Stress Fractures: Symptoms, Causes, Treatment & Physiotherapy

Reviewed by the Physiotherapy Team at Waterloo Sports Medicine Centre 

A stress fracture is a small crack in a bone caused by repetitive loading rather than one major injury. Learn about stress fracture symptoms, causes, risk factors, diagnosis, treatment, healing time, and how physiotherapy can help you safely return to exercise and sport. 

What Is a Stress Fracture? 

A stress fracture is a small crack or area of damage within a bone that develops when repetitive forces exceed the bone's ability to repair and adapt. 

Unlike a typical fracture that may occur after a fall or collision, a stress fracture usually develops gradually from repeated loading. 

Stress fractures are common in athletes and physically active individuals, particularly in activities involving repetitive running, jumping, or impact. 

They most commonly affect the lower extremities, including the shin, foot, ankle, and hip, although stress fractures can occur in many different bones. 

What Causes a Stress Fracture? 

Your bones are living tissues that constantly respond to physical loading. With appropriate training and recovery, bone can adapt and become stronger. 

A stress fracture can develop when the amount or intensity of loading increases faster than the bone can adapt. 

Common contributing factors include: 

• Suddenly increasing running mileage  

• Increasing training intensity too quickly  

• Increasing jumping or impact activities  

• Training on hard or unfamiliar surfaces  

• Repetitive sports participation  

• Inadequate recovery between training sessions  

• Changes in footwear or training equipment  

• Reduced muscle strength or conditioning  

• Previous stress fracture  

• Low energy availability  

• Certain nutritional or hormonal factors  

A sudden change in training volume is particularly important. For example, someone who normally runs 10 km per week and suddenly begins running 30–40 km per week may place substantially greater stress on their bones. 

What Are the Symptoms of a Stress Fracture? 

Stress fractures often develop differently from acute fractures. 

Common symptoms include: 

• Gradually increasing pain  

• Pain that initially occurs only during exercise  

• Localized tenderness over the bone  

• Pain that worsens with impact activity  

• Pain that improves with rest  

• Swelling around the affected area  

• Pain that eventually occurs during everyday activities  

• Pain at rest in more advanced injuries  

A classic warning sign is localized bone pain that repeatedly occurs with running, jumping, or another impact activity. Continuing to train through worsening symptoms can allow a bone stress injury to progress. 

Stress Injury vs. Stress Fracture: What's the Difference? 

You may hear healthcare professionals use the terms bone stress injury (BSI) and stress fracture. 

Bone stress injuries exist along a spectrum. 

Early changes may involve the bone responding to repetitive loading without a visible fracture line. With continued loading and inadequate recovery, the injury can progress and eventually develop into a more established stress fracture. 

This is one reason early assessment and appropriate load modification are important. 

Who Is at Risk of a Stress Fracture? 

Stress fractures can affect anyone, but risk increases when the demands placed on the skeleton change faster than the body can adapt. Risk factors can include: 

Training-related factors 

• Sudden increases in training volume  

• High-impact exercise  

• Repetitive running or jumping  

• Insufficient rest  

• Rapid return to sport after an injury  

  
  

Physical factors 

• Previous stress fracture  

• Lower bone mineral density  

• Muscle weakness  

• Biomechanical factors  

• Changes in running mechanics  

Nutrition and energy availability 

Insufficient energy intake relative to exercise demands can negatively affect bone health. 

Athletes experiencing persistent fatigue, recurrent injuries, menstrual irregularities, or significant changes in training and nutrition should discuss these concerns with an appropriate healthcare professional. 

How Is a Stress Fracture Diagnosed? 

Diagnosis usually begins with your medical and training history and a physical examination. 

Your healthcare provider may assess: 

• Where your pain is located  

• When the pain occurs  

• Changes in your training recently  

• Localized bone tenderness  

• Swelling  

• Your ability to walk or bear weight  

• Previous injuries  

• Relevant risk factors  

  
  

X-rays 

X-rays are commonly used as an initial imaging test, but an early stress fracture may not be visible. This is an important difference between stress fractures and many acute fractures. 

A person can have symptoms strongly suggestive of a stress fracture while having a normal initial X-ray. 

It can identify changes within the bone and help determine the severity and location of the injury. The 2024 American College of Radiology guidance notes that MRI has substantially improved the ability to diagnose stress fractures that are radiographically occult.  If clinical suspicion remains high, additional imaging may be recommended. 

MRI 

MRI is highly useful for detecting stress injuries that are not visible on X-rays.  It can identify changes within the bone and help determine the severity and location of the injury. 

How Are Stress Fractures Treated? 

Treatment depends on the location and severity of the stress fracture. 

Some stress fractures are considered low risk and respond well to activity modification and gradual rehabilitation. Others occur in areas with a higher risk of delayed healing or complications and may require more aggressive management. 

Activity Modification 

The first step is usually to reduce or temporarily stop the activity that is causing excessive stress on the bone. 

This may mean temporarily avoiding: 

• Running  

• Jumping  

• High-impact exercise  

• Competitive sport  

Your healthcare provider may recommend lower-impact activities such as swimming or cycling if they can be performed without aggravating symptoms. 

Protected Weight-Bearing 

Some stress fractures require temporary use of: 

• Crutches  

• A walking boot  

• Other forms of support  

The amount of weight you can safely put through the injured limb depends on the specific bone and severity of the injury. 

Surgery 

Most stress fractures do not automatically require surgery. 

However, surgery may be considered for certain high-risk fractures, fractures that fail to heal with conservative treatment, or injuries in which continued instability creates a significant risk of progression. 

A 2023 systematic review of tibial stress fractures found high return-to-sport rates following both non-operative and operative treatment, although treatment failure was more common among patients initially treated non-operatively.  

How Can Physiotherapy Help With a Stress Fracture? 

Physiotherapy plays an important role in managing the factors that contributed to the injury and safely rebuilding your ability to tolerate activity. Your physiotherapist will work within the restrictions provided by your physician or other healthcare provider. 

1. Activity and Load Management 

One of the most important parts of rehabilitation is determining how much activity your bone can safely tolerate. 

Your physiotherapist can help you modify your training while maintaining as much general fitness as possible. 

2. Maintaining Fitness During Recovery 

Depending on the injury, you may be able to maintain cardiovascular fitness using lower-impact activities such as: 

• Swimming  

• Cycling  

• Deep-water running  

• Upper-body conditioning  

These activities should only be performed if they are appropriate for your injury and do not aggravate symptoms. 

3. Strengthening 

As healing progresses, your physiotherapist can gradually rebuild: 

• Lower-limb strength  

• Calf strength  

• Hip strength  

• Core strength  

• Balance  

• Single-leg control  

Strengthening helps prepare your body for the progressively greater forces required during walking, running, jumping, and sport. 

4. Gradual Return to Running 

Returning to running too quickly can increase the risk of reinjury. 

A physiotherapist can develop a graded return-to-running program that gradually increases the amount of impact placed on the bone.  A 2024 scoping review identified a range of criteria used before and during return to running after tibial bone stress injuries, including resolution of symptoms and progressive loading.  

A return-to-running progression may look something like: 

Walking → walk/jog → easy running → longer running → faster running → hills → sport-specific running 

The exact progression depends on the injury and should be individualized. 

How Long Does a Stress Fracture Take to Heal? 

There is no single healing time for every stress fracture.  Recovery depends on: 

• The bone involved  

• Location of the fracture  

• Severity  

• Whether there is a visible fracture line  

• Whether the area is considered high or low risk  

• How early the injury is identified  

• Whether the bone is adequately protected  

• Individual health and nutritional factors  

Many stress fractures require several weeks of activity modification, followed by a gradual return to impact activity. However, some higher-risk stress fractures can take several months to heal and may require more extensive treatment. 

Importantly, being pain-free during everyday activities does not necessarily mean that you are ready to immediately return to full sport. 

The bone needs to gradually regain its ability to tolerate the forces associated with running, jumping, and competition. 

Can Stress Fractures Be Prevented? 

You cannot eliminate the risk completely, but several strategies can help reduce the risk. 

Increase training gradually 

Avoid sudden increases in running mileage, jumping volume, or training intensity. 

Allow adequate recovery 

Rest and recovery are important parts of training because bone needs time to adapt to repeated loading. 

Maintain adequate nutrition 

Adequate energy and nutrient intake supports bone health and recovery. 

Strength train 

Maintaining strength in the hips, legs, and trunk can help prepare your body for the demands of running and sport. 

Replace worn-out equipment 

Appropriate footwear and gradual transitions when changing shoes or training surfaces can help your body adapt to changes in mechanical loading. 

Listen to persistent pain 

Repeated, localized pain during impact activity should not simply be ignored. 

When Should You See a Physiotherapist or Doctor? 

Consider getting assessed if you develop: 

• Persistent, localized bone pain  

• Pain that repeatedly occurs during running or jumping  

• Pain that is worsening despite reducing activity  

• Swelling around a painful area  

• Pain that progresses from exercise-related pain to pain during walking  

• A history of previous stress fractures  

Do not continue training through progressively worsening bone pain. 

Early assessment can help determine whether you need further investigation and how much activity modification is appropriate. 

Looking for Stress Fracture Rehabilitation in Waterloo? 

Stress fractures can be frustrating for athletes because recovery requires a careful balance between protecting the healing bone and maintaining fitness. At Waterloo Sports Medicine Centre, our physiotherapists can help you manage your activity, rebuild strength, restore movement, and develop a gradual return-to-running or return-to-sport program once it is medically appropriate. 

Looking for stress fracture physiotherapy in Waterloo or Kitchener-Waterloo? Contact Waterloo Sports Medicine Centre to learn how individualized rehabilitation can help you safely return to running, sport, and the activities you enjoy.