, look out for swelling or subtle warmth over the bone,” Workman says.
3. Symptoms Get Better With Rest
BSIs typically start to feel better with rest. (Even a few hours off your feet will likely decrease pain and discomfort, though they won’t make you better.)
“The challenge is, it’s really hard to get runners to rest,” McDowell says. And even if you do take a break from training, you may need to be on your feet for work, family life, or other activities.
4. Pain Builds on a Run
Soft tissue injuries, like tendon or muscle strains, can have a “warmup effect,” Tenforde says. As you start to run and increase blood flow to the area, the discomfort may begin to subside.
However, if you have a BSI, that same workout will likely have the opposite effect. “The more cumulative stress that’s placed throughout the bone, the more those symptoms will worsen,” Tendforde says.
5. Migrating Pain
People tend to think of bone pain as being very focused, but the sensation can occur over a large area or feel like it’s migrating. “Sometimes the body will try to compensate to protect that bone from taking on additional stress,” Tenforde says. As a result, the exact source of the pain and the location of the BSI can be difficult to pin down.
What To Do If You Think You Have a Stress Fracture
To effectively deal with a bone stress injury or a stress fracture, you’ll need an accurate diagnosis, ideally from a sports medicine specialist who works with runners. They will do a full medical exam and check for these common signs. You may get a diagnosis that way, but the only definitive way to confirm a stress fracture is via an MRI.
According to Tenforde, X-rays can be negative in the first couple weeks of an injury’s presentation. “MRIs are the gold standard for detecting the presence and severity of an injury. That’s not to say everyone ultimately will get an MRI to make that diagnosis,” he says. But they are especially useful in identifying more advanced injuries and estimating timeframes for returning to running.
Any pain that persists or worsens for longer than two weeks is worth checking out, especially if you're feeling it in your hip, tibia (shin bone), midfoot, or the fifth metatarsal, which is the bone on the outside of the foot that connects to the pinky toe. BSIs in these areas, Tenforde explains, are considered particularly “high-risk” in that they tend to incur prolonged recovery time and may be more prone to complications, like the need for surgery. The most common areas for BSIs in athletes in particular include the metatarsals, tibia, and fibula (the bone that runs parallel to the tibia), Tenforde says.
If you are diagnosed with a bone stress injury, you can expect to stop running while you heal. In some cases, you may need to wear an orthopedic boot or use crutches to help support your weight.
Hitting pause on your training can be frustrating and disappointing, but it’s crucial to the healing process. Resuming running too early could cause a setback, Tendforde says.
Also, if you’re able, work with a physical therapist. “Everyone with a bone injury should go to physical therapy,” Tenforde says. Physical therapists can not only prescribe sport-specific exercises and help correct problematic movement patterns, but they can also monitor the healing process and determine when someone’s ready to safely return to running.
Tips for Preventing Stress Fractures
As with any running-related injury, you can do all the “right” things and still wind up with a BSI. However, you can take a few common-sense steps to lower your risk and increase your odds of staying healthy.
1. Gradually Increase Mileage
In her practice, McDowell finds that bone stress injuries are common among runners who, after getting a marathon or two under the belt, immediately jump into training for an ultra. “Your bones really need time to build the tolerance to tolerate that kind of load and volume,” she says, noting that any sudden increase in mileage, whether you’re training for a 100K or a 10K, can increase risk of injury.
To avoid BSI (and injury, in general), follow an intentional training plan that gradually ramps up volume and intensity, or get a coach’s input on how to appropriately progress your workouts.
2. Switch Up Your Shoes
It may seem counterintuitive, but McDowell advises against running in ultra-cushioned shoes. “You can’t feel the ground, which means you actually land harder,” she says. If you can sense the ground beneath you, you’re more likely to land softly, which can reduce ground reaction forces. If you have a pair of ultra-cushioned shoes you love, just make sure you have them in a shoe rotation.
3. Eat Enough
“If individuals have inadequate fueling to meet their needs above what they’re doing from an exercise standpoint, it can have effects on hormones and metabolism that make bones more susceptible to injury,” Tenforde says. In other words, don’t run on empty.
4. Get Your Annual Physical
Regular health screenings and bloodwork can help you stay on top of hormone changes, nutrient deficiencies, bone density issues, inflammation, assistant professor of physical medicine and rehabilitation at Harvard Medical School, tells.
5. Avoid Nicotine and Alcohol
Not that you need another reason not to smoke, but lighting up has been associated with an increased incidence of fractures, osteoporosis, and decreases in bone volume and mineral density. And some research suggests a correlation between an increase in alcohol consumption and an increase in the risk of bone fractures.
