STRESS FRACTURE

Stress fractures are tiny cracks in bone from repetitive overload. Bone needs load to heal, but too much too soon makes it worse. Physio treatment is about protecting the healing bone, maintaining fitness, and rebuilding load tolerance so it doesn’t happen again.

1. *Protect and unload phase: 2-6 weeks*

How long depends on location. Tibia and metatarsals take 6-8 weeks. Femoral neck and navicular are higher risk and need longer.

- *Offload the bone*: Crutches, boot, or reduced weight bearing if walking hurts. Pain >3/10 during activity means you’re overloading it.

- *Maintain fitness*: Swim, cycle, or use an elliptical if it’s pain-free. Bone healing doesn’t mean stop moving entirely.

- *Pain monitoring*: Use the “24-hour rule” - pain should settle back to baseline within 24h of activity. If not, you did too much.

- *Nutrition*: Check calcium, vitamin D, and protein intake. Low bone density slows healing.

2. *Loading and strength phase: once pain-free walking*

Start loading the bone gradually. Bone remodels with controlled stress.

- *Gentle loading*: Begin with walking, then marching, then hopping drills on soft surface. Progress only if pain-free next day.

- *Strength work*: Focus on muscles around the site. Tibia stress fracture = calf, tibialis posterior, glute strength. Metatarsal = intrinsic foot muscles, calf.

- *Balance and proprioception*: Single-leg balance, wobble board. Helps with landing mechanics.

- *Mobility*: Stiff ankles/hips increase load on the shin/foot. Ankle rocks, hip mobility drills.

3. *Return-to-impact phase*

This is where most people re-fracture by rushing it.

- *Gradual impact progression*: Start with walk-jog intervals on soft surface. 1 min run, 2 min walk x 15-20 min.

- *Plyometrics*: Start with double-leg hops, progress to single-leg. Land soft, control the load.

- *Sport-specific drills*: Build up to cutting, jumping, sport demands slowly.

- *Load monitoring*: Follow the 10% rule for weekly mileage/time. No spikes.

4. *Fix the cause*

Stress fractures are a load capacity problem. Physios look for:

- *Training errors*: Sudden increase in volume, intensity, or surface change. Most common trigger.

- *Biomechanics*: Overstriding, overpronation, weak glutes increase stress on tibia/foot.

- *Bone health*: History of low energy availability, amenorrhea in women, low bone density. Address this or it recurs.

- *Footwear*: Worn shoes, wrong support, sudden shoe change.

5. *High-risk vs low-risk sites*

- *Low-risk*: Tibia shaft, fibula, metatarsals. Usually heal with load modification in 6-8 weeks.

- *High-risk*: Femoral neck, navicular, anterior tibia, 5th metatarsal base. Higher non-union risk. Often need longer offload and sometimes surgery.

What doesn’t help

Complete rest for 8 weeks without gradual loading leads to deconditioning and re-injury. NSAIDs can slow bone healing - avoid unless prescribed. Passive modalities don’t heal bone; controlled loading does.

Return-to-sport criteria

Pain-free with single-leg hop 20x, single-leg balance 30s, and normal gait. No pain next morning after test session.

Timeline

- Low-risk sites: 6-12 weeks

- High-risk sites: 12-20+ weeks

Stress fractures are a sign you exceeded bone’s capacity. The rehab fixes the bone, but the cause is usually training load, mechanics, or bone health.

Which bone is it, and what were you doing when it started? That tells me the likely timeline and what mechanics to fix.

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