Stress fracture: symptoms, healing time, treatment and return to sport

Gloucestershire Hospitals NHS Foundation Trust says the main symptom is pain. Depending on the bone affected, it tends to hurt in very specific areas, hurts when you touch the exact area where the bone is injured, increases with impact activities such as running or jumping and gets better during rest.

For the foot, Sussex describes a dull pain that increases with activity or when you put weight on the foot and gets better with rest, foot swelling, and increased pain if you press directly on the bone with the stress fracture. Shin and other leg pain can have other causes, so ask about a stress fracture if you have pinpoint tenderness on the bone.

The leaflets read for this guide are about foot stress fractures. Stress fractures elsewhere, such as the shin, hip or pelvis, follow similar principles but can need different advice, so have persistent pinpoint bone pain assessed.

• A dull ache in one precise spot

• Pain that builds with impact or weight-bearing and eases with rest

• Tenderness when you press directly on the bone

• Swelling over the area

The central aim is to reduce the load on the bone. Sussex advises doing much less of, or stopping, the activity that led to the fracture. Some people need an orthopaedic boot or rigid-soled shoe, crutches or both, while others can wear usual footwear but adjust their activities. Keep moving the foot and ankle to stop stiffness and do light exercise that does not cause pain.

Gloucestershire says a stress fracture needs about 6 weeks to fully heal. It advises stopping the activity causing pain, anti-inflammatory medicines such as ibuprofen (ask a GP or pharmacist), an ice pack, raising the foot above heart level when lying down and protective footwear such as a stiff-soled shoe or removable short leg brace shoe. Sometimes, depending on the location, a plaster cast or splint keeps unstable bones in a fixed position and is usually removed after 4 to 6 weeks.

Royal Cornwall Hospitals says a stress fracture needs complete rest from the activity that caused it, and that you can do non weight bearing exercise such as swimming and cycling while it heals.

Sussex explains that the body constantly makes new bone to renew and strengthen it. If a bone is overworked, this may not happen quickly enough to cope with the stress, and a stress fracture can result. The load that is too much differs for everyone and changes at different stages of life.

Common overload triggers listed are doing an activity you have not done before or for a long time, doing more of an activity rapidly, wearing different footwear, doing much less for a period then returning to usual activity, and having an eating disorder or a condition that makes bones weaker.

Risk factors listed by Sussex include high-impact sport or work (repetitive jumping, long-distance running, carrying heavy loads or walking on very uneven ground), increasing activity while eating less, athletes changing training regimes, problems absorbing vitamins and minerals, being post-menopausal, low bone density and osteopenia. Gloucestershire adds that stress fractures can develop from normal use of a bone weakened by conditions such as osteoporosis, and highlights menopausal women whose bones are often weaker.

Sussex says your healthcare professional can usually tell from what you say about your symptoms and how they started. An X-ray is sometimes done to check for a clear break, and some people are diagnosed without one.

Not all stress fractures show on an X-ray because they may be small changes in the bone that cannot be seen. An X-ray taken weeks later may show changes not visible at first. If a new X-ray or scan would not change management you do not need one, though a repeat may be done if the fracture is thought to be unstable. Royal Cornwall mentions CT, MRI or ultrasound may be used in some plans.

The leaflets read give little dietary advice beyond risk factors. Sussex lists eating disorders, increasing activity while eating less, and problems absorbing vitamins and minerals as risk factors, which is why a balanced diet matters if you train hard. Royal Cornwall says eating well, staying hydrated and keeping as active as possible help recovery.

Sussex says smoking and vaping slow healing, most importantly in the first 2 weeks after injury, and Royal Cornwall adds that in extreme cases smoking can stop healing altogether.

Sussex says that if you no longer have symptoms you can slowly return to lower impact sports after 6 weeks, increasing only one aspect (time, speed, agility, power, balance or coordination) by about 10% each session. Avoid pushing through pain, doing more of several activities at once and returning too soon. Swimming, cycling and walking on even ground are suggested while recovering.

If your job needs weight on the foot most of the time you may need a gradual return, with fewer hours or light duties at first. You can return to driving when you no longer use a boot or rigid shoe, can walk comfortably and can deal safely with emergencies such as braking hard, and your insurer covers you.

See a GP, minor injuries unit or fracture service if you have pinpoint bone pain that does not settle with rest. Sussex says to contact the fracture service if after 6 weeks you still have a lot of pain and swelling or are struggling to walk without your boot. Royal Cornwall asks you to make contact if you have significant pain and swelling after 12 weeks or symptoms away from the original site.

Go to A&E or call 999 if you cannot put any weight on the limb after an injury, the limb looks deformed, or you have numbness, a cold pale foot or severe uncontrolled pain.

Foot stress fractures are often seen first in an emergency department or minor injuries unit, then followed up by a virtual or in-person fracture clinic and physiotherapy where needed. Many people are not routinely followed up.

Private orthopaedic and sports medicine services can arrange MRI where it will change management and plan a graded return to sport. Ask whether a scan will change what is done, as the NHS leaflets note not everyone needs repeat imaging.