by Megan Zetter

Respect stress fractures

Stress fractures are a common injury among runners. The most frequent bones to be effected are the tibia (lower leg) and metatarsals (bones in the mid-foot), but it’s not unheard of to get a stress fracture in the femur (upper leg) or pelvis. I’m not sure why, but stress fractures are often viewed as a minor injury and just an annoyance more than anything. However, they are are serious and they should be treated as you would any other fracture of your bone. If treated correctly you can recover in as short as six weeks, with the typical time frame being 8-12 weeks, but if you don’t respect them they can persist for years.


What is a stress fracture? You may have heard the term hairline fracture to describe them or possibly, stress reaction. I liken it to a crack in windshield, but this crack is in your bone. It’s noticeable, but easy to ignore. However, they should not be taken lightly and they should not be viewed as something that you can run through. They are often very small and missed on x-ray. And the first sign of one is typically a slight ache only when running. So this is often mistaken for a muscle injury or “shin splints”. However, in time, if you continue running, the pain worsens to the point that you cannot run. That said, if you have been experiencing an ache in the same area only when running, I suggest cross training for a couple of week or so. If the ache persists even when not running, definitely get it evaluated.

How do these cracks happen? Most people think it is from the pounding nature of running, but what explains stress fractures in the ribs of rowers? Other fallacies of stress fractures are that they only occur in high mileage runners or overweight people or people who heel strike. Running barefoot or in minimal footwear is thought to be the cause, while some think that this form of running is preventative.

Our bodies are constantly breaking down and rebuilding — this is a natural and desired adaptation as we need stress to become stronger. But when the frequency of the stress out paces the bodies ability to mend itself, injuries happen. There are some people who are more susceptible to stress fractures, such as people with disordered eating and women who suffer from the female athlete triad, but no runner is immune.

When we run, our muscles should be absorbing the force of each foot fall and transferring the energy to propel us forward. However, when muscles fatigue, the skeleton has to take on ground forces. Over time, this leads to fatigue in the bone and ultimately a stress fracture. If you recall, our bone is constantly breaking down and rebuilding. In the case of a stress fracture the rebuilding phase can’t keep up.

How do you know if you have a stress fracture? Like I said before, x-ray cannot always show evidence of a stress fracture in the early stages. It’s not until about 2-3 weeks after onset of symptoms does it typically show on x-ray. This does not mean that you should continue to train though! If you suspect that you have a stress fracture the sooner you stop and allow for rest, the sooner you will be running again. Checking in with your healthcare provider is a good idea to ensure you are not dealing with something else. The typical course of care is rest for 6-8 weeks. Protection in the form of a walking boot for the lower leg and foot is often needed. And sometimes a period of non-weight bearing is necessary.

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How do you prevent a stress fracture? Having a sound and reasonable training plan is extremely important. That may sound like a no brainer, but I think we have all fallen into the too much too soon plan. Adequate rest is imperative. More is not always better. I subscribe to quality over quantity. When you get wrapped up in numbers and weekly mileage, you are more likely to add junk miles which can lead to injury. Optimal nutrition for recovery. And no specific diet, such as being vegan, gluten free, high carb, etc.. is necessarily better. Nutrient rich food and adequate caloric intake.should be your focus. Cross training. Cross training allows for you to train, but it places stress on other areas of the body. I also think taking a couple of weeks off, at minimum, each year is very valuable. Optimal biomechanics are important too. If one of your tires on your car is low, the alignment gets off, but if you never put air in your tire, you will never fix the alignment issue. Our bodies are the same. If you have suboptimal movement somewhere in your body, additional stress is placed on other areas.

Return to activity. The key to having a successful return to your running program is to be very conservative. A walk/run plan for a few weeks is what I recommend as your leg or foot has become weak from disuse. And just because you are pain free does not mean you are 100%. One insidious aspect of overuse injuries is that the pain is slow to come on and is typically the first thing to leave Or rather, you were injured before you experienced any pain and you are not fully recovered when you no longer experience pain. So you must approach your return with respect for your injury. You cannot rush it.

While stress fractures seem par for the course in the long distance runner they are avoidable. Smart training, listening to your body, cross training, proper nutrition, rest, optimal biomechanics and of course checking in with your favorite sports chiropractor, are the keys to successful running.



I am a chiropractic physician located in NW Portland, just off of 20th and Overton — a short jaunt from the Lucky Lab and Forest Park. My practice is unique in that I approach the body as one working unit versus only addressing the site of pain. I utilize techniques, such as Graston, kinesio taping, massage/muscle work, functional movement screen (FMS), joint mobilization and rehabilitation. Very few people leave my office without some sort of “homework” because I believe that if you have the knowledge and power to help yourself recover that you will realize long lasting resolution.

Outside of the office, I’m an avid athlete with interests in running, skiing, snowshoeing, rock climbing, cycling and hitting the weights at the gym. I grew up playing soccer, but turned to running in my late teens. I have participated in many road races, from 8k-15k. My first experience with Hood to Coast was at age 17 and over the years I have run it twelve times, but I have not run all the legs. I will never volunteer for leg one! When I was introduced to trail running, I immediately switched gears and found myself absolutely in love with Forest Park. I completed my first official ultra marathon in 2005. And since then, I have completed a handful of additional races and I accomplished my goal of completing the ever daunting 100 miler in 2008 — Rio Del Lago. Unfortunately I have had to park my trail shoes as I recover from a stress fracture, but I will be out there soon!