Stress Fractures: Causes, Symptoms, and Recovery Strategies

Dr. James - Orthopaedic Surgeon in Singapore

Medically reviewed by Dr. James Tan

Stress fractures are an all too common injury, especially for athletes. These incredibly small yet surprisingly painful cracks in the bone are caused by repetitive force or overuse. Unlike sudden fractures that are caused by accidents like whiplash injury, stress fractures happen slowly over time. This slow progression can make it hard to spot symptoms, which often means that the problem gets worse before being treated.

If you have been dealing with nagging pain, it’s essential to know what to look out for. Let’s dive into the causes and symptoms as well as smart strategies for effective pain relief. Whether you’re a dedicated athlete, in the military, or have recently increased your activity level, these are the key strategies you need to know in order to identify, treat, and most importantly, prevent stress fractures.

Here is your complete guide to stress fractures.

What is a Stress Fracture?

A stress fracture is a small crack or severe bruising within a bone. Usually, these are microscopic cracks in the bone and are generally caused by overuse. This might mean intense workouts like F45 and HIIT or a sudden increase in training.

Stress fractures are not the same as your typical bone fractures. Unlike common fractures that are caused by a single traumatic event, stress fractures develop over time. These stress fractures develop from an accumulation of smaller stresses, rather than one overwhelming stress. Stress fractures are common in athletes, especially runners and dancers, but they can affect anyone.

Where Do Stress Fractures Happen?

Stress fractures develop due to the accumulation of smaller stresses, as opposed to one traumatic event. For this reason, stress fractures are most common in your bones which are subjected to repeated stress and regularly bear weight.

  • Lower Leg: Stress fractures often occur in the tibia (shinbone) and fibula (calf bone). This is an especially common issue for runners and athletes.
  • Foot: The metatarsal bones (the bones in your foot), particularly the second and third metatarsals (middle of your foot), are sensitive to stress fractures and prone to foot pain, especially if you do a job or sport requiring repetitive impact.
  • Hip: Stress fractures in the hip can affect the femoral neck (hip bone) or the top of the thigh bone. This is a common issue for long-distance runners and those in the military.
  • Thigh: The femur (thigh bone) is vulnerable to stress fractures, typically in athletes who play high-impact sports.
  • Pelvis: The pubic bone and sacrum (lower spine) are potential locations for stress fractures. These fractures are often caused by sports that involve twisting and turning movements.
  • Lower Back: The vertebrae in the lower back can experience stress fractures. It is especially common among people with osteoporosis and might cause osteoporosis fractures.

How Do Stress Fractures Differ From Regular Fractures?

There are a few key differences between stress fractures and regular fractures. The main differences are the gradual onset versus acute trauma, locations affected, symptom timeline, and detection methods.

To see the difference, it is important to note that stress fractures develop slowly from repeated stress, while regular fractures happen instantly. Stress fractures often affect weight-bearing bones while regular fractures can be any bone.

What Causes Stress Fractures?

Stress fractures occur due to repetitive force or overuse. When you overwhelm your body’s ability to repair and replace bone tissue, you can cause a fracture. This can happen in a few different ways:

  • Overuse: Pushing yourself too hard with high-impact workouts like spinning class without enough rest
  • Increased Intensity: Boosting the intensity of your training too quickly makes you apt for injury  
  • Change in surfaces: Moving from soft to hard surfaces during a workout can cause stress
  • Poor footwear: Inadequate or worn-out footwear increases your odds of injury
  • Muscle fatigue: Tired muscles deliver less shock absorption and increase bone stress
  • Bone density: Lower bone density (osteoporosis) can make your bones susceptible to injury
  • Biomechanical factors: Issues with gait or foot structure can affect load distribution

Stress Fracture Risk Factors: Who is at Risk for Injury?

There are a few different factors that can increase your risk of developing a stress fracture. Let’s take a closer look at who is most susceptible:

  • Athletes: Any who does high-impact sports like running, gymnastics, or basketball.
  • Military personnel: Intense physical training can lead to stress fractures.
  • Female athletes: Women are at great risk, especially those with irregular periods or low body weight.
  • Previous fractures: Having a history of stress fractures dramatically increases your risk of having another.
  • Vitamin deficiency: A deficiency in calcium or vitamin D weakens your bone.
  • Inadequate nutrition: Eating a low caloric intake can weaken bones.
  • Footwear: Athletes with worn-out or unsuitable footwear can contribute to injury.
  • Sudden activity changes: Athletes who increase the intensity or duration of exercise too quickly.
  • Biomechanical Factors: Foot and gait issues can impact load distribution.

Understanding these risk factors is crucial for prevention and early intervention in susceptible individuals.

What Are the Most Common Stress Fracture Symptoms?

If you think that you have a stress fracture, there are a few symptoms that you should look out for, such as the following:

  • Centralised pain: Persistent pain in a highly localised spot
  • Pain during activity: Flare-ups in discomfort during or after exercise
  • Swelling: Tender to the touch and swelling in the area of discomfort
  • Bruising: You may experience bruising near the fracture site
  • Reduced performance: A decline in sports or exercise performance
  • Pain at rest: Discomfort even when you are at rest
  • Worsening pain: Symptoms that get worse with continued activity
  • Limping: A noticeable change in gait in common when your body is moving differently movement to avoid pain

Recognising these common symptoms is essential for early diagnosis and timely treatment of stress fractures.

How Are Stress Fractures Diagnosed?

When you go to get checked for a fracture, your doctor may open for a clinical evaluation as well as imaging techniques. Here is what you can expect:

  • Physical examination: A healthcare professional will assess the affected area and look for signs of tenderness, swelling, or localised pain.
  • Medical history: Your medical history as well as recent activities (especially physical exercise) will be reviewed. To prepare for your appointment, it’s a good idea to make as many notes as possible to cover any possible contributing factors and make note of any questions
  • Imaging tests: Imaging techniques like X-rays, MRI (Magnetic Resonance Imaging), or bone scans will help your doctor take a closer look at any potential fracture.

These diagnostic methods help determine the location and severity of the stress fracture, guiding treatment decisions.

What Imaging Test Can Detect Stress Fractures?

Several imaging tests can be good tools to check for stress fractures, with the most common options being:

  • X-rays: This is often the first tool for identifying fractures, though they are limited because early stress fractures might not show. 
  • MRI (Magnetic Resonance Imaging): These exams are highly effective at detecting stress fractures, offering detailed images of bone and soft tissue.
  • Bone Scans:  A nuclear medicine test that can detect areas of increased bone activity, indicating the presence of a stress fracture.

The choice of imaging test depends on the timing of the injury and the specific clinical situation.

What Is the Treatment for Stress Fractures?

Stress fracture treatment focuses on several approaches including resting the affected bone with crutches or immobilisation devices, activity modification, pain management with medication, and gradually resuming activity under medical supervision once the fracture has started to heal. Addressing any predisposing factors like poor flexibility, muscle imbalances, or nutrition deficiencies is also part of the treatment plan.

  •   Resting the affected bone with crutches or immobilisation
  •   Activity modification
  •   Pain management with medication
  •   Gradually resuming activity under supervision

The main treatment principles are rest, immobilisation, pain relief, gradual return to activity, and addressing predisposing factors like nutrition and training errors.

How Long Does Stress Fracture Healing Take?

Healing periods vary based on the location and severity of the fracture. Foot and ankle fractures may take four to eight weeks to heal with immobilisation. Tibia fractures can require six to 12 weeks of protected weight-bearing. More serious pelvis and femur fractures may need up to six months of limited activity for adequate healing. Setting realistic expectations can help with adherence to treatment and recovery.

  • Fracture location and severity
    • Foot and ankle fractures take four to eight weeks
    • Tibia fractures take six to12 weeks (protected weight-bearing)
    • Pelvis/femur fractures take up to six months (with limited activity)

Most stress fractures heal within eight to 12 weeks with proper rest and immobilisation. Pelvis and femur fractures take the longest at up to six months.

Can You Walk on a Stress Fracture?

Whether it’s OK to walk on a stress fracture depends on the severity of your injury and how much you walk. If walking causes pain, that’s typically a sign you should reduce your activity level or stop walking altogether. However, if you can walk without pain during or after, it may be fine to continue, and could even help the healing process.

Your doctor may still advise no walking, even without pain, if your fracture is in a difficult-to-heal location. To know for sure, discuss your individual case with the healthcare professional overseeing your recovery. They can guide you on safe activity levels. Also watch out for increased afternoon/evening pain after walking, as that’s usually a clue you’re overdoing it. In that case, cut back on walking and standing, even without direct pain during the activity.

Is a Stress Fracture Serious?

Stress fractures can be tricky because they don’t always have the sudden onset or clear signs of a regular broken bone. You may be tempted to think you just have a minor injury that will resolve on its own. However, not properly treating a stress fracture can result in various complications down the line, including:

  • Developing more stress fractures elsewhere
  • Slower healing accompanied by increased pain
  • Progression to a complete fracture
  • Avascular necrosis, which is death of the bone tissue

So even though the initial symptoms may seem mild, it’s important to take stress fractures seriously right from the start, or you risk the fracture worsening and leading to greater problems. Ignoring the early signs and allowing a stress fracture to go untreated can complicate recovery.

Can Stress Fractures Be Prevented?

Certain training errors and lifestyle factors predispose some people to stress fractures. Strategies like gradually ramping up activity, cross-training, taking rest days when the pain starts, correcting muscle imbalances, getting proper nutrition, and using appropriate shock-absorbing footwear can help prevent overuse bone injuries in at-risk individuals. Being aware of risk factors and smart training can reduce fracture risk.

  • Gradually increasing training volume and intensity
  • Cross-training and avoiding high-impact activities on consecutive days
  • Taking rest days when pain emerges
  • Addressing muscle imbalances and flexibility
  • Adequate nutrition for bone health
  • Proper footwear for shock absorption 

Slowly ramping up activity, cross-training, rest, correcting muscle and flexibility imbalances, nutrition, and footwear can help prevent overuse of bone injuries.

Nutrition and Stress Fractures

Nutrition plays a key role in both preventing and recovering from stress fractures. Some important nutritional factors to consider are:

  • Getting adequate amounts of calcium and vitamin D, which are essential for building strong, healthy bones. Dairy, leafy greens, fortified cereals and sunlight exposure provide these. 
  • Consuming enough protein through foods like poultry, fish, beans and nuts to assist with bone and muscle repair.
  • Including magnesium-rich foods such as nuts, seeds, whole grains and leafy greens, which help your body absorb calcium.
  • Eating phosphorus-containing foods like dairy, meat and whole grains, another mineral important for bone health.
  • Getting vitamin K from leafy greens, broccoli and Brussels sprouts for bone mineralisation and metabolism.
  • Incorporating collagen-rich foods or supplements to provide structural support to bones and connective tissues.
  • Consuming omega-3 fatty acids found in fatty fish and walnuts for their anti-inflammatory properties can aid healing.
  • Eating antioxidants like vitamin C and E from citrus fruits, berries and nuts to protect bone and connective tissue.
  • Staying well hydrated, as dehydration raises stress fracture risk.
  • Maintaining a healthy body weight to avoid excess stress on bones.
  • Consider supplements if recommended by a professional to ensure adequate nutrient intake.
  • Seeking treatment for eating disorders that increase the risk of deficiencies and fractures.

Overall, a balanced diet with a variety of nutrients is key for bone health. Those concerned about stress fracture risks may benefit from consulting a dietitian or doctor for personalised nutrition guidance. Diet is just one part of a comprehensive stress fracture prevention/recovery plan.

Finding a Stress Fracture Specialist in Singapore

If you have any reason to suspect that you are dealing with a stress fracture, it is essential to get professional medical help as early as possible. It is crucial to get started on a treatment plan early to get effective treatment. To get started with a local stress fracture specialist in Singapore, reach us via email at hello@quantumortho.com.sg, call +65 6235 8781, or chat with us on WhatsApp at +65 8028 4572.

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Dr. James - Orthopaedic Surgeon in Singapore

About the Author

Dr James Tan is a skilled orthopaedic surgeon who has more than 10 years of experience in sports surgery and exercise medicine. He is a member of the elite Asian Shoulder and Elbow Group and a founding member of the Singapore Shoulder and Elbow Surgery Society.

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