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Stress fracture

Also called stress fractures, bone stress injury, bone stress injuries, stress reaction

An overuse injury to bone, from a stress reaction to a crack. How reviews define it, which athletes and recruits were studied, how long return to sport took by site, and what trials found.

Region
Lower leg
Updated
October 6, 2026
Reviewed
October 6, 2026 · how entries are checked

What it is

How reviews define it

A 2022 review defines a bone stress injury as an overuse injury to generally normal bone, brought on by repeated loads1. A review of these injuries in athletes describes them as a continuum6. Built-up small-scale damage begins as a stress reaction, can progress to a stress fracture, and then to a complete fracture6.

The 2022 review separates two kinds1:

  • Fatigue fractures come from loading above a person’s habitual levels1.
  • Insufficiency fractures happen where altered bone biology, such as osteoporosis (thin, weak bones), lets normal loads cause a similar injury1.

A 2025 expert-panel study noted that international consensus on definitions, risk factors and management was lacking7.

Which bones

A 2001 review states that almost any bone can develop a stress fracture8. Weight-bearing leg and foot bones are affected most often, especially the tibia (shinbone), tarsals and metatarsals (the long bones in the middle of the foot)8.

The sites recorded differ between two groups of athletes9,10:

  • 320 athletes in a 1987 series. Tibia 49.1%, tarsals 25.3%, metatarsals 8.8%, femur (thigh bone) 7.2%, fibula 6.6% and pelvis 1.6%9.
  • 671 stress fractures in US college athletes. Metatarsals 37.9%, tibia 21.9%, and the lower back, lumbar spine or pelvis 12.1%10.
Engraving of the bones of the right foot seen from above, labelled. The navicular sits on the inner side of the midfoot, between the head of the talus behind and the three cuneiform bones in front, with the cuboid beside it on the outer side. The heel bone lies at the back, the five metatarsals and the toe bones fan out in front, and red outlines mark where muscles attach.
Bones of the right foot from aboveHenry Vandyke Carter, in Henry Gray, Anatomy of the Human Body (1918), Fig. 268. Public domain, via Wikimedia Commons. (source, Public domain)

Low-risk and high-risk sites

A 2017 review defines low-risk stress fractures as those with a low probability of spreading, healing late or failing to unite11. High-risk ones have higher rates of each, and of displacement, where the bone ends move out of line11.

ClassSites the review names
Low-risk, in a 2022 reviewSecond and third metatarsal shafts, posteromedial (back and inner) tibia, fibula, shaft of the humerus (upper arm bone) and ribs1
High-risk, in a 2000 reviewTension side of the femoral neck, patella (kneecap), front of the tibia, medial malleolus (inner ankle bump) and talus (ankle bone)12. Also the tarsal navicular, fifth metatarsal and great toe sesamoids12

The femoral neck is the angled part of the thigh bone just below the ball of the hip. The 2000 review attributes poor healing at high-risk sites to tensile (pulling) forces and relatively poor blood supply12. A 2023 systematic review (a study that sums up the research on a question) called sorting by location standard practice, but not sufficiently validated4.

What scans show

A 2022 review describes plain X-rays as insensitive for these injuries, and MRI as the imaging method of choice1. MRI is a scan that shows soft tissue in detail.

Who it affects

How often it was recorded

A review notes that recent data on bone stress injuries are limited6. Two of the figures below use the athlete-exposure, which is one athlete taking part in one practice or game10,13.

Group studiedWhat was recorded
US college athletes, 33 sports, 2016 to 2022Average annual risk of 4%2
US college athletes, 2004 to 20145.70 per 100,000 athlete-exposures10
US high school athletes, 2005 to 20131.54 per 100,000 athlete-exposures13
221 US college distance runners, seven years32 per 100 athlete-years14
748 competitive high school runners, mean 2.3 seasons5.4% of girls and 4.0% of boys15
New US military recruits, as reported by a 2022 reviewUp to 5–10% in the first two to three months of basic training1

Women and men

  • US college sports played by both sexes. Women had about twice the rate of men, 9.13 against 4.44 per 100,000 athlete-exposures10.
  • Runners. A meta-analysis (a study that pools earlier studies) of prospective studies found bone stress injury more frequent in female runners16. It found no difference in overall injury rate16.
  • Military recruits. A 2022 review reports these injuries 3.1 to 3.6 times as often in female as in male recruits1.
  • Track and field. In a 12-month study of 111 competitive athletes, 21.1% had a stress fracture, with no difference between men and women17.

What goes with it

A 2022 review names unaccustomed physical activity as the most important risk factor in athletes and military recruits1. It calls a previous bone stress injury the most universal one1. In a meta-analysis of runners, the pooled odds were 4.99 times higher with a previous stress fracture and 2.31 times higher in women3.

Studies also report on energy and menstrual factors1,18:

  • The 2022 review calls low energy availability a major risk factor that affects bone health in women and men1. The term means too little energy from food left for the body’s needs after training.
  • In a prospective study of 259 exercising girls and women, 10.8% had a bone stress injury18. Risk was about 15–20% with one significant risk factor18. It was 30–50% with combined factors related to the Female Athlete Triad18. The Triad is low energy availability, menstrual problems and low bone density occurring together.
  • In a survey of 183 competitive female distance runners, the 12-month rate was 2.25 times greater in those with fewer than nine periods19.

Another review describes these injuries as arising from many interacting factors6. The review adds that single risk factors predict these injuries poorly6.

What studies found

How it goes over time

A 2022 review states that these injuries bring pain and lost function, and may go on to become a complete fracture1. It adds that they frequently recur, often at a different location1. The same review states that most people recover completely when the injury is found and managed early1.

Of 671 stress fractures in US college athletes, 21.5% were recurrent and 20.7% ended a season10.

Return to sport by site

A systematic review and meta-analysis pooled 76 studies of athletes, covering 2,974 bone stress injuries4. More than 90% of athletes returned to sport, and the time taken depended on the site4.

Pooled days to return to sportPosteromedial tibial shaft44 Fibula56 Femoral neck107 Tarsal navicular127
Pooled days to return to sport. Bars start at zero; the table below gives each value with its source.
SitePooled days to return to sport
Posteromedial tibial shaft444
Fibula564
Femoral neck1074
Tarsal navicular1274

Complication rates were highest for the femoral neck, tarsal navicular, front of the tibial shaft and fifth metatarsal4. They were lowest in the fibula, pubic bone and back inner tibial shaft4.

MRI grade and return time

Studies have disagreed on whether a higher MRI grade goes with a longer return20. The authors of a 2022 meta-analysis noted that some earlier studies found no significant relationship20. Across 16 studies and 560 injuries, they found higher grade correlated with a longer return20. Mean time rose from 41.7 days at grade 1 to 98.5 days at grade 420.

Trials of insoles and orthoses

Reviews of shock-absorbing insoles and foot orthoses (shaped shoe inserts) disagree21,22:

  • 2005 Cochrane review. Its 13 prevention trials were in military recruits21. Four compared shock-absorbing boot inserts with a control, and each reported fewer bone stress injuries with inserts21. The one trial with a significant result lacked important design details21. The authors concluded that inserts probably reduce the incidence (new cases over a set time) in military personnel21.
  • 2017 meta-analysis. Foot orthoses lowered the risk of stress fractures, with a risk ratio (how many times as often it happened) of 0.5922. Shock-absorbing insoles did not, with a risk ratio of 1.1522. Trial quality varied greatly22.
  • 2023 meta-analysis of 11 randomised trials. The risk ratio with foot orthoses was 0.47, on evidence rated low quality23. The authors concluded that orthoses could potentially help in the military setting23.

The 2023 review also concluded that the effect of footwear and training-related strategies on risk is still unknown23.

Trials of stretching, supplements and a medicine

What was testedWho was studiedWhat was found
Leg stretching in warm-upMilitary recruits, two cluster-randomised trialsNo significant effect on lower-limb stress fractures and stress reactions21
Calcium supplement alone1,398 healthy male military recruits, 247 of them allocated the supplementWeekly incidence of stress fractures and tibial stress syndrome over nine weeks was similar with and without it; usual dietary calcium already averaged above 800 mg a day24
Calcium with vitamin D5,201 female Navy recruits5.3% against 6.6% on placebo over eight weeks of basic training5
Risedronate, a bisphosphonate324 new infantry recruitsNo statistically significant difference in stress fracture incidence25
Nutrition education on energy availabilityFemale distance runners at two US collegesOverall rate not reduced: 0.43 against 0.52 events per person-year before26

In the nutrition study, the rate fell at one college and did not fall at the other26. The authors suggest the effect may depend on a team’s culture, environment and resources26.

Trials in people with a stress fracture

Trials of an air-filled leg brace for tibial stress fractures disagree27,28:

  • In a randomised trial of 18 athletes, the brace group returned to full activity in 21 days27. The group managed with rest and a gradual return took 77 days27.
  • In a randomised trial of 31 soldiers (20 finished), the brace made no difference to the trial’s two timed outcomes28.
  • A Cochrane review pooled three small trials and found a shorter time to full activity, with highly inconsistent results21.

Two devices were tested against placebo devices29,30:

  • Pulsed ultrasound. In a double-blind trial of 26 midshipmen, it did not significantly shorten healing time29. A 2023 systematic review found five studies with mixed results31.
  • Electric field stimulation. In a randomised trial of 44 people with posteromedial tibial stress fractures, it made no difference to healing time30.

A systematic review of 18 studies compared surgery with non-surgical care at three high-risk sites32. It drew no strong conclusion, on low-certainty evidence32.

Connections

The bones

Each bone’s own page covers its stress fractures in more detail4,33:

  • Tibia. Front-of-shaft injuries had among the highest complication rates in a meta-analysis, and posteromedial ones among the lowest4.
  • Fibula. In a systematic review of 45 fibular stress fractures, each healed without surgery34.
  • Metatarsals. A review states that shaft stress fractures develop most often in the second metatarsal11.
  • Navicular. This midfoot bone is given as an example of a high-risk site33.
  • Calcaneus (heel bone). Its stress fractures are classed as low-risk35.
  • Femur. A review describes femoral neck stress fractures as relatively rare, most common in military recruits and endurance athletes36.

Shin splints and running

Medial tibial stress syndrome, or shin splints, is pain along the inner edge of the shinbone that comes with exercise. In an MRI study of 22 athletes with leg pain, the eight with stress fractures showed a wide bright signal in one area of marrow37. It was absent in those with shin splints37.

A review reports that bone stress injuries make up 15–20% of musculoskeletal injuries in several sports, including recreational running6.

Stress fracture involves

Stress fracture is one kind of injury to

Stress fracture is compared with

Stress fracture has been counted in studies of

Sources

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Every source the library cites

Changes

  • Re-reviewed after a published correction to a cited source was read and recorded; no change to the page.
  • First published.