Issue 16 • August 2013

Stressing a Good Point

The mere thought of it strikes fear into the minds of runners and endurance athletes. “Could it be… a stress fracture? Is this pain going to derail my season? How long will I be out? What do I do now? When can I run again? What about biking…or swimming or elliptical or anything? I have to do something! I can’t just stop and rest!” Many people have these thoughts at the first onset of pain in the (lower) leg. Although a stress fracture is a relatively uncommon injury, the prolonged recovery phase gives it a bad reputation.

Understanding stress

Our bodies are in a constant state of repair, replacement, and regeneration. The stress of daily activities causes bone to break down and to be replaced with new bone. Stress fractures are an imbalance in this process. The demand placed on bones through physical activity is too great for the body’s replacement process to keep up. There are times when the body cannot regenerate bone sufficiently and small cracks in the bone develop. Several factors can contribute to this type of bone injury:

  • biomechanical deficiencies
  • hormonal imbalances
  • nutritional deficiencies

Who suffers?

In sports that emphasize low body weight and leanness, female athletes who experience the Female Athlete Triad – 1) infrequent menstrual period 2) disordered eating, and 3) low bone mineral density – are at a significantly elevated risk for stress fracture. However, the athlete who does too much, too soon, too fast is the most common stress fracture victim. A sudden increase in duration, intensity, or frequency of exercise will increase most athlete’s risk for injury.

Where do they occur?

Although stress fractures have been mostly documented in long bones of the body, they typically are found in the weight bearing and impact absorbing bones of the lower extremity.  Injuries are typically sports specific:

  • throwing athletes experience injuries to the elbow and upper arm
  • golfers experience injuries in the ribs
  • gymnasts and weight lifters experience injuries to the spine
  • runners experience injuries in the tibia, the 5th metatarsal of the foot, and occasionally the femoral neck

It’s important to note that femoral neck stress fractures should be treated cautiously as there is an increased possibility of their progression to a complete fracture. This can gravely impact the athlete’s potential to ever return to a normal lifestyle.

What does a stress fracture feel like?

Stress fractures are marked by the production of pain in one specific area. Impact activities, such as running, jumping, or hopping will almost always reproduce the symptoms if a stress fracture is present. X-rays almost always miss a recent stress fracture as micro cracking of the bone is not visible. Only when the bone begins to heal, new bony growth, or a healing callus, will be visible on X-rays. Because of this, a bone scan or MRI is typically required to confirm the diagnosis of an early stress fracture. With a bone scan a radioactive tracer is injected into the bloodstream; areas of high bone repair that absorb more of the tracer will show up as a dark spot on diagnostic images. An MRI typically gives a more specific representation of the location and size of the injury.


Regardless of the injury’s location, treatment for stress fractures is similar – stress to the bone must be removed in order to restore normal bone generation and healing. For lower extremity injuries, this means a period of non-weight bearing or immobilization, generally lasting 4-6 weeks.

Unfortunately for Type-A athlete personalities, bone healing is a biological process that takes a certain amount of time and it cannot be rushed without risking further injury or prolonging healing.

During this time, limited-impact activities, such as swimming and cycling can usually be performed as long as they are pain free. The newly developed AlterG, anti-gravity treadmill, is also an essential recovery tool for a lower extremity stress fracture. The AlterG treadmill allows physical therapists to develop a specific program of progressive weight bearing exercise to gradually restore normal function. For those who don’t have access to an AlterG, aquatic exercises, pool running, and elliptical trainers can be used to restore and preserve cardiovascular fitness and prepare the athlete to return to sports.

With any stress fracture, it’s important to seek an examination by a licensed physical therapist, who specializes in dealing with athletes. The therapist’s expertise can be particularly helpful for identifying potential training errors or biomechanical deficiencies that may have contributed to the injury or may hinder a return to activity.

The progression of recovery

Following the rest period and the confirmation of bone healing via X-rays, a return to activity should consist of 4-8 weeks of progressive loading. During the return to activity phase, some level of discomfort is typical, since the athlete has been in a state of relative rest. Upon returning to impact activities, the most common observation is muscular soreness or a dull ache at the injury site during activity (the discomfort should quickly resolve with rest)

Athletes should not have discomfort that lasts into the rest period between workouts and should not begin any impact activity if they are having pain with normal daily activities. Pain that resembles the discomfort experienced at the time of diagnosis should be respected and not worked through. It is important to listen to the body’s response to each progressive step and to not rush the process. The progressive program is designed to slowly apply stress to the bone during the remodeling phase of healing.

Full recovery times vary:
diagnosis >cessation of impact activity>return to normal training= 2-4 months (depending on the athlete’s previous exercise volume) graphic representation

Stressing advice

The best strategy for preventing stress fractures is to follow a smart training program developed by a qualified coach or fitness professional.

High-risk athletes should enlist the help of a medical professional to evaluate potential risk factors for injury. Most of all, driven athletes who have the tendency to minimize symptoms should be cautioned to listen closely to their bodies. A much needed day off or a change in the workout schedule can potentially save weeks of recovery time from an injury like a stress fracture.

Andrew “Drew” Heideman, MPT, ATC, PES is the Site Coordinator of Jacksonville Orthopedic Institute’s largest rehabilitation facility, San Marco. As an athletic trainer and avid triathlete, he enjoys working with elite and amateur athletes who have a special interest in endurance sports, including running, cycling and multisport.



1 Comment

  1. October 8, 2013 at 1:08 am — Reply

    Our body is like a machine to much used is really not good.

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