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foot injury

Stress Fractures: What Are They and How Do They Occur?

By: Jason Rudolph, MD   December 17, 2018

Most people understand that a fracture occurs when a bone breaks, usually from a fall, accident, or direct impact onto the bone. A stress fracture is a little bit more mysterious — it is also a break of the bone, but doesn’t always occur from a specific injury. A stress fracture is the result of an overuse injury to the bone. Think of the bone like a paper clip — if you keep bending the paper clip, it gets warm and eventually breaks. Two types of activities can cause stress fractures: “normal activity on abnormal bone” and “abnormal activity on normal bone.” 

“Normal activity on abnormal bone” refers to an otherwise unsuspecting patient, going about her normal activities, who develops pain in the bone. The underlying cause is then traced back to having “weaker bones.” There are many causes of weaker bones, including osteoporosis, low vitamin D levels, or low activity levels, which can cause the bones to lose their natural strength. 

“Abnormal activity on normal bones” refers to a healthy person who takes up an activity too quickly, without building up a tolerance. Classic examples include new recruit in the army who hikes 20 miles with a heavy backpack at the beginning of boot camp, or a high school athlete who has a lazy summer and then runs for two hours at the first soccer practice of the fall.


A stress fracture typically occurs in one of the bones in the lower extremities, most commonly the tibia, ankle, or one of the bones in the foot. Diagnosis is based on obtaining the appropriate history followed by imaging. Often the initial X-rays are normal and definitive diagnosis is made with an MRI scan. 


Treatment is directed to eliminating the stress that caused the fracture in the first place. This includes activity modification and immobilization of the injured body part with a cast or a removable walking boot. Fractures take four to six weeks to heal, and the same timeline applies to stress fractures. Very rarely, a fracture may not show signs of healing and surgery may need to be considered.


Prevention of another stress fracture is very important. This is directed toward proper preseason training for athletes and maintaining a proper diet with enough calcium and occasionally checking vitamin D levels for others.

Dr. Jason Rudolph is an orthopedic surgeon at Coordinated Health who specializes in foot and ankle reconstruction and sports injuries.

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