Stress fractures are a common overuse injury seen in athletes, runners, dancers, and active individuals. Unlike acute fractures caused by a single traumatic event, stress fractures develop gradually due to repetitive stress and overloading of the bone without adequate recovery. These small cracks or severe bone bruises are usually caused by a combination of factors such as poor biomechanics, a sudden increase in activity, improper footwear, or even nutritional deficits like low calcium or vitamin D.
Bones Commonly Affected
The bones most affected by stress fractures are weight-bearing structures, including the tibia (shin bone), metatarsals in the foot (especially the second and third), the femur, fibula, and foot bones like the navicular and calcaneus. These injuries typically present with localized pain that worsens with activity and improves with rest. Swelling, tenderness to touch, and pain with hopping or weight-bearing are also common. Diagnostic imaging, such as MRI, is the gold standard, as it can detect early stress reactions before they are visible on X-rays.
Phases of Treatment for Stress Fractures
Phase One: Protection & Offloading (Weeks 0–6)
Treating a stress fracture effectively involves a phased approach that includes offloading the injured bone, restoring strength and mobility, and addressing the root cause of the injury to prevent recurrence. Typically lasting 6 weeks, the initial phase focuses on protection and offloading. During this stage, patients are advised to stop high-impact activities immediately. Depending on the severity and location of the fracture, a walking boot or brace may be recommended. In more serious cases, crutches and a non-weight-bearing protocol are necessary. Bone stimulators using low-intensity pulsed ultrasound may also accelerate healing in high-risk fractures. Physical therapy at this stage focuses on maintaining mobility in non-injured joints, correcting gait abnormalities, and initiating gentle strengthening when appropriate.
Phase Two: Controlled Loading & Reconditioning (Weeks 6–12)
The second phase, lasting from approximately weeks 6 to 12, centers on controlled loading and reconditioning. As healing progresses, low-impact cross-training like swimming, cycling, or pool therapy can be introduced. Manual therapy may address soft tissue stiffness or compensatory movement patterns. Resistance training is reintroduced to rebuild strength and endurance, particularly in the lower extremities and core. If biomechanics played a role in the injury, gait retraining and footwear assessment become essential to rehab. Orthotics may be recommended to improve support and alignment for stress fractures in the foot.
Phase Three: Return to Sport or Full Function (Weeks 12–16+)
The final phase, typically between weeks 12 and 16 or longer for complex cases, focuses on returning the patient to sport or full function. At this point, a structured return-to-run or return-to-play program is implemented, starting with walk-jog intervals and gradually progressing to full activity. Plyometric drills, agility training, and sport-specific movements are introduced as tolerated. Functional movement screens may assess readiness and identify any lingering deficits. Throughout this phase, the therapist emphasizes neuromuscular training to improve coordination, reduce injury risk, and educate the patient on load management strategies.
Preventing Future Stress Fractures
Once a stress fracture has healed, preventing recurrence becomes the top priority. Patients are educated on how to gradually progress their training, with no more than a 10% increase in volume per week. Strength training, especially targeting the glutes, core, and lower extremities, is emphasized to support bone loading and prevent muscle fatigue. Proper footwear, regular mobility work, and a balanced cross-training program help reduce the risk of future injury. For those with a history of stress fractures, ongoing nutritional guidance and bone density screening may also be appropriate.
Conclusion
In summary, stress fractures are injuries that require prompt attention, structured care, and a thoughtful return to activity. When managed correctly with a mix of offloading, rehabilitation, and biomechanical correction, most patients return to full function, stronger and smarter about their training. If experiencing persistent bone pain or recovering from a stress fracture, working with a physical therapist ensures a personalized, evidence-based plan that promotes healing and long-term performance.
Schedule an appointment with one of our expert NYC physical therapists at CSCM today. Let’s create a personalized plan to help you heal, rebuild strength, and prevent future injuries.
