Dr. Jordan Metzl provides advice on how to deal with this classic overuse running injury.


Dr. Jordan Metzl provides advice on how to treat or prevent stress fractures.

The Symptoms

Pain that worsens over time, limits the sufferer’s ability to load the bone, and is generally concentrated in one specific area.

What’s Going On In There?

This is the classic overuse running injury. Unlike a bone break, which is the result of a trauma such as a twist or fall, a stress fracture develops over time due to repetitive loading. The demand on the bone simply exceeds the bone’s ability to withstand force.

There are three risk factors for a lower-leg stress fracture:

Activity level. Ramping up your athletic activity too fast can cause a stress fracture, such as adding too much mileage too soon during marathon training.

Mechanics. Excessive pronation—the foot rolling inward as it strikes—while running has been correlated with a greater risk of stress fracture. Also, weak core and hip muscles can promote poor running mechanics.

Bone density. This is common sense: The more brittle your bones, the easier it is to crack them. Low bone density (osteopenia) or very low bone density (osteoporosis) has several possible causes: genetics, as it tends to run in families; inadequate dietary calcium intake (1,300 milligrams a day is the recommended minimum); and, for women, a history of menstrual disorders, e.g., not getting a period for more than 6 months in a row, which can cause a low level of circulating estrogen.

We all acquire 90 percent of our bone density for life by age 18, and women reach their maximum bone density by age 32. After that, it’s about maintenance.

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Fix It

Employ dynamic rest. Cease the offending activity. For how long varies depending on the severity of your injury, but expect at least a month. You can cross-train with swimming and biking as long as you don’t load the injury.

Support your arches. Orthotics (arch supports) can help fix pronation and improve your running mechanics. Over-the-counter products usually work just fine, but if not, consider custom orthotics.

Supplement. Eat more calcium- and vitamin D-rich foods or take supplements.

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Prevent It

Change your shoes. Try switching to a shoe that limits pronation. Arch supports can help as well.

Up your calcium and vitamin D intakes. Try 1,300 milligrams of calcium and 400 micrograms of D per day. Easy food sources are milk and yogurt.

Follow the 10 percent rule. Never up your weekly running mileage by more than 10 percent.

Shorten your stride. A shorter running stride and faster foot cadence can reduce stress in your lower legs. Count your foot strikes for one minute on your right foot—shoot for 85 to 90 per minute.

Train your hips and core. Strengthening these areas will make you a stronger runner, which improves foot strike and body mechanics.

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When To Call A Doctor

With stress fractures, the earlier, the better. Your doctor can confirm the diagnosis with X-rays and MRIs. However, stress fractures typically don’t show up on X-rays unless they’re very serious or already in the healing stage. The key is to treat both the symptoms and the causes, which you can do with the home-based tips found here. Your doctor will guide your care.

Depending on your individual case and family history, your doctor may also do a bone-density scan. If you have low bone density, the doctor can treat you for osteopenia or osteoporosis.

Don’t wait to see a doctor if you suspect you’re developing a stress fracture. It only gets worse the more demand you put on it, and eventually it’ll be so severe and painful that you won’t be able to walk.

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New York City sports medicine specialist Jordan D. Metzl, M.D. is a 29-time marathon finisher and 10-time Ironman. His book, The Athlete’s Book of Home Remedies, has more than 1,000 tips to fix all types of injuries and medical conditions.