Stress Fractures: The Ultimate Runner’s Guide

Jun 19, 2015   //   by Terry Smith   //   Injury & Rehab Information, Stress Fractures  //  31 Comments  //  Affiliate Disclosure  

In this article, I’ll try to give you a good overview of stress fractures generally, as well as giving you a little insight into my mind (scary place to be I know!) when I’m reasoning through how to manage a stress fracture, as there are a number of variables to be aware of.

So if you’re sitting comfortably, we shall begin…

A stress fracture is essentially a crack or break in the bone. It differs from a standard fracture by way of mechanism.

Standard fractures are usually caused by a sudden, severe, high force trauma, like a fall from a great height, or a road traffic accident.

Stress fractures, on the other hand, are the result of an accumulation of sub-maximal loading over time. So the forces experienced are not great enough to break the bone outright, but the repeated application of that stress, without adequate recovery is enough for the bone to fail.

Stress Fracture Lady

Now, I don’t want anyone reading this to worry about running and the health of your bones: Your bones are organic tissue and respond brilliantly to loading. So running is generally great for bone health.

When you load a bone, like in running, and give it sufficient recovery, it undergoes a process of re-absorption and bone formation that ultimately strengthens the bone.

If however, repeated load is placed on the bone, without sufficient recovery time in between, the bone doesn’t have the time to strengthen before the next bout of loading is applied. When this happens regularly, a stress fracture can result.

This is another great example of ignoring the law of adaptation and doing too much too soon. The cardinal sign of most running injuries!

The mechanism of stress fractures can be split into four camps:

Traction (muscles and connective tissue pulling on the bone repeatedly/excessively), impact, rotation or a combination of the above. Most running stress fractures are impact related, with the fractured bone having to absorb the the repetitive ground reaction force.

Fig 1. shows the progression of bone stress.

Stress Fracture Progression

Fig. 1: Stages of bone stress leading to stress fracture

Signs & Symptoms

You can have a stress fracture in any bone, but it tends to effect the weight bearing bones in runners.

Common areas include:

  • 2nd and 5th metatarsals
  • Tibia
  • Fibula
  • Navicular
  • Neck of femur

Diagnosing stress fractures

A big part of diagnosing stress factors, is in the subjective history, or the story the patient tells you.

In runners, there is traditionally a story that involves a change in training. This can be a sharp increase in mileage, or increase in intensity, such as adding in a new plyometric programme.

It could be as simple as a change in footwear but there is usually a change somewhere.

The location of pain, tends to be very local to the area of the fracture. There is often some swelling present too. In the early stages of the condition the pain is felt on weight bearing and is activity related, so pain is felt on running and worsens the more you do. As the condition progresses, the pain is there even at rest and often manifests at night.

Physical tests that can help diagnosis include palpation (touching in and around the painful area), as mentioned above, you would expect quite a local area of pain, not a widespread, diffuse pattern. Impact tests, although a bit cruel, can help with diagnosis. These include hopping, jumping and stamping and you’re basically looking for reproduction of the patients symptoms. These are often used as objective markers, a way to measure progress, so once they are pain free it’s a good sign that you’re ready to progress.

From an imaging perspective, MRI is the method of choice for diagnosing stress fractures.

Prevention / How to manage stress fractures

If I’ve reached the diagnosis of a stress fracture, the next question is: How are we going to manage it?

Not all stress fracture are made equal, so at this stage I have a few things going through my mind:

  1. Is it a high risk fracture?
  2. What are pain levels like? and how irritable is it?
  3. What is the quality of the bone like in the first place?
  4. Biomechanics

Is it a high risk stress fracture?

A high risk stress fracture, is a stress fracture with a high risk of non-union or delayed healing. Any area that has a poor blood supply, or risk of developing into a full fracture, can be classified as high risk.

A high risk fracture is managed with either surgery or at the very aggressive end of conservative management (see fig.2).

High risk fractures include:

  • Neck of femur: Tension side (In certain fractures you get a tension side and a compressive side. In the compressive side, as the name suggests, the bones are being pushed together so actually favours union and healing, whereas the tension side is repeatedly being pulled apart, so it can be difficult for that area to heal and unite).
  • The patella
  • Medial malleolus
  • The base of the 5th metatarsal
  • Navicular
  • Sesamoid bones of the big toe

Pain levels & Irritability?

Having taken on board whether the stress fracture is high or low risk (most running stress fractures are low risk) you can then use pain levels, and how much activity it takes to bring on the pain, as guidance on how aggressively you need to offload.

Intuitively, we need the area to heal. Luckily, all that wisdom is already in your body. All you have to do is give it the right environment to heal in. This means taking the load off the injured area to give it a chance to do this.

In the lower risk stress fractures, you only need to back off activity, to pain free levels. It’s wise to maintain the strength and health of adjacent body parts, so there’s nothing wrong with training the other joints, other leg, or upper body, whilst waiting for the injured area to heal.

You may also cross train, as long as it’s pain free. Common examples are cycling and pool running. I’m a big fan of deep water pool running when you’re injured. You can maintain good running mechanics and still get all the physiological benefits of your run, just without the load!

So, if you work at the right intensity, you can still do a lactate threshold workout in the pool.

Bottom line is, if you understand stress fractures (which hopefully this article is going a long way to helping) and have been cleared of a high risk stress fracture, then there’s still loads you can do to maintain, and even further, your fitness.

Stress Fracture Management

Figure 2: A continuum of conservative offloading.
Conservative or Aggressive Conservative?

What’s the quality of the bone like in the first place?

Clearly, if you have a higher bone density i.e. stronger bones, that bone is less likely to develop a stress fracture and be better able to withstand the repetitive forces of running.

New runners, especially if there has been no other history of regular weight bearing exercises, tend to have less dense bone tissue, compared to runners who have been running and exercising regularly over years.

Poor nutrition and low vitamin D, have also been associated with poor bone health and therefore could put you at a higher risk of a stress fracture.

Women, with what known as the female athletic triad (eating disorders, amenorrhoea and osteoporosis) are also likely to have poorer bone health. It’s been reported that stress fractures in athletes with menstrual disturbances is 2 to 4 times that of eumenorrheic athletes.

A lack of oestrogen (or testosterone in men) has been related to poor bone health.

These issues are important to know, and with the help of a nutritionist or consultant, supplementation or medication can form part of the management plan.

Biomechanics

The last thing whizzing around my brain at this point, is biomechanics. Biomechanics don’t necessarily cause a stress fracture, but they can give us the clues as to “why there?“.

I’m always fascinated why runners come in with pain that manifests in different areas. Why does runner ‘X’ have a stress fracture in his tibia and runner ‘Y’ have a stress fracture in his 5th metatarsal?

Likewise, why does runner ‘A’ have illiotibial band syndrome and runner ‘B’ have plantar fasciitis?

They’re all, likely, guilty of too much too soon, but biomechanical analysis (a posh word for just looking at how you move), gives us an insight into why that particular area has been overloaded.

It may be enough, just to offload the area until pain free, and then just be more graded with your mileage and intensity to prevent further problems. However, some people may benefit from a slight change in running technique to decrease load on that area.

Let me give you a couple of examples of how I change running technique and my reasoning behind each one:

Example 1: Tibial stress fracture

The cues I tend to use here, to offload the anterior medial tibia, are similar to that of medial tibial stress syndrome (MTSS) (some people believe tibial stress fractures and MTSS are on a continuum anyway, so it makes sense)

  1. Increase cadence: One of my most used running re-education cues across the board. The best way to do this is via the use of a metronome. There are lots of free metronome apps if you have an iPhone, or you can by one pretty cheaply from places like Amazon. There’s no set stride rate you should aim for, so have a play around with it a bit. Generally, I go for 5%-10% more than your current cadence at a given pace and see what happens. You can always gradually increase it from there and re-assess the ‘experiment’. The theory behind increasing your cadence is to decreased an over stride, get you landing closer to your centre of mass (CoM) and with a straight tibia, as opposed to your tibia flicking out ahead of the knee. Think of it a bit like a pole vaulters pole. As they approach the jump, they plant the pole ahead of themselves so you see this big, anterior bowing of the pole, great for pole vaulting but not so good for tibias! If you can imagine the pole vaulter placing the pole down vertically, and not ahead of themselves, you will see a pretty crappy pole vaulter, but also less anterior bowing of the pole, that’s what we are looking for: less anterior bowing = less force through the painful area.
  2. Increase step width: Trying to move the load from the medial shin to achieve less varus (side bending) tibial bowing. I try and bring about this change using a variety of cues, and what works for one doesn’t always work for the next. Generally, asking people to have some daylight between their legs, imagine running on either side of a yellow parking line or, recently, i’ve been getting my runners to run with a resistance loop just above their knees, and instruct them to keep the pressure on the band.
  3. Stiffen the ankle: The idea here is to decrease the amount of dorsiflexion the ankle goes through. Lessening dorsiflexion, means less tibial bowing from the action of soleus as it tries to decelerate the tibia. Stiffening the ankle also helps to pretension the muscles so they can work reactively and elastically. Good for speed but also takes the load of the bone itself.
  4. Change the direction of the ground reaction force: Again, we are trying to decrease the anterior tibia bowing. If we go back to our rubbish pole vaulter, as we discussed, if he places the pole out in front of him with forward and downwards force it will create anterior bowing, however, if he plants the pole down with a backward and downwards force, it will not bow anteriorly, but posteriorly i.e the force will go more through the back of the tibia. Any change in the direction of the ground reaction force to a more backwards and downwards force will decrease the load in the anterior tibia and may be enough for us to keep running without pain. To cue this, I often video them and freeze the frame of them running when their swing leg is at its highest. From this position I instruct them to push their leg back and down, in a backwards tick type direction, using their glutes to perform the movement. Sometimes i’ll ask them to paw back on the ground (bit of a controversial cue from a performance perspective, but can just get them to direct the force more backward and down).
  5. Posture: Encourage the patient to run up tall. I often use the ‘helium balloon attached to the crown of the head’ cue. This cue helps decrease an anterior pelvic tilt or a forward lean from the waist. Both of these mechanics lead to the centre of mass shifting forwards. To compensate for this, you will have to over stride with the next step = more load on knee and shin area.

Example 2: 2nd metatarsal stress fracture

There could be a few reasons why the 2nd metatarsal is being overloaded. For simplicity, let’s say that gait analysis showed, generally good biomechanics higher up, but a pronounced forefoot strike. This would put a lot of stress through the metatarsals so would be a good idea to change.

You could work on the “oranges cue” (I have to give credit where it’s due, this cue was taken from the excellent Dr. Andy Franklyn-Miller and John Foster).

Basically, the idea of the “oranges cue” is to imagine that you have an orange taped to the bottom of your foot, around the mid arch area. Your goal is to squash the orange, without letting the orange squirt out the front (heel strike) or back (fore foot strike). As you’ve probably worked out, this will encourage a more mid-foot strike pattern.

Once you have all the above information, you should have enough data to make a decision as to how you’re going to manage this stress fracture, and, where on the management continuum you are going to begin (Conservative? Aggressive Conservative? Somewhere in between?).

Use your objective markers (hopping, jumping, stamping) along the way, to assess progress.

Stress fractures can take anywhere between 4 to 12 weeks to recover so, as always, I firmly believe that prevention is better than cure.

Stress fractures rarely surprise you out of the blue, there are warning signs along the way. Without going too deep in a running article, you’re body has great wisdom, if you listen to what it’s telling you, it will guide you to the right path.

About The Author

Terry is a Physiotherapist who specialises in the rehabilitation of running injuries. He began his career in 2007 with the NHS. Since leaving the NHS in 2010 he has worked in fitness centres/gyms, a pro sports team and spent 2 years in Canary Wharf working for one of the biggest investment banks in the world as an Advanced Lead Practitioner. Terry is also a certified barefoot running coach and UK Athletics Leader in Running Fitness. Visit his website more great running advice.

 

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31 Comments

  • Thanks for this. I am two week into a 4th metatarsal fracture, the bone snapped during a race. Five year prior I fractures the 3nd, then 2nd, than 10 months later my femoral neck. It is no fun, but it does heal. I find that pain continues long after the healing, but for me that is a good thing, it keeps me more conservative for a while.

    • Hi Hilary,

      Thanks for taking the time to comment. It sounds like you’ve definitely had your fair share of stress fractures! I really feel for you, it’s certainly no fun to be out of action with a stress fracture. Whenever, I have an athlete who has a history of stress fractures, their bone health is in the back of my mind. Have you had it checked out? other than this, my advice would be to pace your training as best you can and maybe have someone look at you running. I notice 3 metatarsal fractures you’ve mentioned, could be something to do with your biomechanics?

      Wishing you a speedy recovery

    • Yikes. I am afraid I have a stress fx in my 4th metatarsal as well. I am training for an Ironman in July and was wondering what was the worst that could happen if I ignored it. Guess you just answered my question. Thanks for the info!

      • Hi Maggie,

        I’m glad you found the info helpful. If there was one piece of advice I would give, it would definitely be: DO NOT ignore it! We all have little niggles here and there that come and go with running, but this is definitely not one to run through. Remember, there is plenty you can do to maintain, and even further, your fitness whilst you’re waiting for it to heal.

  • Having had three stress fractures in the last year this was an interesting read. I have added more calcium to my diet and started taking vitamin D to strengthen my bones and ditched my ultra light shoes for something more supportive. But am struggling to regain the same pace as a year ago.

    • Hi Annette,

      I’m glad you’ve added some supplementation to your recovery plan, especially if you’re getting recurrent fractures. The road to recovery can be very frustrating, especially when you’re below the performance level you previously achieved. Keep positive in the knowledge that your body is very adaptable. If you consistently stress it the right amount it will adapt and improve. Just be mindful of over training as you can sometimes over reach in search of your previous fitness levels. Train smart and you’ll get there – Good luck

  • Thanks for this, interesting read and stuff I will take on board. I’m 9 weeks in with neck of femur stress fracture .. pretty fed up but seems like I’m already doing all the right stuff. Hopefully be back a stronger runner soon :)

    • You’re welcome, Cat, I’m glad you found it helpful and gave you the re-assurance you need that you’re on the right track! Remember there’s plenty that you can do to maintain your fitness whilst the stress fracture is healing. Although I strongly advise you discuss this with your medical team first.
      Good luck with your rehab

  • I had a stress fracture in my foot after Brighton marathon 2014. I went to a&e and they said it’s just a strain (aka stop wasting our time and here’s some things to do…) few days later I was at the physio with my son. She asked “did they use ultra sound on it?” Which they did not, to which she replied “then how do they know it’s not a stress fracture?”, she put the ultrasound on the foot… she found the fracture be used it hurts lots! That’s the other way of checking apparently. So the treatment that a&e recommended for a sprain was wrong and in some cases made it worse!

    • Hi Matthew,

      Sounds like you had a frustrating time with your injury. I hope you’re now well on your way to recovery!

      Diagnosing stress fractures can be very challenging. They don’t always show on imaging (such as X-ray) immediately, but they can show up a bit later down the line, so they are often missed. You’re absolutely right, using a high dose of ultrasound over the stress fracture can help diagnosis, as can using a tuning fork (and you’re right, it can be very painful!).

      Good luck with your rehab, I hope you’re back, running strong, soon.

  • Interesting read. I’m a triathlete (been doing triathlons and long endurance-based sports for a number of years) and was diagnosed with a stress fracture in the mid-shaft of the femur 2 weeks ago. No bone density issues, no increase in mileage or any deficiencies so none of the common reasons. I was told that a stress fracture in the shaft of the femur is unusual? I would be interested to know your thoughts in terms of biomechanics which may give a clue as to why it happened where it did?

    • Hi Eva,

      Definitely an interesting one. Obviously it’s difficult giving any accurate advice without seeing you, but here are my thoughts… You’re right, mid-shaft femoral stress fractures are rare, but are noted in the endurance running community. They can be difficult to diagnose but using a test called the fulcrum test can be helpful in diagnosis.

      I think it’s likely that there may be a few factors at play, that accumulated together, have been enough to overload the bone. There is usually and increase in intensity in training, may not necessarily be mileage but maybe intensity, speed, hills for example. Have you changed the surface you run on? I came across an interesting case series in the British Journal of Sports Medicine that looked at femoral stress fractures from girls in the same lacrosse team. They found that moving from the track to harder icy/frozen grass was one of the contributors. Other things that spring to mind are quads strength and bulk. If you have good quads strength/bulk it acts as a shock absorber for the bone, so if this is inadequate it could have led to more stress through the femur. Biomechanically, I can only think of an overstride (landing far in front of your centre of mass) as being another possible contributor, anything that really loads the quads (like an overstride) I can reason would load the femur as well. Does any of this ring true for you?

      • Hi Terry
        Many thanks for your reply. Appreciate that it is difficult for you to give accurate advice so thanks for sharing your thoughts.Quad strength is no issue, I have rather strong quads (and I wonder if this actually delayed the diagnosis since I was told from assessing the scan and the callus formation it happened about 6 weeks prior to the diagnosis. However, I trained another 3 weeks without any pain. The pain I was getting was around the hip, not near where the fracture has occurred).
        I have a suspicion that this stress fracture may have something to do with a niggle around my right heel which occurred after cross country skiing in December last year. It was mistaken as Achilles tendinopathy but turned out it was the Plantaris tendon (ultrasound diagnosis). Is it possible that an altered foot position to avoid niggle could have contributed to this stress fracture? Thanks for your thoughts

  • Hi ,I had been running for a few months with painful hip and numb feeling in my heel. During a run the pain each time I landed on my heel became to much and I has to stop. It took 5 weeks before I was diagnosed with stress fracture in my heel. 4 months later I’m still not able to run. Hip still no better but doctor doesn’t seem concerned about this they just seem to fixate on my heel. Scared to start running again as just walking around still gives me pain in my heel. How much time does it take to heal? Thanks

    • Hi Mandy,

      Usually most stress fractures heal within 4-12 weeks, so it sounds like your way past that. Whenever I come across a patient who is not getting better, i usually think 3 things:

      1) Red flags – this is serious pathology – I would like to think that any serious pathology has been ruled out by your medical team
      2) Yellow flags – These are psycho-social influences on pain. Pain is a fascinating experience (although i know you probably don’t think it’s particularly fascinating at the moment) and pain can still be present, even without any physical damage at all. Thoughts, feelings, emotions, anxiety, stress, depression etc can all maintain pain long after the injury has healed. Obviously i have no idea whether this is happening in your case, but I always screen for it in any patients that are not getting better in a particular time frame. May be worth bearing in mind.
      3) Mechanical stress and strain – This basically means that you keep irritating the area by putting too much load through it. Think of it like having a cut on your hand, and you repeatedly pick the scab off = takes ages to get better. If this is the case you may do better at the more aggressive end of the conservative management continuum e.g. air boot or crutches etc.

      Anyway, these are just my thoughts, i hope they help and i hope you turn the corner soon. Have trust in your medical team and there’s nothing wrong with a second opinion if you feel you need it.

  • I think I may be suffering from a stress fracture of the tibia. Who’s the best person to go to to get a diagnosis. 2 weeks of no running and although it’s not excruciating pain I can still feel localised pain on the inner ankle bone and I know it would be agrivated it I run.

    • Hi Melissa,

      I would advise seeing a Physiotherapist, and ideally one that specialises in running injuries. What part of the world do you live in?

      The other condition that jumps to mind is medial tibial stress syndrome (MTSS). This can often mimic a stress fracture and would have to be ruled out. I’ve got some info on this over at my site if you want to have a look.

  • Thanks, yes, this is interesting. I’ve also done the tibia maybe four times (three diagnosed, plus ‘you’ve broken your leg before’) and the femur last year. Hills don’t seem to help with the femur, though I’m not sure why that might be biomechanically? It’s interesting what you say about anterior pelvic tilt re the tibia and maybe that would play a role with the femur. Stress fracures are more common than is diagnosed – GP didn’t believe me re the femur and I’ve heard of other runners told that they’ve ‘strained the hip flexor’ etc. when it sounds like a potential stress fracture. Bone density is normal in my case so it seems poorly understood why people have a history of recurring stress fractures – in other words, if you’ve fractured already, you’re probably more likely to fracture again. Though I’m just a punter, not an expert.

    • Yes, I was thought to have Psoas (Hip Flexor) Tendinopathy for some time before I got a second opinion and that physio suspected stress fracture of femoral neck. Noone had even suggested to me prior to that. I think I was lucky though really as they usually seem to take even longer to be diagnosed.

      I am being tested for Calcium/Vitamin D levels but I think that’s unlikely (as my diet is very good) and I also can’t pinpoint any of the other obvious causes (my training plan was being supervised by a sports therapist AND I did as I was told!!) so I’m at a bit of a loss as to how I’ve got here, which doesn’t help in trying to do the right thing to ensure it doesn’t happen again! Frustrating..

      • Hi Charlotte/Cat,

        Thanks for taking the time to comment and sharing your stories. I think, because stress fractures are so rare, and can mimic other, more common diagnoses, I think they are often mis-diagnosed. Understanding why you have a stress fracture is very important, especially if it’s a recurring theme. Put simply, any stress fracture is due to too much load at that particular part of the bone, however, this basic understanding does little to work out why/how it’s been overloaded. In my opinion, it is usually a combination of the factors that I discussed in the article. The real skill is working out which if them are playing a part in this particular stress fracture and to what degree. I wish you both well with your running and hope you find a solution to what, I can tell, is a real frustration to you both.

        Best wishes

  • Wow…an interesting read! I unfortunately was diagnosed with a tibial stress fracture 6 days before the London Marathon in 2013!…i have low bone density for two out if the three reasons highlighted and this was a year after a metatarsal stress fracture.
    Thank you for the article, it gives me some hope with regards to future running potential & approach to that!
    Tracey :o)

    • Hi Tracey,

      Thanks for your kind words. It’s great to hear that you found the article helpful. I have always felt that my best “technique” as a physio is education. Helping the patient to understand their problem and giving them the tools to help themselves is a key underpinning of what I do. The human body is a wonderful organism and, I believe, everybody has the healing potential within them, they just need a bit of guidance along the way.

  • Hi, thanks for this article – really informative and a good read. I picked up a stress fracture of the left calcanium 2 months ago after upping my mileage way too much, way too soon when training for an ultra-marathon. It happened on the walk home after taking 7 minutes of my half marathon PB. Elation to agony! It’s been an incredibly slow healing process – aircast boot, several weeks non-weight bearing. I’m now partial weight bearing for another week then hopefully I can ditch the crutches but keep the boot for a fortnight. At this stage I’m really keen to know when I can start running again as my consultant is advising that I can really only do light core work and upper body strengthening with my physio at this stage. Interesting that you didn’t refer to this specific area of the foot in your article so I guess not that common? I have a bone density scan and bloods next week but given the amount of time I spent with my physio before the injury (glutes/sciatica related) I’m fairly sure this will be biomechanical. Anyway, thanks again for taking the time to get your thoughts down.

  • Thanks for your interesting article. I was in a lot of pain when running and s stress fracture of the hip was suspected. Luckily it had not quite reached this stage and an MRI showed bony oedema in the medial border of the femoral neck. It looks like this is the result of a changed gait, due to snapping an ankle ligament. Now working on strengthening the weak ankle . My physio has given me lots of exercises to strengthen the ankle and the hip. I’ve not run for 5 weeks and am not to try for another 5 . I’m still getting pain often when I twist , or move differently. Thoughts keep going through my head now that I’ll never be able to run pain free again , and will it occur again and I end up getting a stress fracture. Once you’ve had an injury like this , what are the odds of it reoccurring? , hopefully my biomechanics will be corrected

    • Hi Fran,

      The first thing I want to do is re-assure you that, if you want to run again, there is absolutely no reason why you can’t. They key to prevent re-occurrence is to work out why it happened in the first place. It’s a good idea to get your bone scan and bloods done. This will give you an idea of the quality of the bone to begin with. If all’s well here then it actually becomes a very simple process. Stress fractures happen because of too much loading. The good news is that bones adapt and get stronger, you just have to get the loading right. When you return to running start slow and always think about under cooking your mileage rather than overcooking it. The reality is that I see people running with the strangest mechanics out there and pain free. They get away with it because their bodies have adapted to cope. Getting a coach to help you progress you mileage safely might be a good solution especially if your worried. There’s this James Dunne guy who’s quite good I’ve heard! Good luck Fran!

  • Hi
    Great article as always, thank you.
    I am returning to running after a stress fracture in my 2nd metatarsal and I’m not sure if I am being sensible or over cautious but it’s getting frustrating. When I run I feel nothing but sometimes afterwards I feel something light and dull in the area, and when I touch it it feels like a small bruise. Am I still ok to run at this point?
    Thanks
    Belinda

    • Hi Belinda,

      It sounds like you’re just about getting away with it at the moment. Be careful not too up your mileage and intensity to quickly and be guided by pain. Like all stress fractures, 2nd metatarsal fractures are a case of too much too soon, however, I often see runners either running too far up on their toes or they have a problem with their big toe which means all their body weight gets shifted to the 2nd met which is not designed to take the load. If the problem persists I’d recommend seeing a physio that specialises in this area or a good sports podiatrist.

      Hope all goes well for you

  • Hi Terry, I believe I have a stress fracture of the navicular bone? Yes, checking with my doctor who didn’t say which bone but it’s higher up on the arch. Never thought as a minimalist runner that I would ever say I have a fracture but of course, the pain says, yes! I was on a track and doing some training in Vibrams when I got the first pains and of course, I failed to give myself a week or two rest. Now, 4 weeks in a boot. :(

    You gave some biomechanical clues causing injuries, any thoughts on form issues that may have contributed to a navicular stress fracture? I would love to hear any ideas so I can avoid this again.

    Thanks,
    Nicole

    • Hi Nicole,

      Sorry to hear about your injury. There’s nothing more frustrating to a runner than not being able to run!

      It’s interesting that you say you were running in Vibrams. Is this a new change in footwear or have you been running in them for a long time? Minimalist shoes will lead to your foot having to take more load, so it could just be that you’ve changed footwear and not given yourself enough time to adapt to the greater stresses gong through your bones. I’ve got an article on my site about the best shoes for running and I’m a big believer in shoe rotation for runners. As far as biomechanical insights I’m thinking that stress through the navicular means stress through the arch. I wonder if you go through lots of pronation when you run. This could be caused by movement from the hip down to the foot itself. I’d be thinking strengthening glutes, foot muscles and widening your step width when running. Obviously I’m just guessing and throwing around ideas at this point so please don’t take this advice as gospel. As always I’d advise getting to see someone that specialises in this area to help you through.

      Best Wishes

  • Classic case for you here Terry. Changing my gait, too much too soon, L2nd metatarsal stress fracture. (actually, from the speed of recovery, I’m thinking it may just be a stress reaction).

    So, in my 3 month journey so far, I’ve been very careful to “listen to my body”. First sign of soft tissue stress and I’ve taken between 1 and 3 days off without hesitation. But the bone didn’t complain before it failed.

    Q. Is there a way of “listening out” for oncoming SF, or is it a case of learning, and acting on hindsight next time?

    Thanks for this excellent article, btw

  • Hi David,

    Thanks for your kind words about the article…It sounds like your being very sensible with your training and adding in rest days where you feel they are necessary. This will stand you in good stead for sure.

    It can be difficult to monitor if there is no pain associated with your condition. You may find that, if you have a feel around the 2nd metatarsal, you can then feel some discomfort and can use that as a marker (not completely accurate though).

    As mentioned to Belinda above, I tend to find runners with 2nd met fractures tend to run too high up on their toes or have problems with their big toes. You big toe is your big toe for a reason. Evolutionary speaking it has evolved to be bigger than the rest of our toes as it’s “designed’ to take our body weight as we run and walk. If you have an issue here such as a stiff big toe (Hallux rigidus, Hallux valgus, Hallux limitus) it could lead to your body weight being transferred to your 2nd met and therefore overloading it.

    I would definitely advise continuing with your approach to management and if the problem persists then a good sports podiatrist or specialist physio would be my next stop to check the above issues.

    Hope this helps and best wishes with your recovery!

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