Stress Fracture (Overuse Fracture)

Also known as: Stress fracture, Overuse fracture, Fatigue fracture, March fracture, Hairline fracture, Bone stress injury (BSI), Stress reaction (bone), Repetitive stress fracture

Last updated: December 18, 2024

A stress fracture (overuse fracture) is a small crack or more severe bone stress injury that can develop when repetitive loading exceeds the bone’s ability to remodel, often in weight-bearing bones. It may begin as a stress reaction before a visible break. Symptoms include localized pain that worsens with running, jumping, marching, or prolonged standing and point tenderness. Many low-risk cases improve over weeks with reduced load.

Key Facts

•A stress fracture be described as a small crack or severe bone stress injury that develop when repetitive mechanical loading exceeds the bone’s capacity to remodel
•Localized bone pain that worsens with running, jumping, marching, or prolonged standing and lessen with relative rest
•Diagnosed through history, physical exam, and imaging
•First-line treatment includes exercise, weight management, and activity modification

What It Is

A stress fracture may be described as a small crack or severe bone stress injury that can develop when repetitive mechanical loading exceeds the bone’s capacity to remodel. It often involves weight-bearing bones and may begin as a stress reaction with bone marrow edema before a visible cortical break appears. Pain typically relates to activity and may reflect localized microdamage, periosteal irritation, and inflammatory signaling within the affected bone. Some stress fractures can progress if loading continues, and certain locations may be considered higher risk for delayed healing due to blood supply and biomechanical forces.

Affected Anatomy

This condition affects several structures in and around the joint:

•Tibial cortex (anteromedial tibial diaphysis) and periosteum
•Metatarsal shafts (typically second and third metatarsals) including cortical bone
•Femoral neck (tension-side and compression-side regions)
•Calcaneus (posterior calcaneal tuberosity and trabecular bone)
•Navicular bone (central third, relatively limited vascular supply region)
•Fibula (distal third, lateral cortex)
•Pelvic ring stress sites (pubic ramus and adjacent trabecular bone)
•Talus (talar neck and dome subchondral bone in selected overuse patterns)

Common Symptoms

Symptoms can vary in intensity and may change over time. Common experiences include:

•Localized bone pain that may worsen with running, jumping, marching, or prolonged standing and can lessen with relative rest
•Point tenderness over a specific bony area that may be reproducible with palpation or percussion
•Pain that can begin only near the end of activity and may progress to earlier onset with continued loading
•Mild swelling or localized soft-tissue fullness near the painful site, often without significant bruising
•Pain that may occur during normal walking in more advanced cases and can sometimes occur at rest or at night
•Altered gait or protective limping that may develop to reduce loading on the affected limb
•Reduced performance or early fatigue during weight-bearing activity due to pain-limited mechanics
•Pain provoked by hopping or single-leg loading tests, which can suggest a bony source when positive

Causes and Risk Factors

Multiple factors can contribute to the development of this condition:

Causes

•Repetitive submaximal loading (overuse) that can outpace normal bone remodeling, leading to microcrack accumulation
•Rapid increases in training volume, intensity, or frequency that may exceed adaptive capacity (often described as “training errors”)
•Biomechanical loading patterns that can concentrate stress on specific bones, such as altered foot mechanics or limb alignment
•Reduced bone mineral density or impaired bone quality that may lower the threshold for microdamage under typical loads
•Nutritional and hormonal factors that can affect bone turnover and repair, including low energy availability and menstrual dysfunction in some athletes
•Footwear or surface changes (hard surfaces, worn shoes) that can increase impact forces and repetitive strain

Risk Factors

•Participation in high-impact or repetitive-load activities (distance running, basketball, dance, military training) that can increase cumulative bone stress
•Sudden training changes, including rapid mileage increases, added hill work, or intensified interval training
•History of prior stress fracture, which may indicate persistent biomechanical or bone-health contributors
•Low bone mineral density, osteoporosis, or osteopenia, which can reduce structural reserve
•Low energy availability, disordered eating patterns, or relative energy deficiency in sport (RED-S), which may affect bone remodeling
•Menstrual irregularities or hypoestrogenic states in some individuals, which can be associated with lower bone density
•Biomechanical factors such as pes planus or pes cavus, leg-length discrepancy, or altered hip/ankle strength that can shift load distribution
•Vitamin D insufficiency or low calcium consumption patterns, which may be associated with impaired bone health in some populations

How It's Diagnosed

Diagnosis typically involves a combination of clinical assessment and imaging studies:

•Clinical history focused on activity-related pain pattern, recent training changes, footwear/surface changes, and prior bone stress injuries
•Physical examination that may include inspection for swelling, palpation for focal bony tenderness, gait assessment, range-of-motion evaluation, and functional loading maneuvers (such as hop testing when appropriate)
•Plain radiographs (X-rays), which can be used to assess for fracture lines or periosteal reaction, although early stress injuries may appear normal
•Magnetic resonance imaging (MRI), which can often identify stress reactions and stress fractures earlier than X-ray by showing bone marrow edema and cortical involvement
•Bone scintigraphy (bone scan), which can show increased tracer accumulation at sites of bone remodeling and may be used when MRI is not available or when multifocal injury is suspected
•Computed tomography (CT), which can help define cortical fracture lines and may be used for certain high-risk locations or surgical planning
•Laboratory evaluation in selected cases to assess contributors to bone health (for example vitamin D status, calcium/phosphate balance, thyroid function, or markers relevant to menstrual/hormonal status), typically guided by clinical context

Treatment Options

Treatment approaches range from conservative measures to surgical interventions, often starting with the least invasive options:

Self-Care and Activity Modification

•Activity modification and relative rest from the provoking impact load, which can allow bone remodeling to progress
•Protected weight bearing or temporary immobilization (for example walking boot or brace) when pain with walking is present or when the location is considered higher risk
•Graduated return-to-activity programs that can span weeks to months and often emphasize stepwise load progression based on symptoms and functional tolerance
•Footwear assessment and orthotics in selected individuals to address load distribution, shock attenuation, or biomechanical contributors
•Nutritional optimization and evaluation for low energy availability, calcium/vitamin D adequacy, and other bone-health factors, often coordinated with sports medicine and nutrition professionals
•Management of underlying bone health conditions (such as low bone density or endocrine contributors) when identified, which can support recovery and reduce recurrence risk

Physical Therapy and Exercise

•Physical therapy focused on strength, flexibility, neuromuscular control, and gait mechanics to reduce recurrent overload patterns

Medications

•Pain management approaches that may include ice and non-pharmacologic modalities; medication choices can be individualized and may consider potential effects on bone healing

Surgery

•Surgical management for selected high-risk stress fractures (for example certain femoral neck, navicular, or anterior tibial cortex injuries) or for cases with delayed union/nonunion, which may involve internal fixation

Prognosis and Recovery

The course of this condition varies between individuals:

•Many low-risk stress fractures may heal with load reduction and gradual rehabilitation, with symptom improvement often occurring over several weeks, while full return to high-impact sport can span longer depending on severity and location
•High-risk locations (such as the femoral neck, navicular, and anterior tibial cortex) can have higher rates of delayed healing and may require closer monitoring and, in selected cases, surgical stabilization
•Earlier recognition and management may be associated with shorter symptom duration and lower likelihood of progression from stress reaction to complete fracture
•Recurrence can occur, particularly when training errors, biomechanical contributors, or bone-health factors persist
•Imaging findings may lag behind symptom improvement, and clinical recovery often involves both pain resolution and restoration of functional loading tolerance

Physical Therapy (Physiotherapy)(Procedure)
Shin Splints (Medial Tibial Stress Syndrome)(Condition)

Frequently Asked Questions

Common symptoms include: Localized bone pain that may worsen with running, jumping, marching, or prolonged standing and can lessen with relative rest; Point tenderness over a specific bony area that may be reproducible with palpation or percussion; Pain that can begin only near the end of activity and may progress to earlier onset with continued loading; Mild swelling or localized soft-tissue fullness near the painful site, often without significant bruising; Pain that may occur during normal walking in more advanced cases and can sometimes occur at rest or at night.

Diagnosis typically involves: Clinical history focused on activity-related pain pattern, recent training changes, footwear/surface changes, and prior bone stress injuries; Physical examination that may include inspection for swelling, palpation for focal bony tenderness, gait assessment, range-of-motion evaluation, and functional loading maneuvers (such as hop testing when appropriate); Plain radiographs (X-rays), which can be used to assess for fracture lines or periosteal reaction, although early stress injuries may appear normal; Magnetic resonance imaging (MRI), which can often identify stress reactions and stress fractures earlier than X-ray by showing bone marrow edema and cortical involvement.

Treatment options range from conservative measures to surgical interventions, including: Activity modification and relative rest from the provoking impact load, which can allow bone remodeling to progress; Protected weight bearing or temporary immobilization (for example walking boot or brace) when pain with walking is present or when the location is considered higher risk; Graduated return-to-activity programs that can span weeks to months and often emphasize stepwise load progression based on symptoms and functional tolerance; Pain management approaches that may include ice and non-pharmacologic modalities; medication choices can be individualized and may consider potential effects on bone healing; Physical therapy focused on strength, flexibility, neuromuscular control, and gait mechanics to reduce recurrent overload patterns.