• RTR

Stress fractures

David Campbell PT CSCS


Stress Fractures are a debilitating injury for any athlete, and one I’ve seen a lot of confusion around returning to full activity. The temptation for the athlete is to take some time off and when it feels ‘ok’ start training too much too soon, running the risk of suffering a reoccurrence or further complications. I propose respecting physiology (there’s no cheating it!), and adopting a tried and tested return to run (RTR) protocol to avoid unnecessary setbacks.

So, what is a stress fracture? A stress fracture occurs when the reabsorption of bone (osteoclast cell) outpaces the regeneration or building cell (osteoblast cell) resulting in a focal point of pain or general diffuse pain during weight bearing activity stopping us from doing what we enjoy, running, or in plain English;

“Bend a hanger too many times and it will snap”

Stress fractures make up about 10% of general sporting injuries and the occurrence is far higher in runners (30%) due to running’s repetitive unidirectional nature. 90% of stress fractures in runners are seen in the lower limb (shin, 5th metatarsal, navicular) however it is not abnormal to observe in the femur, sacrum, or pubis so be aware.

More often than not stress fractures present as a result of training error, when the load exceeds capacity of the bone. These loads can be intrinsic, extrinsic or a combination of both. Intrinsic factors can be hormonal, dietary, congenital etc., extrinsic factors can be training load, shoes, surface etc.. For simplicity sake we’ll say it’s training load, and it’s usually when we see a sharp increase in one or more of these FITT principle training factors, Frequency, Intensity, Type, or Time, that we see injury.

One of the simplest tests we can conduct to diagnose is a single leg hop test, if pain is replicated this can lead to a diagnosis which can be confirmed by MRI or Bonescan.

OK, that’s’ great, but all I care about is what do I do now, and HOW SOON CAN I RUN?

So while relative rest is a big proponent in the recovery process to allow the builder cells ‘catch up’ with the reabsorption cells, the bone needs a graduated load over time to mature and grow stronger.

On average 6-10 weeks relative rest is advised before commencing the RTR that will take another 6 weeks or so. This may appear painfully slow in the initial phases, however try and not be too impatient or you may find yourself back at square one.


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