Nagging pain behind your toes when your foot hits the ground. A deep ache in the shin that won’t let up. Groin discomfort felt with every step.
These symptoms can be easy to dismiss, especially for runners and active people who are accustomed to the discomforts of training. But in some cases, they’re early warning signs of a stress fracture — a bone injury that develops gradually and can worsen quickly if ignored.
"Bones are living tissue, just like your skin, heart and gut," says Dr. Scott Rand, primary care sports medicine physician at Houston Methodist. "Bones build up and break down just like every other part of our body. Stress fractures happen when there's more breakdown than build — when the damage accumulates faster than the body can heal."
Most stress fractures don’t require surgery to heal. But recognizing the symptoms early can make the difference between a short break from activity and a much longer recovery.
What is a stress fracture?
A stress fracture is a small crack or severe bruising inside the bone that is not caused by a single traumatic event. Rather, a stress fracture develops over time when repetitive force overwhelms the bone’s ability to repair itself.
When fatigued muscles cannot absorb the repeated shock, the overload transfers to the bone.
Certain factors make stress fractures more likely:
High-impact sports, such as running and basketball
Sudden increases in mileage or training intensity
Inadequate footwear, such as worn-out shoes
Fragile bones
Poor nutrition
Hormonal imbalance in women
“The most common place we see stress fractures is in the foot, specifically the bone behind the second toe,” Dr. Rand says. “Foot mechanics and how people land also play a big role.”
(Related: What's Causing My Foot and Ankle Pain?)
What are the signs of a stress fracture?
The hallmark of a stress fracture is pain at "foot strike," which is the moment your foot hits the ground during activity. Initially, the pain may be mild and only occur during exercise. You might notice a slight swelling or a spot that’s painful to the touch. Runners may be tempted to push through this discomfort, assuming it is normal.
As the injury progresses, pain may become more constant, linger after activity or interfere with walking or running mechanics.
Three spots in particular should prompt immediate evaluation:
Behind the toes (metatarsals)
The front of the shinbone (tibia)
Deep in the groin (the femoral neck, where the thigh meets the hip)
“If your pain is in any of those places, you stop and you go to the doctor,” says Dr. Rand. “You don't run through that. A stress fracture in the femoral neck is especially worrisome.”
For women: How does nutrition impact the risk?
Hormonal balance plays a significant role in bone health, particularly for women. Some female athletes assume it’s normal to not get their period during intense training, but this is a common misconception.
“If you’re female and being evaluated for a stress fracture, your doctor likely will ask about your periods,” Dr. Rand says. “If you’re not ovulating, you aren’t getting a period. And that can mean your estrogen levels are low, which increases the risk of bone injury.”
Missed or infrequent periods often are linked to inadequate nutrition. You can enhance your performance and bone health by working with a sports nutritionist to address your dietary needs. Bone building peaks around age 35, making nutrition — particularly vitamin D and calcium intake — especially important for younger athletes.
(Related: What Are the Signs of Osteoporosis & How Is It Diagnosed?)
How is a stress fracture diagnosed?
A physical exam is the starting point, but imaging can pinpoint the specific point of injury. Traditional X-rays are typically the first step, but many stress reactions won’t show up on an X-ray. Instead, an MRI is now considered the gold standard for stress fractures because it can detect bone marrow swelling before a crack forms.
“MRI will show different grades of stress reaction,” Dr. Rand says. “That helps us understand how concerned we need to be and how aggressive treatment should be.”
A CT scan or bone scans may still be used in certain cases, though MRI is preferred due to greater accuracy and efficiency.
(Related: 10 Strength Training Exercises for Runners to Avoid Injury)
How are stress fractures treated?
The foundation of stress fracture treatment is simple, though it’s tough for active people to accept: stop doing the high-impact activity that caused the bone stress.
“If a stress fracture is caught early, with just swelling inside the bone, four to six weeks of no impact may be enough for healing,” says Dr. Rand.
However, some stress fractures may require more extensive treatment, such as restricted weight-bearing with crutches or a walking boot.
“A stress fracture in the femoral neck can be very worrisome depending on where the crack or the bony edema appears,” Dr. Rand says. “If that area of the bone is unstable, we might recommend surgery to put a screw in for support before the bone breaks.”
(Related: Is It Achilles Tendinitis or a Rupture? Signs & Treatment Options)
Most stress fractures are minor and temporary. With proper rest and treatment, most people recover fully and return to their usual training routine and activities. But if you ignore the symptoms and push your body through pain, the recovery time can be lengthy.
“We see a lot of anterior tibial stress fractures in basketball players and runners,” says Dr. Rand. “If something like that progresses, their shin bone might break in half. These kinds of complete factures can require surgery to fix. The good news is that most stress fractures are very recoverable.”
(Related: Why You Should Take Ankle Sprains More Seriously)
What’s the best way to prevent stress fractures?
Runners love to run. Basketball players love to be on the court. But cumulative impact can take a toll on your lower extremities. Dr. Rand suggests mixing up your routine to give your bones reprieve.
“Cross-training with low-impact activities such as swimming or cycling can help you maintain fitness while giving your bones a break from repetitive stress,” Dr. Rand says.
To reduce your risk of a stress fracture:
Increase training intensity or frequency gradually
Incorporate rest days
Maintain a healthy diet
Ensure adequate calcium and vitamin D
Replace worn shoes to support proper foot mechanics
(Related: Tips for Choosing Running Shoes)
Don’t brush off lingering pain
Stress fractures start quietly, and ignoring the symptoms can turn a small problem into a major setback.
If you feel sharp, localized pain that worsens with each foot strike, especially in the toes, shin or groin, stop training and see a doctor. Listening to your body is one of the most effective ways to stay active for the long run.
