Foot stress fracture: symptoms, healing time and recovery

Bones are living tissue. The body is constantly laying down new bone to renew and strengthen them. A stress fracture happens when the load on a bone is a lot more than it is used to and the bone cannot renew itself quickly enough to keep pace. The result is a tiny crack, or several, rather than the single sudden break most people picture when they hear the word fracture.

Cambridge University Hospitals explains the difference from a traumatic break: a fracture caused by a sudden forceful injury, such as dropping a heavy weight on the foot, is different from a stress fracture, which occurs over a longer period of time because of overuse such as repeated impact on the bone or an increase in training without adequate rest. University Hospitals Sussex adds that sometimes a stress fracture may only cause inflammation (swelling, heat and pain), but it can progress to a full break in the bone if the load continues.

The British Orthopaedic Foot & Ankle Society (BOFAS), writing for clinicians, describes stress fractures as the result of microscopic injuries following repeated submaximal trauma. It says they account for about 10 to 30 per cent of all sports injuries and that about 32 per cent of those are in the foot. This is a clinician-facing resource, so the figures are given here for context rather than as a prediction for any one person.

The Sussex leaflet lists the usual features of a foot stress fracture. The pain is typically dull and gets worse with activity or when you put weight on the foot, then improves when you rest or avoid the activity. There may be some swelling of the foot, and pressing directly on the affected bone tends to increase the pain.

Most foot stress fractures occur in the metatarsals. BOFAS says that 80 to 90 per cent of stress fractures in the foot sit in the second and third metatarsals, because these rays are stiffer. Other sites it names as common in athletes are the fifth metatarsal, the navicular, the calcaneum (heel bone), the sesamoids and the talus.

• A dull ache in the forefoot or midfoot that builds up during a run, walk or shift on your feet.

• Pain that settles with rest but returns when you start again.

• Tenderness when you press on one particular spot on the bone.

• Swelling over the painful area.

• For the fifth metatarsal, BOFAS describes chronic pain on the outer side of the foot with tenderness over the base of that bone.

• For the navicular, BOFAS describes activity-related pain on the top of the midfoot that improves with rest.

The Sussex leaflet is clear that the amount and type of activity that counts as too much differs from person to person and can change at different stages of life. It lists several common reasons for a bone to be overloaded: doing an activity you have not done before or not done for a long time, doing much more of an activity quickly, wearing different footwear, and doing a lot less of an activity for a period and then going back to your usual level.

It also lists risk factors that make a stress fracture more likely.

• High-impact sport or work, especially repetitive jumping, running long distances, or walking while carrying heavy loads or on very uneven ground.

• Increasing activity levels, especially if you are eating less.

• Athletes changing their training regime.

• Eating disorders, or problems absorbing vitamins and minerals from food.

• Being post-menopausal.

• Low bone density, or a health condition that makes the bones less dense over time (osteopenia).

According to the Sussex leaflet, a healthcare professional can usually tell whether you have a stress fracture from what you tell them about your symptoms and how they started. Some people are diagnosed without an X-ray, and an X-ray is sometimes done to check for a clear break, and you may not need a repeat X-ray if it would not change the advice you are given.

The reason the picture can be confusing is that early X-rays often look normal. The leaflet says not all stress fractures show on an X-ray as they may just be small changes in the bone, and an X-ray taken weeks after the first can show changes that could not be seen earlier. BOFAS makes the same point for clinicians, saying stress fractures are often difficult to see on initial X-rays but become apparent later, and that ultrasound or MRI can be considered if the result is likely to affect management. It adds that a delay in diagnosis may contribute to non-union, where the bone fails to knit.

A normal first X-ray therefore does not mean nothing is wrong. If the pain pattern fits and the bone is tender, a clinician may manage it as a stress fracture on the history and examination alone.

For most people the treatment is offloading the bone and letting it heal. The Sussex leaflet says to reduce the load on the foot in whichever way suits you: stop or do much less of the activity that led to the fracture, and some people will need an orthopaedic boot or rigid-sole shoe, crutches or both, while others can wear usual footwear and adjust their activity. It also advises keeping the foot and ankle moving so they do not stiffen, and doing light exercise that does not cause pain.

Cambridge University Hospitals says metatarsal stress fractures are minor and stable and can be managed in a supportive boot worn for up to 6 weeks, with crutches in the early stages if needed. It advises weight-bearing as pain allows in the boot and gently moving the ankle to prevent stiffness. BOFAS states that for most stress fractures of the foot a shoe, boot or cast will suffice, and that surgery is considered for proximal fractures or painful non-union. For the fifth metatarsal and the navicular, the BOFAS text describes more specific measures, including a non-weight-bearing cast for navicular stress fractures, and checking and treating vitamin D levels for the fifth metatarsal.

The Sussex leaflet says that if you no longer have symptoms you can slowly return to lower-impact sports after 6 weeks. It suggests increasing only one aspect of your sport at a time, such as time, speed, agility, power, balance or coordination, and by about 10 per cent each session. Cambridge University Hospitals gives similar advice: build back up gradually, by no more than 10 per cent in intensity, frequency and duration per week.

Things the Sussex leaflet asks people to avoid include pushing through pain when returning, doing more of several activities at once rather than building them up one at a time, and returning too soon. While recovering it suggests lower-impact choices such as swimming, cycling or walking on even ground, and thinking about what overloaded the bone in the first place, for example technique, footwear or training intensity.

If your job keeps you on your feet, the leaflet suggests a gradual return, perhaps fewer hours or lighter duties at first, which you can discuss with your employer and GP.

The Sussex trust does not routinely follow up this injury, but says that if after 6 weeks you still have a lot of pain and swelling or struggle to walk without your boot or rigid-sole shoe, you should contact its fracture service for advice. The Cambridge leaflet advises contacting your GP if the condition is not improving or pain relief is not adequate, and the fracture clinic if it is getting worse.

In practice, see a GP or use NHS 111 if the pain is worsening despite rest, you cannot put weight on the foot, or the foot is markedly swollen or changes shape. Persistent bony tenderness that does not settle should be re-examined, because BOFAS notes that stress fractures at some sites, such as the navicular, are often missed on X-ray and need a CT or MRI scan to confirm.

Most foot stress fractures are assessed through an urgent treatment centre, emergency department, fracture clinic, virtual fracture clinic or the GP and managed in primary care or by physiotherapists. Imaging beyond X-ray is generally reserved for cases where the diagnosis is uncertain or the site is one known to heal poorly.

Some people choose to see a private orthopaedic foot and ankle specialist or sports physician to speed up an MRI or to get specialist advice on a return to elite sport. The underlying principles of treatment, offloading, gradual return and addressing the cause, are the same in either sector. Whichever route you use, it is worth asking what caused the overload and whether bone health, nutrition or training load need attention.