Stress fractures form part of what is known as ‘bone stress injuries’. These occur when a bone is unable to handle repetitive loads put through it and cause localised pain over an area of bone. These injuries start out as a stress reaction that is not yet a full fracture but causes pain. A stress fracture is a progression of this and is a small break in a bone. When a stress fracture is not treated, the injury can progress to becoming a complete fracture. Find out the common areas of bone stress injuries below. 

What causes stress fractures/injuries?

Bone stress injuries are thought to be due to an imbalance between normal microdamage and bone remodelling. These injuries are seen in both elite level athletes and inactive people. Women sustain 2–10 times more bony stress injuries than men. These injuries can be caused by:

  • high training loads
  • a sudden increase in physical activity or training
  • biomechanical factors such as muscle strength, footwear and technique
  • factors that increase risk due to impact on bone health or remodelling
  • diet and nutrition—deficits in calcium and vitamin D increase risk, as well as low calorie intake
  • hormonal balance—menstrual disturbance and post menopause
  • systemic bone illnesses and steroidal or anticonvulsant medications
  • genetic factors.

How do I know if I have stress fractures/injuries?

Bone stress injuries such as stress reactions and stress fractures typically cause localised pain over the affected bone. Usually, this pain has a gradual onset and, in the beginning, may only hurt with activities such as jumping, running or walking. As it progresses it may cause pain when resting or at night. If a bone stress injury is suspected, after thorough assessment, your physiotherapist or GP will refer you for a scan to evaluate the integrity of the bone. An MRI scan is best—X-rays and CT scans are poor at picking up these injuries. A nuclear medicine bone scan may also be used; however, it does not provide as much information as an MRI and has a higher dose of radiation.

Bone stress injuries can theoretically occur anywhere; however, the most common sites in the foot are:

  • the small bone on the inside of the foot below the ankle (navicular)
  • the bone connecting to the fifth toe on the outside of the foot (fifth metatarsal)
  • the bone connecting to the second toe in the middle of the foot (second metatarsal)
  • the bony knob on the inside of the ankle (medial malleolus).

How can physiotherapy help with stress fractures/injuries?

Your physiotherapist will be able to help assess and diagnose any bone stress injuries. These injuries may be more difficult to pick up in the early stages, hence thorough assessment is important. They will be able to refer you for investigations. In some cases, you may be referred to your doctor to further investigate and manage any nutritional, mineral or hormone deficiencies.

Management of bone stress injuries varies hugely between which bone is affected and how severe the presentation is (stress reaction vs fracture). In all cases the overloading factor should be identified, and training or activity may be decreased or stopped temporarily to allow the bone to heal. It may be necessary to have a period of non-weight bearing in a cast or boot. Certain types of stress fracture may also require surgical fixation. Your physiotherapist will need to advise you on what course of action should be taken.

Once the fracture or stress reaction has healed, any deficits in muscle strength, foot posture or other regions should be treated. They will then advise on a plan for a structured gradual return to your desired activities.

How effective is physiotherapy for stress fractures/injuries?

Given the multifactorial nature of bone stress injuries, and the collaborations required for their management between doctors and physiotherapists, studies looking at the effectiveness of physiotherapy for bone stress injuries are scarce.

A research paper summarising other previous studies supported the conservative management of a variety of bone stress injuries in runners. A study investigating navicular stress fractures showed that conservative management was as successful as surgical management on pain and function.

What can I do at home?

It is extremely important to adhere to the plan your physiotherapist or doctor has given you, including periods of non-weight bearing to allow the bone to heal, followed by a gradual increase in loadbearing activity.

It is possible to do exercises on the unaffected leg when resting the bone. Your physiotherapist can advise you of exercises to complete at home. This may be helpful to maintain strength, as a portion of gains can be carried over from the uninjured side to the affected side to maintain strength even while you are resting it. This may help in a quicker return to activity or sport.

How long until I feel better?

Time frames on return to activity or sport vary depending on the bone stress injury itself. A period of at least six weeks of offloading may be necessary, followed by a period of gradual increase in activity, which may take up to three months depending on your demands. More complex injuries may take as long as 12 months for full resolution. Time frames may differ because of where the fracture is in the bone, and which bone is affected.