John Davis

Written by John Davis


High-Risk Stress Fractures: How to Treat them Properly

While every runner dreads getting a stress fracture, not all are aware that stress fractures range in their seriousness.

Stress fractures, tiny cracks in the surface of your bone due to overuse and excessive forces on your body, vary in both location and severity.

Because the forces from running are distributed unevenly throughout your skeleton, and because various bones are known to have differing healing capabilities, the seriousness of a stress fracture is affected by not just the severity of the fracture itself, but its location.

This week, we’ll be taking a look at high-risk stress fractures—areas of the body that, when affected by a stress fracture, are at risk of complications which could jeopardize your ability to run in the future.

Understanding high-risk stress fracture

The injury and healing process for most stress fractures is straightforward: excessive forces on a bone, whether from the impacts associated with running or the “active forces” that arise when your muscles contract to push you off the ground, cause microscopic cracks to occur in the bone, which grow as activity continues. These cracks lead to swelling in the bone marrow, muscular tightness in the surrounding area, and of course, a sharp localized pain on the bone.

Classically, this pain coincides with activity but also tends to ache while you are not on your feet doing weight-bearing activities like running. While many runners continue to run on a stress fracture until it’s diagnosed, 6-8 weeks’ time away from impact activities is usually enough to allow the bone to heal normally.

Recovery period

Competitive athletes, like professional or division one college runners, might push the envelope by continuing to train and race with a stress fracture for a few weeks, albeit at much lower volumes and with heavy supplementation of aqua jogging or other cross-training exercises. While this will certainly prolong recovery (as the full recovery time still needs to be taken at some point) and is not by any means recommended, it does not typically lead to any complications.

However, in a high-risk stress fracture, the risk of complications is much greater than normal.

Often, these stress fractures take many weeks or even months to heal. For example, in a nonunion stress fracture, the two edges of bone on either side of the crack do not heal back together properly, requiring surgical intervention. Additionally, poor healing at the site of a high-risk stress fracture can cause it to be susceptible to reinjury, starting the process all over again.

Avascular necrosis, where bone cells die due to interrupted blood supply, has also been linked to certain high-risk stress fractures, and can be a career-ending injury.

Types of high-risk stress fractures

A 2006 article by Steven Murray and colleagues outlines the types of stress fractures considered high-risk.

In runners, the relevant locations are the:

  • Femoral neck, the “bend” in your femur by your hip
  • The patella (kneecap)
  • The anterior side of the tibia—not the same location for shin splints or run-of-the-mill tibial stress fractures
  • The medial malleolus, which forms the inside of your ankle, the talus bone in the foot
  • The fifth metatarsal, along the outside edge of your foot
  • The navicular, which lies along the top of your foot
  • And the sesamoids, two small bones on the underside of the ball of your foot.

But what is it about these locations that makes them so difficult to heal when afflicted with a stress fracture?

Whether a certain stress fracture is high-risk or low-risk depends chiefly on its anatomic location.

A scientific review article by Jason Diehl, Thomas Best, and Christopher Kaeding at The Ohio State University describes how a stress fracture located on the “tension side” of a bone is at a much higher risk for delayed healing or nonunion, as the intrinsic forces associated with weight bearing are pulling the cracks in the bone apart, discouraging healing.

In contrast, most low-risk stress fractures occur on the compression side of the bone, where weight bearing has a tendency to push the bones together.

How to handle a high-risk stress fracture

Because of the risks of complications, high-risk stress fractures need to be treated much more aggressively than their low-risk counterparts.

Several weeks or months of non-weight bearing activity are necessary, often including a period of time on crutches or in a “boot” (for fractures to the lower leg and foot). Depending on the injury, you may also need surgical fixation to encourage healing and prevent the complications discussed previously.


  • It’s always good to follow your doctor’s advice, but this is especially true with risky injuries like high risk stress fractures. Your future running isn’t something you should be gambling with.
  • Like normal stress fractures, a high-risk stress fracture needs to be diagnosed by a doctor, and usually requires high-tech imaging like a bone scan, MRI, or CT scan to pinpoint.

On the bright side, however, high-risk stress fractures are quite rare in runners. Studies have found that the vast majority of running-related stress fractures occur in low-risk locations like the medial side of the tibia, the fibula, and the first through fourth metatarsals. Regardless of where it is, any sharp, aching pain in or near a bone that gets worse when you run should be examined by a doctor.

Don’t run on anything you might suspect is a stress fracture until you’ve gotten a proper diagnosis, and definitely don’t mess around if you have a high-risk stress fracture. With proper care, they don’t have to be career-enders—early diagnosis and treatment can prevent long-term complications.

Need Help Recovering From a Stress Fracture?

Download our Stress Fracture Treatment Outline inside your Insider Members area.

It’s a PDF with the treatment options for runners with stress fractures.


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1. Niva, M. H.; Kiuru, M.; Haataja, R.; Pihlajamaki, H., Fatigue injuries of the femur. The Journal of Bone & Joint Surgery 2005, 87-B (10), 1385-1390.
2. Murray, S. R.; Reeder, M. T.; Udermann, b. E.; Pettitt, R. W., High Risk Stress Fractures. Pathogenesis, Evaluation, Treatment. Comprehensive Therapy 2009, 32 (1), 20-25.
3. Diehl, J. J.; Best, T. M.; Kaeding, C., Classification and Return-to-Play Considerations for Stress Fractures. Clinics in Sports Medicine 2006, 25, 17-28.
4. Arendt, E.; Agel, J.; Heikes, C.; Griffiths, H., Stress injuries to bone in college athletes: a retrospective review of experience at a single institution. American Journal of Sports Medicine 2003, 31 (6), 959-968.
5. Bennell, K. L.; Malcolm, S. S.; Thomas, S. A.; Reid, S. J.; Brukner, P.; Ebeling, P. R.; Wark, J. D., Risk factors for stress fracture in track and field athletes: a twelve-month prospective study. American Journal of Sports Medicine24 1996, 6 (810-818).

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