Stress Fractures in the Foot: Early Signs, Causes and When to Get Checked

Maybe you added miles before a spring race, or spent a long weekend hiking after a quiet winter. Now a spot on the top of your foot aches when you walk, and it isn't easing up. That kind of slow-building pain can be a stress fracture.

Here's what a stress fracture is, why it happens, what it tends to feel like, and when to have it looked at.

What Is a Stress Fracture?

A stress fracture is a small crack in a bone, or severe bruising inside a bone.¹ It doesn't come from one big injury. It builds up when a bone takes repeated pressure and doesn't get enough time to recover.² You may also hear it called a hairline fracture.²

The bones of the feet and lower legs are especially likely to get them, because they absorb force with every step, run and jump.¹

Where in the Foot Do They Happen?

In the foot and ankle, stress fractures happen most often in the metatarsals. These are the long bones that run through the middle of your foot to the base of your toes.¹ The second and third metatarsals are most prone. They are thinner, and often longer, than the first metatarsal behind your big toe.¹

A metatarsal stress fracture is sometimes called a "march fracture."⁴ Stress fractures can also happen in the heel bone (calcaneus), the outer leg bone (fibula), the ankle (talus), the midfoot (navicular) and the small sesamoid bones under the big toe.¹

What Causes a Stress Fracture?

The most common cause is doing "too much, too soon."¹ Things that can raise your risk include:

• A sudden jump in activity. Increasing how often, how long or how hard you exercise, or starting a new sport without building up to it.^1,2
• A change in surface. Switching to a new training or playing surface.^1,2
• Worn-out shoes. Shoes that are worn or flimsy and have lost their shock absorption.¹
• High-impact activities. Running, dancing, jumping and marching put a lot of pressure on the feet.³ Basketball, tennis and gymnastics also carry a higher risk.²
• Foot shape. Cleveland Clinic lists bunions, flat feet and high arches as risk factors.²
• Weaker bones. Osteoporosis and low vitamin D raise the risk.^1,2,3 AAOS notes that female athletes are more prone to stress fractures, in part because of low bone density linked to a condition called relative energy deficiency in sport (REDs).¹
• Loss of feeling in the feet. Nerve damage, such as from diabetes, is also a risk factor.³

Having one stress fracture also matters. StatPearls reports that about 60 percent of people with a stress fracture have had one before.⁴

Why Do Montana Winters Matter?

Two points from the American Academy of Orthopaedic Surgeons (AAOS) stand out for those of us in Southwest Montana. First, stress fractures are more common in winter, "when Vitamin D levels are lower in the body."¹ Second, runners who trained less over the winter "may be anxious to pick up right where they left off" when the season returns.¹ The same caution makes sense for anyone getting back into a busy season.

What Does a Stress Fracture Feel Like?

Pain is usually the first sign. It tends to come on gradually and get worse with weight-bearing activity.¹ Common signs include:

• Pain that starts during activity and eases with rest, at least at first^1,3
• Pain spread over a wide area of the foot early on, then focused in one spot over time³
• Pain that becomes constant as the injury goes on³
• Tenderness when you press on one spot of the bone^1,2
• Swelling, and sometimes bruising^1,2

Foot pain has many causes, and some feel similar. If pain in the ball of your foot feels more like a pebble in your shoe, our article on Morton's neuroma may be worth a read.

Why Didn't My X-Ray Show Anything?

A stress fracture starts as a tiny crack, so it is often hard to see on X-rays at first.¹ MedlinePlus notes an X-ray may not show the fracture for up to six weeks.³ A normal first X-ray doesn't always rule one out. Your provider may order an MRI or a bone scan, which can pick up a stress fracture earlier.^1,3

How Is a Stress Fracture Treated?

Most foot stress fractures are treated without surgery.^1,4 Treatment depends on which bone is involved and how severe the injury is. Options described by AAOS, Cleveland Clinic and MedlinePlus include:^1,2,3

• Rest from the activity that caused it, and switching to lower-impact exercise such as swimming or cycling if your provider says it's OK.^1,3
• The RICE approach: rest, ice, compression and elevation.¹
• Protective footwear, such as a stiff-soled shoe or a removable boot. Some people need a cast.^1,2,3
• Crutches to take weight off the foot when walking is painful.^1,3
• Over-the-counter pain relievers. MedlinePlus advises talking with your provider first if you have heart disease, high blood pressure, kidney or liver disease, or a history of stomach ulcers or bleeding.³

Surgery is not common. It may be considered for certain fractures, or when a bone doesn't heal.^1,2,4

How Long Does a Stress Fracture Take to Heal?

Healing times vary. AAOS and Cleveland Clinic say it usually takes six to eight weeks.^1,2 MedlinePlus gives a range of 4 to 12 weeks for metatarsal stress fractures.³ Some fractures take longer, and you may need to avoid sports for a few months.^1,2

Don't rush back. AAOS warns that returning to activity too soon can delay healing and raise the risk of a complete fracture.¹ MedlinePlus advises returning only when you can do the activity without pain, building up slowly, and stopping to rest if your foot begins to hurt.³

Can I Prevent a Stress Fracture?

These habits may lower your risk:^1,2

• Increase new activity slowly. AAOS says that in most cases, a 10% increase per week is appropriate.¹
• Mix up your activities (cross-train) and add strength training.¹
• Eat a diet with enough calcium and vitamin D.¹
• Replace worn-out shoes.¹ Our article on proper footwear has tips on choosing supportive shoes.
• Warm up and cool down, and stop exercising when pain starts.^1,2

When Should I See a Podiatrist?

Cleveland Clinic advises seeing a provider as soon as you notice new pain and swelling.² MedlinePlus also advises contacting your provider if pain doesn't go away or gets worse.³ A podiatrist can examine your foot, decide whether imaging is needed, and talk with you about protecting the bone while it heals. If you have diabetes or numbness in your feet, have new foot pain or swelling checked promptly. Our diabetic foot care page explains why.

The Bottom Line

A stress fracture is a small crack in a bone caused by repeated stress, and the metatarsals in the middle of the foot are the most common spot. The pain usually builds gradually and gets worse with activity. Early X-rays can look normal. Rest and protecting the foot are the usual treatment, and healing often takes six weeks or more. When you get back to activity, build up slowly.

If foot pain is getting in the way of your season, our podiatrists can help. Request an appointment and our team will follow up within one business day. You can also find your nearest office on our locations page.

This article is for general education and isn't a substitute for medical advice. Talk with a podiatrist or your doctor about your own symptoms.

Sources

1. Stress Fractures of the Foot and Ankle. OrthoInfo, American Academy of Orthopaedic Surgeons (AAOS). www.orthoinfo.org
2. Stress Fractures: Symptoms, Causes & Treatment. Cleveland Clinic. my.clevelandclinic.org
3. Metatarsal Stress Fractures – Aftercare. MedlinePlus Medical Encyclopedia, U.S. National Library of Medicine. medlineplus.gov
4. Koo AY, Tolson DR. March Fracture (Metatarsal Stress Fractures). StatPearls, NCBI Bookshelf, National Library of Medicine. www.ncbi.nlm.nih.gov