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It’s the kind of thing runners say offhand when they or a friend have foot pain: “I hope it’s not a stress fracture.” Stress fractures, especially those of the foot, are one of those injuries that can put you on the sidelines for months, which is why it’s crucial to pay attention to injury warning signs and stay on top of injury prevention.
Here, Jordan Metzl, M.D., a sports medicine physician at the Hospital for Special Surgery in New York City and creator of Runner’s World’s IronStrength workout, explains what a foot stress fracture is, how to do a foot stress fracture test, and how to prevent these types of injuries in the first place.
What to Know About Foot Stress Fractures
A stress fracture is a tiny crack in the surface of a bone, usually in the lower leg or the metatarsals of the foot for runners. Stress fractures often occur when we increase the intensity and volume of our training over several weeks to several months. Muscle soreness and stiffness can progress during this period, and a pinpoint pain may develop in the area of the sore bone.
Stress fractures start as a stress reaction. “A stress reaction or a stress injury happens when the bone starts to swell inside,” says Metzl. “The worse the symptoms get and the more you don’t pay attention to them, the more likely you are to turn a stress reaction or stress injury into a full-blown stress fracture.”
While it’s hard to tell the difference between a stress reaction and stress fracture, if you feel significant pain and it’s building day after day, see a doctor or podiatrist immediately, as further running will only worsen the issue. “Like almost every overuse injury, the worse the symptoms get and the more you try to run through the pain, the worse you’ll make this injury,” says Metzl.
How to Do a Foot Stress Fracture Test
According to Metzl, there are three main ways to test for a foot stress fracture at home:
- Point tenderness
- Swelling and/or bruising
- Changes in your typical running form
To feel point tenderness, perform “the hop test.” Gently hop four to five times on the injured foot. If you have pain when you land, it could be a stress fracture. Tenderness in the middle of the bone could also signal a fracture.
Swelling in the affected area is another sign. The most common place is noticeable swelling on the top of foot. Compare one foot to the other and if you don’t see the contour of the veins on the top of the injured foot, you may have a stress fracture. Any swelling should signal that you should see a doctor. Bruising is also common with stress fractures, so that’s also a sign to see a professional.
Finally, changes in your running biomechanics could also be a sign of a stress fracture. “If you notice you’re not landing on your foot the same way you usually do because it hurts too much, get it checked out,” Metzl says.
In the end, a stress fracture is a clinical diagnosis injury meaning that your doctor can tell you if you have one with some simple tests. So if you suspect you have one, skip the at-home stuff and just head into your doctor’s office to be sure.
Common Causes of Stress Fractures
There are a few things that could lead to a stress fracture. The first is ramping up your mileage too quickly. “Bone needs time to get used to the more loading force of running, so make sure you give your bones enough time,” Metzl says.
New terrain (like more hills) or new or worn-out shoes could also contribute to the load you’re experiencing, upping your risk of stress fractures.
People who overpronate are more prone to stress fractures because they put a lot more medial loading force on their legs. Having osteopenia (lower than average bone mineral density) or osteoporosis (much lower than average bone density) can also cause stress fractures. Both genetics or not getting enough calcium in your diet can cause these two issues. Your doctor may order a bone density test to determine if you are at risk.
What’s more, a pair of studies from Thomas Jefferson University in Philadelphia sought to identify overlooked physiological factors and lack of knowledge that contribute to stress fractures in women who run. They found that those who increased their training load more quickly and those who didn’t pay much attention to nutrition and strength training were more likely to suffer a stress fracture than those who followed general mileage and nutrition recommendations.
How to Treat a Foot Stress Fracture
Upon suspecting you have a stress fracture, treat the area with ice and take a recommended dose of anti-inflammatories, but keep in mind that stress fractures are not a self-diagnosis or self-treatment type of injury. A proper X-ray or bone scan is necessary to prescribe treatment and depending on the location of the fracture, recommendations may differ, so consult your doctor immediately.
Some stress fractures won’t show up on an X-ray, so doctors typically do MRIs to definitively diagnose a stress fracture because they can detect both stress reactions and stress fractures. (An X-ray can only detect severe or already-healing stress fractures.)
Once you’ve been diagnosed, you’ll mainly want to stay off of the bone and give the bone enough time to heal. One thing Metzl notes is that stress fractures farther away from your heart heal slower because they receive less blood flow.
However, just because you have a stress fracture doesn’t mean you can’t still exercise. You can still keep your cardiovascular fitness going by cross-training. Metzl recommends low-impact activities, such as cycling or swimming, but talk with your doctor to discuss the activities you should and shouldn’t be doing as your stress fracture heals. You could also take the time to build strength with resistance training.
When you’re ready to return to running, don’t jump back into the mileage you were doing. Start with run/walk intervals and progress from there.
How to Prevent Foot Stress Fractures
First and foremost, Metzl advises gradually adding mileage to your long runs so you’re not taking on too much too soon. Experts recommend increasing your weekly mileage by no more than 10 percent each week.
Metzl also recommends shortening your running stride and quickening your cadence. A cadence of 80 to 90 steps per minute with your right foot (160 to 180 with both feet) can decrease your chance of injury.
Finally, make sure you get enough calcium in your diet to prevent osteopenia or osteoporosis. Adult runners should aim for 1,000 milligrams of calcium per day, and a good source of calcium should have at least 100 milligrams per serving. Foods such as yogurt, milk, cheese, tofu, and dark, and leafy greens are all great options.
Nutrition, in general, can play a vital role in injury prevention. Getting the right amount of calories, as well as vitamins and minerals, is important for keeping your bones healthy and therefore, sidestepping stress fractures.
Jordan Metzl is a sports medicine physician in New York City. He’s the author of three bestselling books and the creator of the Ironstrength Workout, a functional fitness program for runners.
John Vasudevan, M.D. is an associate professor at the University of Pennsylvania. He is board-certified in Physical Medicine & Rehabilitation and Sports Medicine. He is a Team Physician for UPenn Athletics and medical director of the Broad Street Run and Philadelphia Distance Run, and previously for the Rock 'n' Roll Half-Marathon and Tri-Rock Triathlon in Philadelphia. He is a director of the running and endurance Sports Medicine Program at Penn Medicine. Dr. Vasudevan provides non-operative management of musculoskeletal conditions affecting athletes and active individuals of all levels, and combines injury rehabilitation with injury prevention. He utilizes a variety of ultrasound-guided procedures and regenerative approaches such as platelet-rich plasma and percutaneous ultrasonic tenotomy. He sees patients at the Penn Medicine and the Philadelphia Veterans Administration hospital. Dr. Vasudevan attended medical school at the University of Wisconsin School of Medicine and Public Health in Madison. After his Transitional Year in Tucson, Arizona, he went to residency in PM&R at Thomas Jefferson University in Philadelphia and onwards to Stanford University for his fellowship in Sports Medicine. He has been in practice at the University of Pennsylvania since 2012.
