Written by Nic Bartolotta
Tibial stress fractures are one of the most common running injuries. The repetitive impact on hard surfaces combined with increased pace and mileage place stress along the shin bone, causing it to fracture. But if they’re so common amongst runners, can they really be that bad?
Yes, stress fractures from running can sideline you anywhere from 6 weeks to 6 months. So it’s important to diagnose, recover, and train your body to prevent future injuries. From common causes to treatment protocol to prevention, this is the runner’s ultimate guide to navigating stress fractures.
What is a stress fracture?
A stress fracture is a crack in the bone caused by repetitive stress, specifically when overused muscles are unable to absorb the shock. As a result, the load is transferred to the bone which fractures under stress.
According to Dan Dobrowolski DAT, LAT, ATC, OTC, “Wolff’s Law states that bones react to the forces that they are placed under and over time adapt and remodel according to these stresses. Repetitive mechanical stresses and forces, such as the ones that present in running, are typically the driving cause for the development of stress fractures and reactions.”
Stress fractures can occur in any weight-bearing bone in the human body but are most common in the foot, shin, and femoral bones.
Symptoms & diagnosis
The repetitive stress from hard, uneven surfaces on the tibia makes runners more susceptible to stress fractures than most athletes. And compared to bone injuries in the foot, pelvis, and femur, tibial fractures are low-risk stress fractures. Nonetheless, they’re serious injuries that must be carefully diagnosed.
How long does it take to get a stress fracture from running?
There are multiple factors that play a role in a person’s ability to withstand stress fractures. And though it varies between individuals, stress fractures can occur within a few weeks of sudden increases in mileage, speed, or pace.
This is especially the case in runners who are in their first year of training. They improve substantially early on in their training, increasing their mileage and accelerating their pace. But all of those improvements can come at a cost. Even though muscles & cardiovascular system adjust to the higher workload within a week or two, your bones take longer. In fact, they actually weaken before getting stronger, a process that takes several months.
The symptoms of a stress fracture from running present in different ways depending on the root cause and individual’s health. And while there isn’t a surefire way to diagnose yourself, there are a few signs that could indicate a stress fracture.
How do you tell if you have a stress fracture from running?
- “Deep” pain that appears out of nowhere and only worsens with use, it will feel different than a muscle or tendon injury
- Constant soreness, even when you’re not running
- Aching or burning point at a specific, isolated location on the bone
- Pressing directly against the bone is painful
- Perform a hop test – jump 3-5 inches off the ground and if it hurts when landing, you likely have a stress fracture
If you have one or more of these symptoms, be sure to visit your doctor for an official diagnosis. And though you may be reluctant to visit the doctor to avoid hearing the bad news, it’s important to treat stress fractures as early on as possible. In fact, an early diagnosis may indicate just a "stress reaction," which is similar to a bone bruise. But if left untreated, a stress reaction will eventually worsen to become a stress fracture.
Your doctor will likely use a bone scan or MRI to determine the exact location and severity of the stress fracture. From there, they’ll determine if you need a boot, crutches, physiotherapy, or another treatment regiment. In some cases, you may be subjected to a gait analysis, a scientific evaluation of how you run and walk.
Treatment & Recovery
As an athlete, taking time off is the last thing you want to do. But most stress fractures take at least 6-8 weeks to heal completely. This means you can’t run on the track, treadmill, or road for the duration of the healing process.
If you resume running before your fracture heals fully, you’ll risk a complete break. A complete tibial fracture will put you on crutches and in a boot for upwards of 6 months depending on the location & severity of the break. Take the recommended time off to prevent further damaging the bone.
So in the meantime, you may be asking yourself – “what can I do to heal my stress fracture?”
To heal properly, you need to avoid any unnecessary load on your shin. This means no running, jumping, or lower body strength training. But you can maintain your cardiovascular endurance and muscle mass by cross training with an exercise bike, swimming, and/or aqua jogging. Cross-training will help you maintain fitness levels while taking time off from running. But if you want to make a full recovery, you’ll need to treat the muscles surrounding the bone to prevent future injury.
Tibial stress fractures are often exacerbated by tight calves. So at least once per day during your 6-8 weeks off, give yourself a deep tissue massage to release muscle tension and alleviate pain near the fracture. Don’t massage the bone though – this will cause a sharp pain and delay the healing process.
How to prevent stress fractures from running?
Adjust your training program and weekly mileage
Stress fractures from running are almost always caused by “too much too soon,” especially in new runners. If you’re training for a marathon or half-marathon, you must increase your mileage to prepare for the race. But make sure to do so gradually, only increasing your mileage by 10% each week and scheduling down weeks.
Here are things to keep in mind when you’re building a training program:
- Limit mileage increase to 10% each week
- Schedule a down week once per month, reducing your mileage by 40-60% for the entire week
- Take 1-2 off days per week to prevent stress fractures and other overuse injuries
The recommended training schedule should include three straight weeks of increased mileage followed by a rest week once per month. Down weeks help your bones rest and recover from the repetitive stress.
Change running surfaces
Changing running surfaces will strengthen the muscles around your tibia and reduce the repetitive force on your bones. Add hills, trails, treadmills, and sand into your program to strengthen your lower leg muscles and reduce the likelihood of future stress fractures.
Incorporate strength exercises into your training program
Stronger muscles protect your bones from stress fractures. They’ll also help you improve your mileage, pace, and recovery times. The calf is the largest of these muscles and can be trained with calf raise variations, jump rope, and single-leg jumping exercises. Train the rest of your lower body with exercises that target the glutes, hamstrings, quadriceps, and hips.
Warmup, cool down, and recovery
Jumping straight into a training pace without warming up places you at a greater risk of injury during your workout. Similarly, “forgetting” to stretch or cool down after running places you at a greater risk of injury in future workouts.
Stimulate blood flow and release muscle tension before easing your way into a training pace. And once you’re done, stretch and foam roll your lower body to break down scar tissue and kickstart recovery, among other benefits. Then make sure to consume plenty of water and nutritious food to replenish your muscles.
Fix your running form
Poor running form and postural abnormalities of the foot, knees, and hips are common causes of stress fractures and other running injuries. Tibial fractures often result from overstriding and a hard heel strike. This motion also increases the likelihood of hip injuries and upper leg/femoral fractures.
Shorter strides that force your entire body weight onto the forefoot aren’t any safer. The short steps place excess load over the foot, often resulting in a stress-related fracture. But if you’re lucky enough to avoid stress fractures, chances are that you’ll struggle with patellar tendonitis.
Sometimes, your running shoes can even cause stress fractures in your shin. Your old, worn down shoes carried you for hundreds of miles, but it’s time to rotate in a new pair. Over time, the cushioning wears down, providing inadequate support for your bones as you strike the ground. But new, expensive shoes can do the same. Shoes that are too thin, too wide, or too arched present the same issues and may cause stress fractures. We recommend choosing a running shoe that hugs your foot, has ample cushioning, and a near-flat arch.
Upgrade your nutrition
Runners are susceptible to stress fractures, we’ve covered that. But some runners are even more prone to bone-related injuries because of nutrition and genetic differences.
Just as with all sports, your diet plays a critical role in athletic performance. And there are several nutritional risk factors that increase the likelihood of stress fractures:
- Overweight - Even 5-10 extra pounds of body weight can place undue stress on the tibia, causing it to fracture.
- Underweight - Weak bone density and low muscle mass are side effects of malnutrition. And unfortunately, fragile bones surrounded by weak muscles are almost guaranteed to break.
- Calcium deficiency - Calcium is imperative to building strong bones. Without it, weakened bones will fracture under minimal force. And a lifelong calcium deficiency can lead to early onset osteoporosis, which may prevent you from running ever again.
- Lack of vitamin D - Vitamin D helps your bones absorb calcium. So even with enough calcium, a lack of vitamin D can negatively impact your bone health. Athletes who run outside during the winter are especially at risk of stress fractures due to a lack of sunlight. Make sure to supplement your diet with vitamin D to keep your bones strong through the cold weather.
- Too much caffeine - Studies suggest that excessive caffeine intake puts individuals at a greater risk of bone fractures. The research suggests that coffee drinkers are at the greatest risk as it draws calcium directly out of the bones.
- Elevated sodium intake - Excess sodium levels cause humans to urinate and sweat more than normal. As a result, calcium is often excreted during these processes.
- Plant-based diets - More athletes, endurance runners especially, are turning to plant-based diets to fuel their performance. But oftentimes, new plant-based eaters struggle to consume enough vitamin D and calcium, both of which are necessary for bone health.
- Women - Biological female runners are at a greater risk for stress fractures compared to biological males. A condition called the ‘female athlete triad’ is an energy deficiency that occurs as a result of decreased caloric & nutritional intake paired with increased caloric expenditure from exercise. According to Dobrowolski, this can lead to irregular menstruation which weakens bones and increases the risk of fracture. Additionally, factors like inadequate estrogen production, menopause, birth control, and wider hip structure increase the likelihood of stress fractures.
Most of these nutritional deficiencies can be resolved with a healthy diet and adequate sleep. And in most cases, runners live generally healthy lifestyles.
Stress fractures from running aren’t fun; neither is recovery. But if you rest for 6-8 weeks, strengthen your muscles, improve your mobility, and treat your body right, you’ll be well on your way to a healthy recovery. And, you won’t have to worry about another tibial fracture derailing your training in the future.