Stress Fracture in the Shin or Foot: Symptoms, Treatment and Recovery

01Causes

Why stress fractures happen

• Increasing running distance, speed or frequency too quickly.
• Changing surfaces, shoes or sport.
• Not eating enough to match training (low energy availability), with menstrual disturbances in women.
• Low vitamin D or calcium, and low bone density; see vitamin D deficiency symptoms.
• Foot shape, biomechanics and previous stress fractures.
• Insufficient recovery between sessions.

02Shin

Stress fracture of the shin

Tibial stress fractures usually cause pain in a small area of the inner or front of the shin, which you can point to with one finger. Pain worsens during running and may persist after exercise, at night or with walking. Hopping on the affected leg is often painful.

Fractures on the front of the middle shin are considered high risk because they heal slowly and can progress, and need specialist management. See shin pain after running.

03Foot

Stress fracture in the foot

• Metatarsals: the second and third are most often affected, causing pain and swelling on the top of the forefoot (“march fracture”).
• Fifth metatarsal base: on the outer edge of the foot; high risk of poor healing.
• Navicular: deep pain on the top of the midfoot; high risk and often missed.
• Heel bone (calcaneus): pain when squeezing the heel from both sides; see heel pain.

See also top of foot pain.

04Shin splints

Stress fracture vs shin splints

• Shin splints: diffuse pain along a longer stretch of the inner shin, often easing as you warm up.
• Stress fracture: pinpoint pain on the bone, worsening with continued activity and present at rest or night.
• Shin splints can progress to a stress fracture if loading continues.

05Diagnosis

How it is diagnosed

A physiotherapist or doctor suspects a stress fracture from the history and tenderness over the bone. X-rays are often normal for the first 2 to 3 weeks, so MRI is the most accurate test when the diagnosis is uncertain or the site is high risk.

Blood tests for vitamin D, and assessment of diet, menstrual history and bone density, are considered after recurrent stress fractures.

06Treatment

Treatment

• Stop running and impact activities; continue pain-free activities such as cycling or swimming.
• Use a walking boot or crutches if walking is painful, as advised.
• Apply ice and raise the leg for swelling; paracetamol for pain.
• Address nutrition: enough energy, calcium and vitamin D.
• High-risk fractures may need a longer period without weight bearing or surgery.

Most low-risk stress fractures heal in 6 to 8 weeks.

07Return

Returning to running

• Walk pain-free for several days before starting running.
• Bone should be non-tender to press and hopping pain-free.
• Start with a walk-run programme on flat, even surfaces, every other day.
• Increase running time gradually, around 10% per week, with no pain during or the day after.
• Include strength training for the calf, hip and foot muscles.

08Prevention

How to prevent stress fractures

• Increase training gradually and include rest days.
• Vary surfaces and replace worn running shoes.
• Eat enough to fuel training, with adequate calcium; see calcium-rich foods.
• Maintain vitamin D levels.
• Do strength training two or three times a week.
• Listen to localised bone pain and reduce load early.

09REDs

Low energy availability and bone health

Relative energy deficiency in sport (REDs) occurs when an athlete does not eat enough to cover the energy used in training. It can affect hormones, menstrual cycles, bone density and performance, and increases the risk of stress fractures in both women and men. Missed periods in active women should never be considered normal and need assessment. A sports dietitian and doctor can help.

11Summary

Key points to remember

• Stress fractures are caused by repeated loading that outpaces bone repair.
• Pinpoint bone pain worsening with impact is the key sign.
• Most heal in 6 to 8 weeks with reduced loading.
• Gradual training, good nutrition and strength work prevent them.