Keys To Treating Stress Fractures In The Endurance Athlete

John Mozena, DPM

What Is The Most Effective Diagnostic Imaging For Stress Fractures?

Plain radiographs are the first option for evaluating stress fractures. Unfortunately, the sensitivity may be low. X-rays are positive only 33 percent of the time for navicular stress fractures.8,9 Often, it takes up to three weeks to visualize the stress fracture when bone callus and bone resorption occur.

   A bone scan is almost 100 percent diagnostic for stress fracture but a positive result can indicate other issues as well.8,9 Magnetic resonance imaging (MRI) is also good for detecting stress fractures and can also help with soft tissue injuries. Computed tomography (CT) scans may be the best imaging technology for certain stress fractures but it is important to do 1.5 mm cuts so one does not miss the fracture.8,9

Pertinent Insights On Fracture Treatment

Rest is always the best option for treating stress fractures. The amount of rest varies upon location of the fracture, severity, the strength of the body’s healing response and nutrition. One should cast a stress fracture for four to eight weeks at a minimum.10 However, 12 to 16 weeks may be required for certain fractures and certain bones. Returning to activity depends on pain and the amount of healing the doctor perceives.

   Treatment starts with no weightbearing for certain high-risk stress fractures and may progress to weightbearing as tolerated. The athlete’s activities may progress to non-weightbearing activities, such as swimming. This progresses to partial weightbearing activities like riding on a spin bike with low resistance at first and progressing to higher resistance, and standing with time. Eventually, patients can use an elliptical trainer and finally do full weightbearing exercises. Once runners are clear for activity, they should increase their mileage by 10 percent a week and start with softer surfaces like soft groomed trails and tracks.

   Using a below the knee cast for treatment of stress fractures can be very beneficial since it redistributes weight and decreases motion at the fracture site. Using an air cast also may be helpful. It puts light pressure on the bone, increasing blood flow to the area to assist in the healing. Control of swelling caused by the fracture should begin as soon as possible to prevent prolonged healing. Anti-inflammatories may also be helpful.

   Another key component of treatment is the custom orthotic device. Functional orthotics can help control subtalar pronation. Use of these devices can decrease the vector forces through the foot, which can alleviate some of the weightbearing forces. Orthotics can also redistribute the weight equally throughout the foot, keeping extra pressure off the fracture site. Studies have shown that orthotics not only treat but can prevent lower extremity stress fractures. In a study involving military recruits, Finestone, Milgrom and their respective colleagues showed that orthotics can lower the incidence of stress fractures to 10 to 15 percent in comparison to 27 percent without them.10,11

   Other treatment considerations would include but are not limited to nutrition, vitamin therapy, running surfaces, avoiding a large cant in the road, shoe therapy, body mass index, gravity and quality of training, hormonal therapy, age, race genetics, calorie intake and calcium levels.2,4

In Conclusion

High-risk stress fractures include the anterior cortex of the tibia and medial malleolus, the navicular, and the base of the second and fifth metatarsals. Low-risk fractures include the fibula, calcaneus and the metatarsal shafts. More aggressive treatment is required for high-risk fractures. One should consider treatments such as additional rest, casting, non-weightbearing and possibly surgery.3


Stress fractures can also arise in recreational runners, especially over a long weekend with nice weather. Speaking from experience, I was one of five runners who presented to a single office a few summers ago after a long 4th of July weekend with lot of daylight and cool temperatures. We all forgot the rule not to increase distance by more than 10% a week. After five days of continuous long runs, our first marathon training was derailed.

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