Stress Fractures in the Foot From Running
- Jordan Metcalf
- Jul 8
- 5 min read
Stress fractures are scary.
Sometimes they come on quickly, sometimes they come on slowly.
But every time they happen, they remind you how much you care about running because you HAVE to take time off.
And that sucks
But your best hope at avoiding these debilitating injuries is boosting your knowledge on how to identify them, and what to do about them if they do happen.
Today, we’re going to focus on stress fractures in the foot from running.
Let’s dive in!
Identifying Stress Fractures in the Foot From Running
Stress Fracture Risk Factors
Stress fractures in the foot from running can occur in even the best training conditions, but there are certain factors that increase the risk of developing one.
Sudden increase in training load
While researchers have not determined “how much is too much too quickly” when progressing training load, it’s often easy to spot.
These training load spikes can often occur in the first 4 weeks of the season for seasonal track athletes, or in the first 4 weeks of a marathon training cycle if the program is a little too aggressive.
When I’m writing or auditing one of my client’s training programs, I always use their acute to chronic workload ratio to get a feel for how quickly they are progressing their training.
This ratio tells us how big of a change occurred in the current training week compared to the previous four weeks. An acute to chronic workload ratio of > 1.3 is where injuries seem to be more likely to occur. (1)
Under fueling
Running on an empty stomach? You could be putting yourself at risk for a stress fracture. Bones are very sensitive to under fueling. When your body doesn’t have enough calories to meet the demands of your activities, that’s called low energy availability. When your body is in that state, it can cause hormonal imbalances that impact your bone mineral density negatively.
The most obvious signs of under fueling occur in the reproductive system (remember, hormone imbalances). For females, unexplained loss of menses (period) and for males, loss of morning erections and low sex drive are very clear signs that you are at increased risk for developing a stress fracture. (2)
Previous fracture history
Research shows that a prior history of fracture increases the risk of a bone stress injury by six fold in females, and seven fold in males. (2)
It is the single greatest risk factor for developing a bone stress injury. Those who have symptoms of a stress fracture in the foot who have a history of stress fractures should be extra vigilant in identifying and preventing these injuries.
Low Bone Mineral Density
The average person probably doesn’t know whether they have low bone mineral density unless you've done a DEXA scan recently. However, your sporting history can tell you how likely you are to have lower bone mineral density.
Bones increase in density with high intensity, multidirectional loads that are created by field and court sports. This means that if you played soccer, lacrosse, field hockey, basketball, etc. in your teens, you likely have stronger bones and are therefore less likely to develop a stress fracture.
On the flip side, being sedentary through your teen years or participating in sports like swimming, cross country, or cycling do little to build bone mineral density.
Medications
Certain medications can have a negative impact on bone mineral density. Here is a list of some of the most commonly taken ones:
Corticosteroids (prednisone, dexamethasone, hydrocortisone)
Thyroid medications
NSAIDS (yes, ibuprofen and Advil can impair bone growth and repair!!!)
Antacids, specifically proton pump inhibitors or PPIs (Omeprazole, Nexium, and others)
Stress Fracture Symptom Characteristics
There are some somewhat universal characteristics of stress fractures that help to differentiate them from other types of injuries like tendinopathy.
The most unique characteristic is pain with prolonged weight bearing. Most tendon related pain is reproduced by loading the tendon, meaning if you are just standing still it shouldn’t be too bothersome. However, stress fractures often cause pain with simply standing or walking.
The other unique characteristic of stress fracture symptoms is that they don’t warm up. With tendinopathy, you might feel like your symptoms start when you start a run, but then you feel better as you warm up. This is not likely to happen with a stress fracture.
These two characteristics can help you narrow down the possible causes of symptoms, but understanding where foot stress fractures tend to happen and what factors influence their onset are two more important pieces of the diagnosis puzzle.
Foot Stress Fracture Locations and Risk Level
While stress fractures can technically happen in any bone in the body, they are much more likely in specific areas that experience higher amounts of stress. In the foot, these are the most common locations:
You’ll notice that these locations are labeled either low risk or high risk. The level of risk is referring to the likelihood that a stress fracture will heal without surgery.
A low risk site generally has better blood supply and is more likely to heal with conservative treatment i.e. rest and physical therapy.
High risk sites generally have worse blood supply and are more likely to need surgery to heal properly.
Another thing you might notice is that these common stress fracture sites are all on the top of the foot, not the bottom. Because there are less soft tissue structures on the top of the foot, you should be more suspicious of a stress fracture with top of the foot pain.
Most stress fractures are tender to palpation, meaning that if you poke the injured bone near the fracture, it will hurt.
If you have pain on the top of your foot in one of the locations identified in the picture above that is tender to the touch, that hurts more with prolonged standing, and that doesn’t warm up, the likelihood of a foot stress fracture is relatively high.
Treatment of Running Related Stress Fractures in the Foot
The most important concept in treatment of a running related stress fracture in the foot is progressive return to activity. Spending some time with a physical therapist to help you optimize the way your foot moves can be helpful, but the most important factor to get right is how to go from offloading to running again without re-injury.
Here is a breakdown of the rehab phases of a foot stress fracture:
Summary
Stress fractures in the foot from running are common injuries that should NOT be handled without help. In fact, while writing this blog post, I am working with my own health care team on rehabbing a navicular bone stress injury.
If there’s anything I’ve learned from this recovery process, it’s that getting in front of the right pair of eyes and assembling the best team to help you recover is super important because these injuries can be easy to miss, and their recovery easy to get wrong.
At Alterra, we specialize in helping runners get to the root cause of their injuries so that they can stay on track with their training and enjoy running without pain. If you're a local runner in Boston and are dealing with a stress fracture in your foot, we'd love to help! Book a free discovery call to chat with a therapist today.
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Disclaimer: The information in our blog posts is not a substitute for professional medical advice. Consult a healthcare provider before making decisions related to your health. Use our content at your own risk.
Sources
Maupin D, Schram B, Canetti E, Orr R. The Relationship Between Acute: Chronic Workload Ratios and Injury Risk in Sports: A Systematic Review. Open Access J Sports Med. 2020;11:51-75. Published 2020 Feb 24. doi:10.2147/OAJSM.S231405
Tenforde A, Sayres L, McCurdy M, et al. Identifying Sex-Specific Risk Factors for Stress Fractures in Adolescent Runners. Medicine & Science in Sports & Exercise. 2013;45(10): 1843-1851. DOI: 10.1249/MSS.0b013e3182963d75
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