Stress Fractures

What are Stress Fractures?

Stress fractures are different from an acute fracture and generally occur in a physically active person and are a result of repetitive stress in the long bones.

Stress Fracture Mechanism

  1. Acute fractures:  Typically involve one specific injury to the bone normally from a direct blow
  2. Stress fractures: Occur over a longer period of time as a result of repetitive application of stresses that weaken the outer surface of the bone.

What Causes a Stress Fracture

Stress fractures are a result of repetitive application of stresses that is lower than the stress required to fracture the bone.

Over a period of time this stress results in injury to the cortex of the bone this is called a stress fracture.

Stress Fracture Mechanism

Romani et al. 2002 (1) provides an excellent in depth explanation of the mechanism of what causes a stress fracture (click here for the article)

Risk factors for Foot and Ankle Stress fractures

Risk factures are classified as intrinsic or extrinsic risk factor.

Extrinsic risk factors Intrinsic risk factors
– Running surface (1,17) – Female (7, 23)
– Type of exercise (1, 10, 17) – Smoking (23)
 – Inadequate recovery period (22) – Older age (20)
–  Footwear (1) – Family history (17)
– Altered foot mechanics (1)
– Previous Stress fractures (3, 7, 14)
– Poor nutrition (25)


Where do Stress Fractures in the Foot and Ankle Occur

Typically stress fractures in the foot occur in the long metatarsal bones. Stress fractures that occur in the metatarsal bones are considered low risk (they heal well with conservative treatment).

There are high and low risk stress fractures that occur in the foot. High risk stress fractures have a greater chance of non union due mainly to ‘watershed’ areas in the bone ( areas with low blood flow)

The following table from Mayer, Joyner, Almekinders, & Parekh, (2014) 29 shows the high and low risk fractures in the foot and ankle.

High Risk Low Risk
Medial malleolus Calcaneus
Talus Cuboid
Navicular Cuneiforms
Fifth metatarsal base Lateral malleolus
Sesamoid Metatarsals 1-4


Diagnosis of Stress Fractures

Diagnosis is generally made with specific signs and symptoms – when the pain occurs and the location.

X-ray can be beneficial if the stress fracture has been there for a prolonged period.

At the Ankle, Foot and Orthotic Centre we are able to provide additional information about the presence of a stress fracture with ultrasound imaging. A stress fracture will usually appear as a disruption of the normal linear pattern of the cortex of the bone.

Tibial Stress Fracture

Treatment of Stress Fractures

Treatment of a stress fracture will depend if the stress fracture is high or low risk

High Risk Low Risk
Medial malleolus Calcaneus
Talus Cuboid
Navicular Cuneiforms
Fifth metatarsal base Lateral malleolus
Sesamoid Metatarsals 1-4

Initial treatment of a stress fracture involves trying to reduce the stress to the bone.

This can be eliminating the activity that is causing the stress – running or high impact activity.

Immobilisation in a CAM walker with a supportive insoles may also be necessary to allow the bone to heal

Typically stress fractures as with most bony injuries can take 6 to 8 weeks to resolve duration of healing will depend on how long the stress fracture has been present

Complications of  Stress fractures

A complication of  stress fracture is non union of the fracture (not healing)

There are certain high risk stress fractures that occur in the foot and ankle this is a link to an article that discusses high and low risk stress fractures in the foot and ankle


The Ankle and Foot Centre’s Northcote Podiatrists can help you with all lower limb complaints, including Stress Fractures . Make an appointment to get your foot and ankle pain under control.



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2. Bennell, K. L. M., Crossley, K. A. Y., Jayarajan, J., Walton, E., Warden, S., Kiss, Z. S., & Wrigley, T. I. M. (2004). Ground Reaction Forces and Bone Parameters in Females with Tibial Stress Fracture. Medicine & Science in Sports & Exercise, 36(3), 397-404.

3. Bennell, K. L. M., Malcolm, S. A., Thomas, S. A., Wark, J. D., & Brukner, P. D. (1996). The Incidence and Distribution of Stress Fractures in Competitive Track and Field Athletes. The American Journal of Sports Medicine, 24(2), 211-217.

4. Bennell, K. L. M., Malcolm, S. A., Wark, J. D., & Brukner, P. D. (1996). Models for the pathogenesis of stress fractures in athletes. British Journal of Sports Medicine, 30(3), 200-204.

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17. Milgrom, C., Finestone, A., Segev, S., Olin, C., Arndt, T., & Ekenman, I. (2003). Are overground or treadmill runners more likely to sustain tibial stress fracture? British Journal of Sports Medicine, 37(2), 160-163.

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22. Ross, R. A., & Allsopp, A. (2002). Stress Fractures in Royal Marines Recruits. Military Medicine, 167(7), 560-565.

23. Shaffer, R. A., Rauh, M. J., Brodine, S. K., Trone, D. W., & Macera, C. A. (2006). Predictors of stress fracture susceptibility in young female recruits. American Journal of Sports Medicine, 34(1), 108-115.

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28. Warden, S. J., Burr, D. B., & Brukner, P. D. (2006). Stress Fractures: Pathophysiology, Epidemiology, and Risk Factors. Current Osteoporosis Reports, 4(3), 103-109. Wohl, G. R., Towler, D. A., & Silva, M. J. (2009). Stress fracture healing: fatigue loading of the rat ulna induces upregulation in expression of osteogenic and angiogenic genes that mimic the intramembranous portion of fracture repair. Bone, 44(2), 320-330.

29. Mayer, S. W., Joyner, P. W., Almekinders, L. C., & Parekh, S. G. (2014). Stress Fractures of the Foot and Ankle in Athletes. Sports Health, 6(6), 481-491.