Is It a Stress Fracture?

Research shows that the number of adults over 50 with low bone mass is expected to reach 71.2 million by 2030 (a 29 percent increase from 2010), and the number of fractures is expected to grow proportionally, according to a study published in the Journal of Biomedical Science.

Especially vulnerable groups include women and people with a low body mass index (BMI). “Most stress fractures are 5 to 1 in women versus men,” Kadakia says. “Women have a harder time than men because they have rapid bone loss after menopause.”

In a study published in 2022 in the journal Sports Health, researchers looked at more than 41,000 people with stress fractures, most of whom were over the age of 60 and had a BMI of less than 30 (a BMI over 30 is considered obese). They found that the majority of stress fractures in older adults occurred in those with a low BMI, especially women. “There’s a reason for that,” Kadakia explains. “Fat cells generate estrogen, and that helps generate bone stock. That’s why people who are heavier have better bone quality than people who are thinner.”  

Other risk factors for stress fractures include steroid use, smoking and nutritional deficits of calcium and vitamin D, as well as protein. In fact, a review of research published in 2019 in Computational and Structural Biotechnology Journal suggests that protein intake above the recommended dietary allowance may reduce the risk of hip fractures and may help maintain bone density in older adults.

Warning signs of a stress fracture

Stress fractures can occur anywhere, but they commonly develop on weight-bearing bones such as the shin, heel and foot bones, Martin says. Given the fact that “these injuries almost universally result from an increase in activity, they can be misdiagnosed as a sprain or tendinitis, especially in areas like the foot in which many other overuse injuries to surrounding soft tissues — like tendons and ligaments — are seen.”

Some telltale signs that a stress fracture is the cause of your pain:

• The pain starts and gets worse during physical activity.
• It persists even when you’ve stopped the offending activity.
• It’s more noticeable when you’re resting (a sign the injury has progressed to a more advanced stage, Martin says).
• The affected area is swollen.
• The affected bone is tender to even the lightest touch.

When to see a doctor

Another way stress fractures are sneaky: They don’t immediately show up on an X-ray. You’ll feel the pain, but “you won’t see a change in X-rays for five to six weeks,” Kadakia says. “A true stress fracture is a fracture that’s incomplete, which means the bone hasn’t cracked in half yet. It’s a tiny microscopic fracture of the bone, versus a large macroscopic fracture of the bone. That’s why you can’t see it on X-rays initially.”

That’s not to suggest you should wait to see a doctor. “After a week, if you still have pain and swelling, you should see your physician,” Kadakia advises. If your doctor suspects a stress fracture but can’t see it on an X-ray, they may recommend a bone scan or MRI.

When it comes to treatment, the goal is to control the pain, give the bone time to heal, prevent complications (including a complete break) and restore normal use of the fractured area. Recovery usually takes six to eight weeks.

“Depending on the bone involved and the stage of injury, different treatment options may be recommended, ranging from nonoperative treatment with rest and/or a cast or splint to surgery,” Martin says. Only rarely is surgery required.

That’s the good news: “Stress fractures almost universally heal on their own,” Kadakia says.