Stress Fractures: Do I Have One and How Long Will it Take to Heal?
What is a Stress Fracture?
A stress fracture is probably the most accurately named injury as it equally encompasses the physiological and psychological components. Other viable names could include “Bummer Fractures,” “I-Don’t-Wanna Bone Breaks,” or “Oste-OH-NO Fracture.” Regardless, identifying and treating stress fractures should always include the aspects of the entire athlete that are affected by this injury. Mind, Bone, and Spirit.
As human beings, we have 206-213 bones that make up our body. The variance comes from the difference in the number of ribs, vertebrae, and digits (i.e. fingers and toes). Thought to be static structures, bones have many functions including movement, protecting vital organs, assisting with breathing, and producing cells in the marrow (fluid inside the bone). Bones are constantly undergoing remodeling, which is influenced by the demands being placed on them. In order to maintain healthy remodeling and strong bones, we must give fuel to the fire. Proper caloric intake, vitamins, and fluids are the gasoline to your boney engine. That’s an odd metaphor, but you get what I mean.
What are Common Areas for Stress Fractures to Occur?
Stress fractures are one of the most common sports-related injuries and typically affect the shock-absorbing (or weight-bearing) bones in the human body. The most common areas for stress fractures to occur in runners and athletes include (but not limited to):
Tibia (usually closer to the ankle, but can occur anywhere along the shaft)
Metatarsals (bones in the feet)
Femoral neck (closer to the hip)
Pelvis (near the groin)
Sacrum and Low back
Stress Fracture vs. Stress Reaction
There is a spectrum of severity for bone stress injuries, which of course dictates the amount of rest, rehab, and time away from sport. Stress reactions are when initial stages of inflammation and breakdown are happening at the bone; however, there are no signs of an actual fracture.
Stress fractures are when there has been enough microtrauma at the bone to cause actual “fractures.” I use quotes because these fractures are actually small cracks within the bone and not full/complete breaks. A stress fracture is truly an injury of repetitive trauma until your bone just cracks. However, if appropriate rest and recovery are not taken, then by George you can expect yourself a full blown fracture sooner or later.
How Do Stress Fractures Happen?
The most common mechanism of injury for stress fractures is simply over-training. The continuous repetitive pounding combined with not enough rest periods typically leads to muscle fatigue, boney weakness – and – ipso facto – a stress fracture. But it is more than just “too many miles” or “too much exercise.”
Our body isn’t always in break-down mode. If it were, then we’d all be piles of mush by the time we were two. Bone remodeling occurs 24/7 throughout our body and throughout our entire lives as we adapt to different loads and stressors from various activities. On the cellular level, destruction from osteoclasts releases calcium to assist with specific metabolic demands – this is a good thing! At the same time, your osteoblasts are working hard to rebuild boney material so your body can withstand the demands placed upon it. As long as your osteoclasts and osteoblasts are in a healthy, balanced relationship, then you have a strong boney foundation for running and adventure.
Understanding and controlling the osteoclasts vs. osteoblast relationship isn’t easy. It is affected by many external and internal factors which are sometimes (but not always) under our direct control. For example, taking rest days and getting enough sleep each night helps our osteoblastic friends, while incorporating strategic mechanical loading through strength training helps reduce overactivity from the osteoclasts. This system works in favor of bone remodeling which keeps us strong and protected. Other variables that affect this relationship and our bone health in general include medications (i.e. corticosteroids like Prednisone), stress and poor mental health, hormonal changes (reduced estrogen, progesterone, and testosterone), and a lack of nutrition.
It would seem a disservice to not discuss RED-S in the topic of stress fractures. Relative Energy Deficiency Syndrome (or RED-S) is a growing term that improved the understanding of low energy availability and injuries in runners. Formally known as “The Female Athlete Triad,” the RED-S term helps to better recognize all of the physiological and mental processes involved while also including men in the conversation.
How Does RED-S Lead to Stress Fractures?
The under-consumption of calories and the depletion of hormonal levels are the aspects of RED-S that lead to stress fractures. By under-fueling, you essentially take away fuel from your osteoblasts and enter a constant state of bone resorption/breakdown. You also take away fuel sources for your muscles, leading to quicker onset of fatigue and more forces to be absorbed by your bones. Overtime, your body cannot keep up remodeling bone tissue and the repetitive breakdown (of bones AND muscle tissue mind you) leads to stress fractures.
Your body has a never ending fire burning inside your core, especially when you are active. The more you feed logs to the fire, the bigger and brighter your fire can burn. However, if you start to take away logs – OR – you only give it small kindling – that fire will slowly dwindle.
If you need any more resources on RED-S, disordered eating, eating disorders, or under-fueling, then check out these resources to help get you started.
What Are the Symptoms of a Stress Fracture?
Stress fractures can occur abruptly or feel like a gradual onset as you start to feel a deep soreness or ache in the injured area. Maybe after a run one day, you notice a mild throbbing soreness while sitting at your desk. It doesn’t limit your ability to stand or walk, but you are concerned about the new sensation. The feeling subsides overnight, and on your run the following day you start to feel a mild soreness around mile 4 or 5. Again, it is very low level and you continue running – hoping it is just a niggle. All of a sudden, you have throbbing pain at night and find redness, swelling, and an unfortunate limp when you finally get out of bed the next morning. It is the change in gait and inability to fully bear weight without sharp pain that is the most concerning and warrants seeing your physical therapist as soon as possible.
Depending on the location of the stress fracture, you may experience sensations besides soreness and deep aches. Other symptoms and their potential meanings include:
Tingling – swelling can compress on nerve tissue nearby.
Sharp pain – this usually occurs in the initial stages, especially if the stress fracture is near a joint line and range of motion is limited.
Electricity – again, a nerve is being compressed or irritated throughout the healing process.
Tight – I find patients use this word at times when they don’t know how else to describe something; however, it is a legitimate sensation. You may use this word to describe the restricted muscles around the stress fracture or the restricted mobility of the joint involved.
Warm – during the initial phases of inflammation and injury, the area that is red and swollen will sometimes feel warm or burning. This is typically because of the nerves or blood vessels working hard to heal and bring fresh blood to the area.
As always, take the above information with a grain of salt as not everyone experiences injuries in the same way nor do they describe them with the same words either. But DEFINITELY take Googled information with zero grains of salt. Googling diagnoses and health information will likely lead you down a rabbit hole of uncertainty, fear, and extra anxiety of wondering if you have cancer in your foot instead of a stress fracture. Or maybe that’s just me….
The Psychological Effects of a Stress Fracture
I want to take this opportunity to also highlight the psychological symptoms of how a stress fracture “feels”. Let me be honest in saying that I have never had a stress fracture (knocks heavily on the wooden cabinet next to me). What I know of the psychological stressors of this injury comes from my patients, my friends, and stories from elite athletes. And for very valid and relatable reasons, it seems stress fractures come with the most psychological upsets in comparison to other sports-related injuries.
What makes stress fractures different from other injuries is their somewhat sudden onset without explanation. You push yourself so hard and give so much of yourself to this sport only in the end to literally break unintentionally. The fracture happens, and you immediately fall into the spiral of “What did I do wrong?” “How could I let this happen?” “I’m not as good of a runner as I thought I was.”
Other injuries (i.e. achilles tendinitis, hamstring strains/tears, instability issues) seem easier to digest (despite still being hard to deal with). They come with less guilt, less fear, and less self-consciousness as we navigate telling our teammates or friends the bad news. When a bone breaks, we mentally fall apart. Maybe because we know it involves many weeks off of activity, many weeks away from our teammates and friends, and many weeks of feeling isolated. We blame ourselves and drown ourselves in shame because maybe – just maybe – we subconsciously are not surprised. We know we’ve been running a lot and wouldn’t be shocked if a dietician told us we needed to eat more. We haven’t been sleeping very well and our stress levels outside of running have been high. Running was our way to escape – our way to feel a sense of control and strength. So, the stress fracture happens and we realize it might be longer than 6-8 weeks before this bone and everything else in our lives is healed.
Other common “feelings” with stress fractures include:
Depression – whether that is from loneliness, missing out on running, social isolation, etc.
Anger – who isn’t angry about injuries? Especially those that cause us to be away from activity.
Lost – it is hard to navigate the initial weeks of a stress fracture. What can I do? What should I eat? How long will this take? Where did I go wrong? Ask for help when answering these questions – the negative spiral of thoughts clouds our brains from finding actionable solutions sometimes.
Frustration – especially as symptoms continue when we try to run again. Give yourself grace. It’s not a linear progression.
Fear – you may feel unsure of how you got this stress fracture, or unsure of what will make it worse, unsure of what will make it better, unsure of how you will ever return to your previous level of training and get back your fitness. Remember that fear is just a product of anxiety – it’s a sign of wanting to love ourselves but not knowing how. Again, ask for help and talk about your fears with anyone who will listen.
Again, the diagnosis of a “stress fracture” comes with a variety of symptoms – physical and mental. Use the time away from sport to address it all – find a sports psychologist, find a dietician, find a physical therapist – even if you just consult with each of them one time. A consult is like asking a stranger in the woods for directions when you approach a fork in the trail. Yes – you have no idea what challenges are ahead in either path, but you are afraid of going the wrong direction and you are tired of feeling lost. You’ll face each upcoming “fork” or challenge as it comes, but one trail will for sure lead you to your preferred destination. Even the most seasoned of hikers cannot travel alone without help – they have maps, or compasses, or GPS systems. Everyone needs a little bit of help sometimes. So pack up your depression, your fear, your sadness, and your frustrations and show them to your support system. It may seem like a puzzle to you, but someone – or a team of people – will help you sort out the edge pieces from the center pieces and all of a sudden the picture will look much clearer.
Side Note – I cannot be the only person who starts a puzzle with the edge pieces. Right?
What Activities Can I Do with a Stress Fracture?
Even on the very first day of symptoms, there are things you can work on despite not being able to run or exercise. Below is a list of physical activities you can do while healing from a stress fracture. However, I challenge you to devise your own list – both of physical activities and other endeavors – that you can do during the next 6-8 weeks.
Physical Activities to Do with a Stress Fracture:
Please remember it is important to be cleared by your physical therapist or other medical provider prior to trying these activities as there are certain areas of a stress fracture that would make the below activities unsafe. There should never be >3/10 pain when doing any of these activities, nor should there be increased pain afterwards (within 24 hours). Find something that feels good and make sure to not overdo it!
Indoor (or outdoor) cycling.
Swimming or Aqua Jogging.
Hiking in nature.
Yoga or Pilates. This can help target core strength, hip stability, joint mobility – which are all things we know we need to work on anyway.
Strength Classes. Starting a strength program now will help you build a strong base and a good routine for when you are back to full exercise and running again.
Indoor Rock Climbing – this is a tricky one. Make sure you are cleared by your PT or medical provider before trying this activity.
Martial Arts or Boxing – what a great way to release your physical and mental stressors by punching a bunch of things. Just be careful with the kicking – may want to stick to just upper body aggression.
Non-physical Activities to Try When Healing from a Stress Fracture:
Cooking/Baking. I find baking to be incredibly difficult and frustrating at altitude. So I stick to cooking. But I have all the faith that you can be Star Baker.
Learning an instrument. Unless you have roommates and neighbors who do not like noise. Then it may be an air guitar for you….
Reading books or starting a book club.
Journaling – even if it happens to be about your stress fracture journey. This can be a great way to let out emotions throughout the process.
Doing a puzzle.
Painting or other crafts. I enjoy the “drink wine and paint” nights with friends.
Learning a new hobby/skill like photography.
Knitting. I’ve never done this but would find the activity to be soothing – especially as it has a physical component to it and makes for great Christmas gifts.
How Long Does it Take for Stress Fractures to Heal?
If we are only considering the average time for bone to heal, then I would answer this question with the standard response of “6-8 weeks.” BUT – and that is a biiiigggg but – we cannot just take into account the time for bone to heal. To answer this question, we must understand our end goal. Do we need this bone to tolerate sport? Do we need this bone to tolerate sport AND other weight bearing tasks throughout the day. Does this bone need to be stronger than it was before it was fractured? Does this bone also deal with other co-morbidities and medication demands (i.e. corticosteroids, osteoporosis, diabetes, etc.)? Does this bone belong to a human who also struggles with disordered eating, poor sleep, and mental health?
Oof – those are a lot of questions to answer and now I have made the situation worse by basically saying it will likely take longer than 6-8 weeks. Well, yes. Yes it will. BUT – (i like big but’s and I cannot lie) – those 6-8 weeks don’t necessarily mean time away from sport/activity. All it means is that by the end of it, your bone will likely be put back together.
What we need to be cautious of of (and healthcare providers as well) is returning to sport too much, too soon. The “too much, too soon” strategy is what leads to most running injuries anyways. This becomes particular important when talking about bone. I’ll tell you why
Think about a command strip – those adhesive strips you use to hang pictures or mirrors on a wall. Have you ever followed the true directions written on the back of those packages? The last step – and likely the most crucial step – is likely where the command strip obtains its strength and longevity. According to the Command Strip packaging, the final step states: “Wait 1 hour for adhesive to build. Align strips. Press frame until each pair of strips clicks.”
Wait 1 hour. After the strip has been pressed into the wall, it is recommended to wait another hour before hanging the picture, mirror, whatever onto the wall. This is when the adhesive builds.
We need to have the same protocol for returning to sport after a stress fracture. Just because the bone is “healed” doesn’t mean it is strong enough to withstand loads – this takes time. And much longer than 1 hour.
About 20% of all running related injuries are stress fractures, and approximately 12% of those athletes will experience a recurring stress fracture in the 1-2 years following the original injury. Younger athletes are more likely to sustain a stress fracture when compared to their older athlete counterparts – up to 19% incidence in athletes 15-19 years old. It takes longer than 6-8 weeks to occur, so it makes sense that it takes longer than 6-8 weeks to heal properly. Most of us want to be in this sport for the rest of our lives – however that looks. So let this injury be a reminder that sometimes what you are doing now isn’t always the best way to get to where you want to be. Especially if you were over-training, not eating enough, or putting your sleep schedule low on the priority list. Use the time now to reflect on what was working and what was causing harm. That is usually what an injury is anyways right? A learning lesson. An annoying, poorly timed learning lesson; however, one that always makes us better and stronger in the end.