Stress Fracture in Sweden: Symptoms, Causes & Treatment | aihealz
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Stress Fracture.Care & specialists in Sweden
In Sweden, stress Fracture is managed by sports medicines. Stress fractures are partial or complete fractures of bone that arise from repetitive sub-failure loading rather than a single high-energy event. Annual incidence in distance runners reaches 20% in some cohorts and exceeds 30% per year in military recruits during basic training.
aliases · Stress fracture (bone stress injury)· Bone stress injury· Fatigue fracture· Fractura por estrés· reviewed May 14, 2026
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Reviewed by AIHealz Medical Editorial Board · Sports MedicineLast reviewed May 13, 2026
Stress fracture (ICD-10: M84.3) is a fatigue or insufficiency failure of bone caused by repetitive mechanical loading that exceeds the bone's adaptive remodeling capacity. The continuum of bone stress injury (BSI) progresses from periosteal edema through marrow edema, cortical microtrauma, partial cortical fracture (stress fracture), and ultimately complete fracture. The Fredericson MRI grading classifies tibial BSI from grade 1 (mild periosteal edema only) through grade 4 (visible fracture line) and predicts return-to-sport time. Anatomic site determines management: low-risk lesions (posteromedial tibia, fibula, sacrum, pubic ramus, second through fourth metatarsal shafts, calcaneus) have abundant compressive blood supply and reliably heal with conservative care; high-risk lesions (superior cortex of femoral neck, anterior tibial cortex 'dreaded black line', medial malleolus, talar neck, navicular, base of fifth metatarsal, sesamoid bones, patella, pars interarticularis) sit on the tension side of loading, in watershed blood supply, or in load-bearing locations where non-union and progression to complete fracture are common.
key facts
Prevalence
Annual stress fracture incidence in distance runners 15-20%; 5-31% in military recruits during basic training; women 1.5-3.5× higher rate than men in matched athletic populations
Demographics
Female athletes affected at higher rate, particularly with the Female Athlete Triad/RED-S; male endurance athletes at elevated risk during high-volume training; military recruits in first 12 weeks of training
Avg. age
Athletic stress fractures: typical age 15-35; older runners with bone loss after age 50 at rising risk
Global cases
Stress fractures account for 0.7-15% of all running-related injuries depending on population; tibia accounts for 33-55% of all stress fractures, metatarsals 20-25%, femoral neck 5-10%
Specialist
Sports Medicine
§ 02
How you might notice it
The key symptoms of Stress Fracture are: Insidious onset of activity-related bone pain at a specific anatomic site that begins during or shortly after running, jumping, or marching and worsens with continued loading., Pain that progresses from end of activity, to during activity, to with daily walking, and finally to rest pain — the diagnostic-grade progression suggesting high-grade bone stress injury., Localized point tenderness directly over the bone (e.g., medial tibial border, dorsum of midfoot, dorsal sacrum) reproducible by direct palpation., Pain reproduced by a single-leg hop test or focal percussion of the suspected bone — sensitivity 70-90% for tibial and metatarsal lesions., Pain on the fulcrum test (femoral or tibial) and on the FABER (flexion-abduction-external rotation) and FADIR (flexion-adduction-internal rotation) tests for hip and pelvis lesions., Localized swelling, warmth, and palpable callus over a metatarsal or tibial border in subacute and healing stress fractures., Antalgic gait with shortened stance phase on the affected side and reluctance to bear weight in higher-grade lesions..
01Insidious onset of activity-related bone pain at a specific anatomic site that begins during or shortly after running, jumping, or marching and worsens with continued loading.
02Pain that progresses from end of activity, to during activity, to with daily walking, and finally to rest pain — the diagnostic-grade progression suggesting high-grade bone stress injury.
03Localized point tenderness directly over the bone (e.g., medial tibial border, dorsum of midfoot, dorsal sacrum) reproducible by direct palpation.
04
§ 03
How it’s diagnosed
diagnosis
Diagnosis combines a focused history, examination, and confirmatory imaging. The history details onset (insidious activity-related pain), recent training changes (volume, intensity, surface, footwear), nutritional and menstrual history, prior injury, and bone-relevant medications. Examination locates point tenderness over specific bony landmarks (medial tibial border, dorsum of midfoot, navicular tubercle, sacrum, pars interarticularis), checks for swelling and warmth, and applies provocation tests: single-leg hop test for tibia and metatarsals, fulcrum test for femoral shaft, single-leg extension test (Stork test) for pars interarticularis, and FABER/FADIR for femoral neck and pelvis. Imaging strategy depends on suspicion and site. Plain radiographs are 15-35% sensitive for stress fractures within the first 2 weeks but rise to 50-70% sensitivity at 4-6 weeks; they detect cortical thickening, periosteal reaction, and visible fracture lines. MRI is the gold standard for early detection with 95-100% sensitivity within days of symptom onset, distinguishes bone stress injury from soft-tissue mimics, and grades severity using the Fredericson (tibia) or Arendt (foot) systems. CT is useful for navicular and pars stress fractures where MRI is equivocal. Bone scintigraphy with technetium-99m MDP has near-100% sensitivity but limited specificity and has largely been replaced by MRI. DXA bone density measurement is recommended in any athlete with recurrent stress fracture, RED-S features, or trabecular-rich site fracture (sacrum, pelvis, femoral neck). Laboratory workup in recurrent or atypical cases includes vitamin D, calcium, phosphorus, thyroid function, parathyroid hormone, urine pregnancy test, menstrual history, and energy availability assessment. Risk stratification (high-risk vs low-risk site) determines treatment urgency and modality.
Key tests
01
Plain radiograph (X-ray) of suspected siteInitial imaging; detects cortical fracture line, periosteal reaction, and callus; sensitivity 15-35% in first 2 weeks rising to 50-70% at 4-6 weeks
02
§ 04
Treatment & cost
medical treatments
✓Relative rest with protected weight-bearing
✓Walking boot (CAM walker) or stiff-soled postoperative shoe
✓Non-weight-bearing on crutches
✓Calcium 1,000 mg/day and vitamin D 1,000-2,000 IU/day supplementation
surgical options
Intramedullary screw fixation for fifth metatarsal (Jones) fractureReturn-to-sport at 6-8 weeks (operative) vs 12-16 weeks (non-operative); union rate above 95% with surgery vs 75-85% non-operative
Femoral neck cannulated screw fixationUnion rate 80-90% when performed before complete fracture; significant risk of avascular necrosis if fracture has displaced
Intramedullary tibial nailing for anterior cortex stress fractureUnion and return-to-sport in 80-90% of refractory cases; converts a high-risk slow-healing fracture into a more reliable healing environment
Open reduction and screw fixation of navicularUnion 90-95% in surgical series; return to sport 4-6 months after fixation
§ 05
Causes & risk factors
known causes
Rapid increase in training volume, intensity, or frequency
Adding more than 10% weekly mileage, abrupt transition from offseason to high volume, or stacking heavy training days produces mechanical loading that outpaces bone remodeling. Up to 70% of stress fractures in runners follow recent training change.
Female Athlete Triad / Relative Energy Deficiency in Sport (RED-S)
Low energy availability (insufficient dietary intake for training expenditure) causes menstrual dysfunction and low bone mineral density. Affected female athletes have 2-4× higher stress fracture incidence. RED-S extends to men and includes broader physiologic effects (IOC 2014/2018).
Biomechanical malalignment
Cavus foot, pes planus, leg-length discrepancy >5 mm, excessive forefoot supination/pronation, and weak hip abductors raise specific-site stress fracture risk. Tibial varum increases anterior tibial cortex tension-side loading.
Footwear, surface, and equipment factors
Worn-out running shoes (over 600-800 km), sudden transition to minimalist shoes, change from track to road or vice versa, and rigid playing surfaces (artificial turf, concrete) raise mechanical load delivered to bone.
Low bone mineral density
Z-score below -1.0 in young athletes or T-score below -1.0 in adults raises stress fracture risk 2-3 fold. Vitamin D deficiency (25-OH vitamin D below 32 ng/mL) is independently associated with risk in military recruits (Lappe randomized trial 2008).
Medications affecting bone metabolism
Long-term corticosteroids, depot medroxyprogesterone acetate (DMPA), aromatase inhibitors, proton pump inhibitors, and selective serotonin reuptake inhibitors are associated with reduced bone density and elevated stress fracture risk.
risk factors
§ 06
Living with it
01Increase weekly training volume by no more than 10% per week; build adequate base mileage before adding intensity.
02Include at least one rest day per week and a recovery week every 3-4 weeks of progressive loading.
03Maintain energy availability above 30 kcal/kg lean body mass per day, especially in high-training-volume athletes.
04Supplement vitamin D to maintain 25-OH vitamin D ≥32-40 ng/mL and calcium intake to 1,000-1,200 mg/day.
05Choose appropriate running surface and footwear; replace running shoes every 600-800 km.
06Address biomechanical risk factors (leg-length discrepancy, weak hip abductors, excessive pronation) with physical therapy and orthotics when indicated.
07Female athletes: screen for menstrual irregularity and disordered eating annually; restore menstruation with adequate energy intake rather than oral contraceptive masking.
recommended foods
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§ 07
When to seek help
why see a sports medicine
Suspected stress fracture in an athlete warrants sports medicine or orthopaedic assessment. High-risk sites (femoral neck, anterior tibia, navicular, base of fifth metatarsal, talar neck, sesamoids, pars interarticularis) require urgent specialist evaluation because delay or premature return to activity risks complete fracture, non-union, and career-altering complications. Recurrent stress fractures or those occurring in atypical locations warrant comprehensive bone health and energy availability assessment with endocrinology and dietitian input.
01Progression to complete fracture in high-risk sites — femoral neck displacement leading to avascular necrosis and career-altering disability.
02Delayed union or non-union, particularly in anterior tibial cortex, navicular, base of fifth metatarsal, and pars interarticularis — may require surgical fixation or bone grafting.
03Stress fracture recurrence at the same or different site (12-21% incidence) when training and risk-factor errors are not addressed.
04Reduced peak bone mass and elevated lifetime fragility-fracture risk in female athletes with sustained Female Athlete Triad / RED-S.
05Psychological impact: depression, anxiety, identity disruption affecting 20-30% of athletes during prolonged rehabilitation.
Tibial stress fracture (low-risk: posteromedial; high-risk: anterior cortex)Tibia accounts for 33-55% of all stress fractures. Posteromedial tibial stress fractures are common in runners and military recruits, heal in 6-12 weeks with relative rest. Anterior tibial cortex stress fracture ('dreaded black line') is a high-risk tension-side lesion that may need months of non-weight-bearing or intramedullary nailing.
Metatarsal stress fractureSecond, third, and fourth metatarsal shaft stress fractures (low-risk) heal with 4-6 weeks in a stiff-soled shoe or walking boot. Base of fifth metatarsal (Jones fracture) is high-risk with non-union potential; many athletes are managed with primary intramedullary screw fixation for fastest return-to-sport.
Femoral neck stress fractureSuperior (tension-side) cortex stress fracture is a true emergency: progression to complete fracture causes avascular necrosis with career-ending implications. Compressive (inferior cortex) stress fracture heals with non-weight-bearing in most cases. MRI and orthopaedic referral are mandatory for any groin or thigh stress pain in a runner.
Navicular stress fractureHigh-risk midfoot stress fracture, typically in jumping and sprinting athletes. Diagnosis often delayed because plain X-rays miss most cases. Non-weight-bearing immobilization for 6 weeks is standard; surgical fixation is increasingly used in athletes.
Sacral, pelvic, and pubic ramus stress fractureLower-risk lesions in distance runners and military recruits; present with low back, buttock, or groin pain reproduced by single-leg hop. Heal with 6-8 weeks of relative rest.
Pars interarticularis stress fracture (spondylolysis)Stress fracture of the lumbar pars interarticularis in adolescent athletes performing repeated hyperextension (gymnasts, divers, cricket fast bowlers, dancers). Bilateral defects progress to spondylolisthesis. Treated with activity modification, bracing, and core rehabilitation.
Living with Stress Fracture
Timeline
Low-risk stress fractures: pain-free walking 2-4 weeks, pain-free jogging 6-8 weeks, full return-to-sport 8-12 weeks. High-risk stress fractures: pain-free walking 4-8 weeks, pain-free running 12-16 weeks, return-to-sport 16-24 weeks (faster with surgical fixation). Energy availability and menstrual cycle restoration require 6-12 months. Bone density recovery after RED-S takes 12-24 months of restored energy availability and menses.
Lifestyle
01Strict adherence to graded return-to-running program — pain-free walking before jogging, then short interval running, then sustained running.
02Cross-train with cycling, swimming, or pool running to maintain cardiovascular fitness during recovery.
03Increase calcium and vitamin D intake through dairy or fortified plant alternatives plus targeted supplementation.
04Sleep 8-10 hours per night to support hormonal recovery and bone remodeling.
05Avoid NSAIDs in the first 1-2 weeks of bone healing per evolving evidence of impaired bone union with prolonged use.
06Track training volume and pain in a daily diary to identify training errors and prevent recurrence.
Daily management
01Adhere to weight-bearing instructions (full weight-bearing, partial, or non-weight-bearing) until clearance
Complementary approaches
Pool running and cross-trainingDeep-water running with a flotation belt and cycling preserve cardiovascular fitness during non-impact recovery without reloading the injured bone. Most athletes maintain 80-90% of fitness with 6-8 weeks of cross-training.
Energy availability and menstrual cycle restoration in RED-SSports dietitian-led nutritional repletion with 30-45 kcal/kg lean body mass per day plus adequate macronutrients. Combined with reduction in training volume restores energy availability and bone turnover within 6-12 months.
Gait retraining and biomechanical correctionRunning-gait analysis with cadence increase (5-10% above habitual), reduction of overstriding, and forefoot or mid-foot strike pattern when appropriate reduces tibial loading by 20-30% in some athletes.
Choosing a doctor
Choose a sports medicine physician with athlete experience, ideally affiliated with a high-volume university or professional sports program. Look for access to MRI, running gait analysis, DXA bone density, and integrated services (dietitian, physical therapist, mental health). For high-risk fractures or surgical consideration, an orthopaedic surgeon with sports-fracture experience is needed. Female athletes with recurrent fractures benefit from a coordinated Female Athlete Triad / RED-S program.
Female Athlete Triad Coalition →Multidisciplinary group providing patient and clinician education on energy availability, menstrual dysfunction, and bone density in female athletes.
A stress fracture is a small crack in bone caused by repeated mechanical loading rather than a single injury. Typical sites include the shin, foot, hip, and lower spine. Pain starts during activity and worsens over weeks. Most heal in 6-12 weeks with relative rest and protected weight-bearing.
How is a stress fracture diagnosed?▾▴
Diagnosis combines a history of activity-related bone pain, point tenderness, and provocation tests with confirmatory imaging. MRI is the gold standard with 95-100% sensitivity within days. X-rays are often initially negative and may not show changes for 2-6 weeks. CT helps in selected midfoot and spine fractures.
What does a stress fracture feel like?▾▴
Stress fracture pain is localized to a specific bony point, worsens with activity, and improves with rest. Over weeks it progresses from end-of-activity pain to during-activity pain to rest pain. There may be swelling, warmth, and a positive hop or fulcrum test at the affected site.
How long does a stress fracture take to heal?▾▴
Low-risk stress fractures (posteromedial tibia, fibula, sacrum, second-fourth metatarsal shafts) heal in 6-12 weeks. High-risk stress fractures (femoral neck, anterior tibial cortex, navicular, base of fifth metatarsal, pars interarticularis) take 12-24 weeks and may need surgical fixation.
Can I run with a stress fracture?▾▴
Running on a stress fracture risks progression to complete fracture, particularly at high-risk sites. Stop running immediately if you suspect a stress fracture. Cross-train with cycling, swimming, or pool running to maintain fitness until pain-free walking is restored.
What is a high-risk stress fracture?▾▴
High-risk stress fractures sit on the tension side of bone, in poor blood supply zones, or in critical load-bearing sites. Examples include the superior femoral neck, anterior tibial cortex, navicular, base of fifth metatarsal, talar neck, and pars interarticularis. They require urgent specialist assessment.
What causes stress fractures?▾▴
Stress fractures result from repetitive sub-failure loading that outpaces bone remodeling. Major causes include sudden training volume increase, biomechanical issues, worn footwear, low energy availability (RED-S), low vitamin D, low bone density, and certain medications affecting bone metabolism.
Are women more prone to stress fractures?▾▴
Yes. Female athletes have 1.5-3.5 times higher stress fracture incidence than matched males. Contributing factors include the Female Athlete Triad (low energy availability, menstrual dysfunction, low bone density), smaller bone size, and biomechanical differences. Screening and prevention are essential.
Can I prevent stress fractures?▾▴
Prevention includes gradual training progression (no more than 10% weekly increase), adequate rest, calcium 1,000-1,200 mg and vitamin D 1,000-2,000 IU daily, appropriate footwear, energy availability above 30 kcal/kg lean body mass per day, and addressing biomechanical issues with a physical therapist.
What is the Female Athlete Triad?▾▴
The Female Athlete Triad is the interrelated combination of low energy availability (with or without disordered eating), menstrual dysfunction (oligomenorrhea or amenorrhea), and low bone mineral density. It affects 0-16% of female athletes depending on definition and confers 2-4 times higher stress fracture risk.
What is RED-S?▾▴
Relative Energy Deficiency in Sport (RED-S) is the IOC framework extending the Female Athlete Triad to include men and broader physiologic consequences of low energy availability — bone, endocrine, gastrointestinal, immunological, hematological, cardiovascular, and psychological effects.
Do I need surgery for a stress fracture?▾▴
Most stress fractures heal without surgery. Surgery is considered for high-risk lesions (femoral neck displaced, anterior tibial cortex resistant to conservative care, base of fifth metatarsal in elite athletes, displaced navicular) and for chronic non-union. Intramedullary screw fixation is the most common operation.
Can stress fractures heal on their own?▾▴
Yes, with appropriate rest. Low-risk stress fractures heal in 6-12 weeks with relative rest, protected weight-bearing, and cross-training. Returning to full activity must follow pain-free walking and graded reintroduction of impact. High-risk fractures require more intensive immobilization or surgery.
Does vitamin D help stress fracture healing?▾▴
Yes. Vitamin D and calcium are universally recommended in stress fracture management. The Lappe randomized trial showed calcium 2,000 mg plus vitamin D 800 IU daily reduced stress fracture incidence in female navy recruits by 27%. Maintain serum 25-OH vitamin D at 32-40 ng/mL or higher.
Should I use a walking boot for stress fracture?▾▴
A walking boot (CAM walker) is used for many metatarsal and selected tibial stress fractures to allow protected weight-bearing while reducing site-specific load. Use is typically 4-6 weeks until pain-free. High-risk sites may require non-weight-bearing on crutches rather than a boot.
What is the difference between shin splints and stress fracture?▾▴
Shin splints (medial tibial stress syndrome) produce diffuse 4-6 cm of medial tibial pain that improves with continued running. Stress fracture pain is focal (under 2 cm), reproducible at a specific bony point, worsens with activity, and progresses to walking pain. MRI distinguishes them clearly.
Can children get stress fractures?▾▴
Yes. Adolescent athletes can develop stress fractures, particularly in the pars interarticularis (gymnasts, divers, cricket fast bowlers, dancers), tibia, and metatarsals. Skeletal immaturity and rapid growth phases raise risk. Comprehensive assessment of training load and bone health is essential.
Will my stress fracture come back?▾▴
Recurrence rate is 12-21% if training errors and risk factors are not addressed. Recurrence is higher in female athletes with persistent low energy availability and menstrual dysfunction (2-4 times baseline). Addressing nutrition, training progression, biomechanics, and bone health normalizes future risk.
When can I return to running after a stress fracture?▾▴
Return to running follows pain-free walking, then progressive walk-jog intervals, then short continuous running. Most low-risk fractures allow running at 8-12 weeks; high-risk fractures require 12-24 weeks. A 10% weekly volume increase rule prevents over-loading the healing bone.
Are NSAIDs safe in stress fracture?▾▴
Short-term NSAID use (under 1 week) for pain is acceptable. Prolonged use may impair bone healing per animal and human evidence and is generally avoided. Discuss with your sports medicine physician; acetaminophen is a reasonable alternative for ongoing pain control.
Should I have a bone density scan after a stress fracture?▾▴
DXA bone density scanning is recommended after recurrent stress fractures, in atypical sites, in patients with Female Athlete Triad or RED-S features, or in athletes with extended menstrual dysfunction. It identifies underlying osteoporosis or osteopenia that warrants additional management.
Pain reproduced by a single-leg hop test or focal percussion of the suspected bone — sensitivity 70-90% for tibial and metatarsal lesions.
05Pain on the fulcrum test (femoral or tibial) and on the FABER (flexion-abduction-external rotation) and FADIR (flexion-adduction-internal rotation) tests for hip and pelvis lesions.
06Localized swelling, warmth, and palpable callus over a metatarsal or tibial border in subacute and healing stress fractures.
07Antalgic gait with shortened stance phase on the affected side and reluctance to bear weight in higher-grade lesions.
08Difficulty with daily activities (climbing stairs, prolonged standing) when the injury progresses to grade 3 or 4 cortical fracture.
09Groin or anterior thigh pain in a runner — must be assumed to be femoral neck stress fracture until proven otherwise.
10Low back pain provoked by lumbar extension in an adolescent athlete — concern for pars interarticularis stress fracture.
early warning signs
•Bone pain during activity that diminishes early in a session and returns after
•Recent training volume or intensity increase of more than 10% per week, change in surface, footwear, or technique
•Persistent localized bony tenderness on palpation outside the soft tissues
•Female athlete with menstrual irregularity, low body weight, or restrictive eating patterns
•Recurrent stress reactions or fractures at any site — investigate energy availability, bone density, and vitamin D
● emergency signs
•Sudden inability to bear weight after exertion in a runner with prior groin or thigh pain — exclude completed femoral neck fracture with urgent X-ray and CT/MRI
•Anterior tibial 'dreaded black line' visible on lateral X-ray of a runner — high risk of complete fracture; non-weight-bearing and same-week orthopaedic review
•Acute increase in pain, swelling, or deformity at a known stress fracture site — possible completed fracture or non-union
•New neurological deficit, urinary retention, or saddle anesthesia in a patient with sacral or pars stress fracture — exclude cauda equina syndrome
•Persistent rest pain or night pain unrelieved by NSAIDs — consider pathological fracture, infection, or atypical lesion; reimage urgently
MRI of suspected site
Gold-standard early imaging with 95-100% sensitivity; grades severity (Fredericson 1-4) and excludes soft-tissue causes
03
CT of suspected site (selected use)Best imaging for navicular, pars interarticularis, and tarsal stress fractures where MRI is equivocal
04
DXA bone density scanMeasures bone mineral density at hip, spine, and forearm; identifies osteopenia/osteoporosis contributing to stress fracture
Energy availability assessmentIdentifies low energy availability driving RED-S; calculated as (energy intake − exercise energy expenditure) / lean body mass
07
Single-leg hop and fulcrum testsBedside provocation testing; reproduces stress fracture pain at the affected site
Outlook
Outcome is excellent for low-risk stress fractures: 90-95% of athletes return to pre-injury performance within 8-16 weeks with adherent rehabilitation. High-risk lesions detected early have similarly good outcomes when treated aggressively, with 80-95% return-to-sport. Late or missed diagnosis of high-risk lesions (especially femoral neck and anterior tibia) risks complete fracture, non-union, and career-ending complications. Recurrence rate is 12-21% in athletes returning to the same training environment without addressing risk factors. Female athletes with persistent low energy availability and menstrual dysfunction have 2-4× higher recurrence; restoration of normal cycles and energy availability roughly normalizes future risk. Long-term bone density may remain reduced after RED-S-related stress fractures, conferring elevated lifetime fragility-fracture risk if not addressed.
Female sexnon-modifiable
Female athletes have 1.5-3.5× higher stress fracture incidence than matched males, partly due to higher prevalence of menstrual dysfunction, lower body weight, and lower bone mineral density.
Sudden training increase or transitionmodifiable
Weekly volume increases above 10%, sudden surface change, or abrupt minimalist shoe transition account for 50-70% of stress fractures in distance runners. Gradual progression with 1 rest day per week reduces risk substantially.
Low energy availability and menstrual dysfunctionmodifiable
Energy availability below 30 kcal/kg lean body mass per day suppresses estrogen, raises cortisol, and reduces bone formation. Amenorrheic athletes have 2-4× higher stress fracture risk. Recovery of normal menses correlates with normalization of bone turnover.
Vitamin D deficiency (25-OH vitamin D below 32 ng/mL)modifiable
Lappe et al. 2008 randomized trial: calcium plus 800 IU vitamin D daily reduced stress fracture incidence by 27% in female navy recruits versus placebo. Supplementation to maintain serum 25-OH vitamin D ≥40 ng/mL is recommended in at-risk athletes.
Prior stress fracturenon-modifiable
Personal history of any stress fracture raises lifetime risk of subsequent fracture 5-10 fold, often at a different site. Recurrent fractures should trigger comprehensive bone health and energy availability workup.
Restrictive eating pattern, anorexia nervosa, or low BMImodifiable
BMI below 18.5 kg/m², disordered eating, or clinical anorexia nervosa profoundly affect bone density and confer multi-fold elevated stress fracture risk. Multidisciplinary management is essential.
Adolescent age and skeletal immaturitynon-modifiable
Pars interarticularis and physeal stress injuries are particularly common in adolescent athletes during periods of rapid growth, when bone mass acquisition lags behind training load.
Military or occupational repetitive loadingenvironmental
Marching, prolonged standing, and load carriage in military recruits and laborers produce 5-31% stress fracture incidence during early training phases. Gradual conditioning and adequate rest reduce incidence.
Adequate energy intake calibrated to training expenditure — aim for energy availability above 30-45 kcal/kg lean body mass per day
•Calcium 1,000-1,200 mg daily from dairy, fortified plant milks, leafy greens, and sardines
•Vitamin D 1,000-2,000 IU daily targeting serum 25-OH vitamin D ≥32-40 ng/mL
•Adequate protein (1.4-2.0 g/kg/day) and carbohydrate distribution to support training and bone formation
foods to avoid
•Severe energy restriction or weight cutting during periods of high training load
Sports medicine and orthopaedic clinicsUniversity and professional athletic training programsBone density and metabolic bone disease clinicsPhysical therapy and rehabilitation servicesRunning gait analysis labs
Female Athlete Triad / Relative Energy Deficiency in Sport (RED-S) bone stressCombination of low energy availability, menstrual dysfunction, and low bone mineral density predisposes athletes to repeated stress fractures at atypical sites. IOC 2018 RED-S framework expands this to include men and broader physiologic consequences.
02Take calcium and vitamin D supplements daily
03Cross-train at prescribed intensity to maintain fitness
04Apply ice and elevation for swelling control as needed
05Record pain level (0-10) before and after activity to monitor healing
06Attend physical therapy and sports medicine follow-up at scheduled intervals
Exercise
During healing, maintain cardiovascular fitness with cross-training. After clearance, follow a graded program: pain-free walking 7-10 days, walk-jog intervals 2-4 weeks, slow continuous running 2-4 weeks, and progressive volume increase by no more than 10% weekly. Maintain at least 1 rest day per week. Resume competitive training when at 80-90% of pre-injury performance pain-free.