Stress fracture in the foot
A stress fracture is a small fracture in the bone, often referred to as a hairline fracture. Stress fractures are most commonly seen in the foot and affect the female athlete greater than the male.
Any activity that places high impact stress on the foot can lead to a foot stress fracture. These include netball, running, football, tennis and athletics to name but a few.
Stress fracture in the foot – anatomy
The most common place to sustain a foot stress fracture is in the metatarsals. These are the long bones within the foot that connect the major joints within the mid foot to the toes. Any metatarsal bone can suffer a stress fracture but the most common ones are the third and fourth metatarsals. A foot stress fracture can occur in other bones within the foot and leg such as the toe bones (phalanges) and even the tibia (shin bone) but these are more rare.
During exercise the metatarsals are put under a great deal of stress as they act as the ‘bridge’ between the mid foot and the forefoot. When the athlete transitions into the tip toe phase of gait, forces going through the metatarsals are at their greatest. This is when foot stress fracture is most likely to occur.
Poor biomechanics can lead to foot stress fractures. The biomechanical forces occurring at heel strike, mid stance and toe off phase of gait can create mechanical instability within the forefoot. The resulting stress can lead to fracture. Stress fractures are most likely to occur in over pronators and athletes with a rigid (under pronating) foot type. Read more about biomechanics->.
High impact forces can directly cause a stress fracture of the foot. Increased ground reaction force such as when running can put massive loads through the foot leading to sustained micro trauma of the bone. Over a period of time the bone becomes weakened and eventually breaks. Foot stress fracture is a common injury in soldiers, hence its other name ‘march fracture’. The repetitive nature military of training with heavy loads such as equipment etc leaves our military personnel more susceptible to stress fracture in the foot.
Increased activity with out allowing the foot to strengthen and adapt to the new demands placed on it can lead to foot stress fractures. It is very important to strengthen foot and leg muscles prior to increasing activity levels.
Worn footwear. As sports shoes age the shock absorbing properties of the shoe get markedly worse. When a running trainer has lost its shock absorbency then high impact forces are transferred directly to the foot increasing the probability of a foot stress fracture. See our running shoe guide->.
Osteoporosis Stress fractures can occur in patients with weakened bones such as sufferers of osteoporosis, or where there is bone insufficiency. Weakened bones are more likely to fracture when the forces of exercise place stresses on weakened areas. Starting new activities which would not normally be deemed as high impact can be a cause of foot stress fractures, as weak bones are unable to cope with even normal forces.
A poor diet that is low in calcium can lead to weakening of the bones and can cause a stress fracture in the foot to occur. This is particularly prevalent in the hard working female athlete that has neglected their nutritional intake.
Prescription medication can also cause stress fractures in the foot. Epilepsy medication for example can lead to weakened bones, despite taking supplements such as vitamin D and monitoring calcium intake.
It is not usually hard for the athlete to spot whether or not they have a foot stress fracture. Pain is usual severe with weight bearing being particularly uncomfortable. Other symptoms of a stress fracture can include.
Redness on the top of the foot.
The area of the fracture will be warm to the touch.
Bruising (often quite evident after a few days).
Difficulty putting shoes on.
Tingling or numbness of one or two toes due to swelling.
Stress fracture foot treatment in the acute phase.
PLEASE NOTE. It must be emphasised that if a stress fracture is suspected then medical attention should be sought immediately. Treatment in the early stages will not differ from what is described below however it is very important to ascertain the underlying cause of the stress fracture particularly in the female athlete. This will be carried out by a medical professional and may include further tests such as bloods, x-rays and possible DEXA bone scan to calculate bone density.
Ice packs and compression bandages are excellent to reduce pain and swelling
Protect the fracture site with an air cast walker. This works like the traditional plaster of Paris casts but is designed to be taken on and off for bathing etc.
Foot stress fracture – restoring normal function
Once the foot stress fracture has healed it is necessary to rehabilitate the affected leg.
How theraband is used in exercise (whole body).
Foot stress fracture – hamstring stretches
Why stretch the hamstrings when a stress fracture in the foot is the problem? Tight hamstrings causes the knee to stay flexed throughout the gait cycle. This has the ‘knock on’ effect of overloading the front of the foot by causing early heel lift when running. Tight hamstrings are one of the major causes of a foot stress fracture that goes undetected.
Foot stress fracture – muscle strengthening exercises
Foot muscles -strengthening
To have the best chance of a rapid recovery, it is a good idea to strengthen the muscles in the foot, ankle and legs. This will help to reduce unwanted stress on the fracture site. The single best exercise to improve strength of the muscles around the foot ankle is eccentric loading. This is usually done none weight bearing, however the use of a wobbleboard is an excellent way to strengthen muscles around the foot and ankle in a controlled and gentle manner. It also has the added benefit of improving proprioception too. Proprioception is the nerve connection from the brain to the foot. This is often damaged/ disrupted after a stress fracture and can increase the chances of injury from recurring. It can also significantly delay recovery.
Golden rule- Don’t ignore the problem, it won’t go away! If you have been afflicted by this injury it is virtually certain that you will have another attack sooner rather than later.
The way we function biomechanically is predominantly controlled by genetics, its hereditary (runs in the family).
The is the cheapest and most cost effective way for any athlete to reduce the risks of injury from occurring and to prevent re-injury is follow our checklist below. Overall costs for the average athlete will run into pennies per mile/hour of sport.
1. Check your footwear
Are your running shoes worn and in need of replacing? If so change them. A foot stress fracture can is usually caused by high impact forces so a good shock absorbing shoe is a must. For more advice on running trainers our running shoe advice page is worth reading. Read more->
Below are a selection of trainers that are ideal for athletes.
Trainers for a neutral/ under pronating foot type
(Trainers are the same for neutral and under pronators)
Trainers for over pronators
2. Rectify poor biomechanics with orthotics if necessary
The way your foot strikes the ground and the forces that are placed on it can have a direct effect on causing a foot stress fracture and can also delaying healing times. Check our biomechanics page for detailed information. Read more->
Think you require bespoke orthotics for your foot stress fracture? Visit our sports podiatry clinic pages for a clinic near you.
3. Strengthen weak foot and ankle muscles
Wobbleboard exercise is a great way to strengthen foot & ankle muscles and help prevent stress fracture in the foot.
4. Improve shock absorbency
Combined with footwear this is a vital consideration for preventing foot stress fracture. This injury is caused by high impact forces being directed through the forefoot, particularly in running activities. Purchasing some shock absorbing insoles is a cheap and effective way of vastly improving shock absorbency and reducing unwanted ground reaction force. These little pads slip into the shoe and are not noticed by the athlete when partaking in sport.
5. A Good diet
Ensure that your diet is rich in calcium to help promote healthy bones, particularly if you are female.
6. If you are female..
Get your calcium levels checked regularly. If you have a family history of osteoporosis and have suffered a stress fracture in the past ask for a DEXA bone scan. This scan calculates the bone density and ascertains the risk of possible osteoporosis.
Foot stress fracture injury prevention checklist summary
- Rectify Biomechanics if necessary
- Check Running shoes
- foot and ankle strengthening
- Improve shock absorbency
- Check you diet
- Make a doctors appointment
Returning to Activity
With a foot stress fracture the goal of rehabilitation is to return you to your sport or activity as soon as is safely possible. If you return too soon you may worsen your injury, which could lead to permanent damage. Everyone recovers from injury at a different rate. Return to your activity is determined by how soon your stress fracture recovers, not by how many days or weeks it has been since your injury occurred.
After suffering from a stress fracture in the foot, you may safely return to your sport or activity when, starting from the top of the list and progressing to the end, each of the following is true:
You have full range of motion in the injured foot compared to the uninjured foot.
You have full strength of the injured foot compared to the uninjured foot.
You can jog straight ahead without pain or limping.
You can sprint straight ahead without pain or limping.
You can do 45-degree cuts, first at half-speed, then at full-speed.
You can do 20-yard figures-of-eight, first at half-speed, then at full-speed.
You can do 90-degree cuts, first at half-speed, then at full-speed.
You can do 10-yard figures-of-eight, first at half-speed, then at full-speed.