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Run Well! - Stress Fractures

Posted Sep 02 2009 5:35pm

We are excited to kick off a new series in partnership with Sports Injury Clinic.

   This site has been a well used site by me over the last year as I have worked through various injuries.  It provides the right amount of detail about the injury and tips on treatment as well.   And while we hope you don' t have the need for the resources, we are pleased to offer articles in tips in the event you are dealing with a running injury.


Past articles can be found in the Injury and Recovery section in the Lounge.


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Stress fractures are microfractures which occur as a result of repetitive loading of the bone. They can occur due to increased stress at a focal point in the bone due to biomechanical issues, or through the action of a muscle pull across the bone.


In runners, stress fractures can occur in a number of locations, with the most common being:


Ø     The foot – Metatarsals or Calcaneus

Ø     The lower leg – Tibia

Ø     The thigh – Femur


Metatarsal stress fractures

There are 5 metatarsals in each foot, which are the ‘rays’ leading towards each toe. They can be fractured through an impact, as seen in sports such as soccer, or through repetitive impact, as is the case with a stress fracture. The 2nd, 3rd and 4th metatarsals are the most commonly injured.




Ø     Forefoot pain aggravated by running/walking etc

Ø     Pain gradually worsens with activity

Ø     Tenderness when applying pressure to the metatarsal


Calcaneal stess fractures

The calcaneus is the heel bone. Stress fractures most commonly occur at the back or inside of the bone.




Ø     Heel pain that comes on gradually

Ø     Pain aggravated by running or even weight bearing in more severe cases.

Ø     Pain when squeezing the sides of the heel together at the back


Tibial stress fractures

The Tibia is the larger of the two lower leg bones, and the only bone which is ‘weight-bearing’. The most common area for a tibial stress fracture is 2-3 inches above the medial malleolus (bony part on the inner ankle).




Ø     Gradual onset of leg pain

Ø     Pain is aggravated by activity

Ø     The Tibia may be tender when touched

Ø     Calf pain my be present


Femoral stress fracture

The Femur is the thigh bone and the largest bone in the body. Stress fractures can occur either in the mid-shaft of the bone, or at the neck of the femur, just below the hip joint.




Ø     A dull ache in the thigh

Ø     Poorly localised pain

Ø     Pain may refer to the knee

Ø     Pain may be exacerbated by sitting with the leg hanging over the edge of a bench/high chair, especially if a downward pressure is applied to the knee.


A stress fracture of the femoral neck may produce:


Ø     Pain in the groin which comes on gradually

Ø     The pain is poorly localised and aggravated by activity

Ø     Pain at the extremes of hip joint motion



Stress fractures are overuse injuries. In runners, this usually means, running too far or for too long, too soon, with insufficient rest! It is one of the main reasons behind the 10% increase rule.

Other issues can also contribute to the development of a stress fracture. Usually these are biomechanical issues which place extra stress on the bone. For example, the 2nd metatarsal is most commonly fractured in people who overpronate, and Tibial fractures can be caused by a leg-length discrepancy.



Generally, the treatment of a stress fracture involves plenty of rest (usually 4 weeks of partial or non-weight bearing), correction of any biomechanical factors, followed by a very gradual return to activity. This should only commence when walking is pain free and bone tenderness has cleared. Non-impact exercise should be introduced initially (e.g. cycling/cross-training, swimming), followed by a gradual return to running.


There is one major exception to this rule. A stress fracture to the femoral neck can be on either the superior (tension) side, or the inferior (compression) side. Those to the superior aspect should be treated as an emergency, with either surgical fixation or complete bed rest. The reasoning for this, is that due to the tension on the upper surface, there is a possibility of the stress fracture developing into a full fracture, which would stop the blood supply to the head of the femur, leading to a possible avascular necrosis – bone death.



Stress fractures can be prevented by following these simple rules:


Ø     Don’t overtrain – increase mileage by no more than 10% per week.

Ø     Get a gait analysis to determine if you overpronate, oversupinate or have a neutral foot.

Ø     Make sure you are wearing the correct trainers for you

Ø     Change your trainers before they get worn out

Ø     Don’t run on hard surfaces (i.e. concrete) all the time

Ø     Try to mix it up and include grass, sand and tarmac running


For more information onmetatarsal,calcaneal,tibialandfemoral stress fractures, please visit:

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