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Analyzing Stress Injuries in Runners

Published in Orthopedics, Women's Services, Men's Health, For the Health of It, Exercise Author: Stephen Jacobsen,MD

Stress injuries are a common cause of pain in runners, particularly after an increase in mileage or intensity of running, such as when training for an event. They can occur in just about any bone, but most commonly affect bones in the feet (metatarsals), lower legs (tibia) or hip (femur). They are a result of repetitive stress on the bones of the lower extremities, causing microscopic damage to the bones without sufficient time for recovery. A stress injury may start out as a stress reaction, with bruising and swelling in the bone, then progress to an actual stress fracture, when a crack develops in the bone and can result in the bone breaking.


Typically, symptoms start as an aching pain in the affected bone that gets worse with activity, then may progress to a sharper pain with tenderness in one location, and eventually, pain present at rest. If the stress fracture is in the lower leg or foot, especially toward the front of the foot, there may be visible swelling compared to the other side.


Evaluation of a stress fracture starts with a physical exam and X-rays, although early stress fractures or stress reactions may not be visible in X-rays at first. If a runner has persistent pain, and X-rays do not show an obvious cause, an MRI may be helpful to identify an early stress fracture or other cause of pain.


The mainstay of treatment for stress fractures is rest, or at least, avoiding the activity that caused the injury for a period of time. Depending on the severity, treatment may also require protection with a boot or crutches. Most fractures take six to eight weeks to heal if they are adequately protected. However, it is often possible for a runner to stay active while a stress fracture is healing, by switching to low impact exercise such as cycling or swimming in order to maintain cardiovascular fitness. If a stress fracture persists or recurs despite conservative treatment, surgery may help the injury to heal, but most of the time surgery can be avoided with adequate rest.


The best way to prevent a stress injury is to gradually increase mileage and intensity when training, allowing enough time for your body to recover and adapt. Alternating with other types of exercise, such as cycling or weight training, is a great way to maintain fitness and still give your body time to recover. Good nutrition and supplementation with vitamin D and calcium may reduce the risk of stress injuries, especially in the wintertime when we’re typically exposed to less sunlight. Aside from this, stretching to maintain flexibility and wearing well-fitting supportive shoes can help reduce the risk of stress injuries.

Stress injuries can be painful and frustrating for runners but allowing time to gradually increase intensity and doing a variety of exercises can help reduce the risk. If you have symptoms of a stress injury or suffer other sprains or breaks while training, our orthopedic providers are here to help.