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Is It a Stress Fracture?

Warning signs and symptoms of the common injury

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Stress fractures are sneaky. Unlike a regular fracture, which wastes no time making itself known (the bone is broken immediately on impact), a stress fracture takes its time, developing gradually over a period of days.

Even then, it doesn’t reveal itself on X-rays. That’s how tiny and microscopic the break, or crack, in the bone is — compared with a regular fracture, which is more obvious on imaging tests.

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Stress fractures occupy one end of the spectrum in a category of what experts call “stress-related injuries,” which happen when too much strain is placed on a particular part of the body, explains Murphy P. Martin III, M.D., assistant professor of orthopedic surgery at Tulane University School of Medicine. When that body part is the bone, the added stress can result in anything from a bruise to a small break, also known as a stress fracture.

5 Warning Signs of a Stress Fracture 

  1. Pain that gets worse during physical activity
  2. Pain once you stop physical activity 
  3. Pain at rest 
  4. Swelling
  5. Tenderness

It doesn’t take much to wind up with one. “You don’t have to be a walker who’s suddenly training for a marathon” to experience a stress fracture, says Anish R. Kadakia, M.D., professor of orthopedic surgery at Northwestern University Feinberg School of Medicine. Even a small change can do it, especially if the stressed body part doesn’t have time to heal.

“If you’re a 2-mile walker and now you’re going 2½ miles, that sudden increase in activity can absolutely be a cause for a stress fracture,” Kadakia says.

Who’s at risk of a stress fracture?

If you know a little about stress fractures — namely that they’re common among competitive athletes and people who serve in the military — you may think you’re in the clear. Turns out, people over age 50 are also at particular risk for stress fractures. The culprit: dwindling bone mass. As bone mass decreases, the chances of experiencing a stress fracture increase.

“As we age, we all lose bone stock,” Kadakia says. “By age 30, you’ve deposited all the bone you’re ever going to deposit. After that, it’s a slow decrease.”

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.”

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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.
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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.

Stress Fracture vs. Fragility Fracture: What’s the Difference?

There’s a difference between stress fractures and fragility fractures. “Stress fractures occur when normal bone is subjected to abnormal loads,” Martin says. For example, you’ve taken your exercise regimen from a zero to a 10 — overnight.

Fragility fractures, on the other hand, “occur when abnormal bone is subjected to normal loads,” Martin says. “Fragility fractures are those typically thought of as falling and breaking a hip. They are more common in women because of age-related hormonal changes in the body, which affect the density of bone.”

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