Stress Fractures: How Physiotherapy Can Help You Return to Running

Stress fractures, or bone stress injuries, are common in runners.  They are especially common in athletes training for long distances, such as marathons and ultramarathons.  Symptoms often start as a dull ache that can resolve or reduce during a run. But overtime symptoms tend to get progressively worse, sometimes resulting in an inability to continue running, pain with walking and night pain.

The cause is generally due to changes in training volume and/or intensity, or changes in running surface.  When bone is exposed to a mechanical stress (ie. running/impact) it remodels, which allows the bone to adjust its shape and strength.  However, bone has to breakdown before it can regenerate and come back stronger.  So if the application of the mechanical stress exceeds the ability for the bone to repair itself, a stress fracture occurs.

Common areas for stress fractures are the shin (tibia), foot and thigh bone (femur).  Some stress fractures are called high risk, which means there is an increased risk of poor healing.  It is important that these stress fractures are monitored closely by medical professionals. See the table below for a list of high risk stress fractures.


High Risk Low Risk
Femoral neck Posteromedial tibia
Anterior tibia Fibula
Medial malleolus Femoral shaft
Talus Pelvis
Navicular Calcaneus
5th metatarsal 2nd-4th metatarsals
Base second metatarsal
Sesamoid bones of the big toe


Many factors make bone more susceptible to stress fractures.  For example muscle fatigue, poor nutrition/energy deficit, lack of sleep and hormonal factors.

Management involves identification of training errors or other factors that may result in the development of a stress fracture, and strength training to increase the capacity of the lower limb to absorb load.   In some cases, running gait retraining can be beneficial.

Strength training can stimulate tissue adaptation without having to do large running loads, so it is ideal in the management of stress fractures.  However, to cope with the cumulative loads and rate of load application a targeted reloading program (which includes a graduated return to running) is important if the goal is to return to running.   Reloading the bone too quickly, or not enough, can result in re-injury.  Bone needs small bouts of a stimulus, followed by a period to recover, because after approximately 20-40 loading cycles the bone response to load diminishes.

At Physiotas we have physiotherapists with a Masters in Sports Physiotherapy and a special interest in bone stress injuries.

Your physiotherapist can help identify training errors and other factors that may be increasing your susceptibility to stress fractures. Then, following a thorough assessment, formulate an individualised strengthening program and advise on an appropriate reloading program to improve your capacity to tolerate the demands of running.

About the Author:

Lia Giovanovits is a Director and Physiotherapist at Physiotas.

Lia is a Director of Physiotas. She is an APA Sports Physiotherapist, Musculoskeletal Physiotherapist and an Associate Fellow at the Australian College of Physiotherapists Specialisation program.  Lia is part of the medical network for the Tasmanian Institute of Sport.

Lia is the clinical leader at our Launceston Clinic and has worked under leading UK Sports and Orthopaedic physiotherapists at Oxford and Nottingham. Lia has also worked with elite athletes across many sports, including the Australian Rowing Team (09′-13′), Canadian Women’s Rowing team (13′-14′), the Australian Para cycling team in the lead up to the Rio Olympics and she volunteered at the London Olympics.

Lia has a special interest in hip, ankle and knee injuries (especially patellofemoral and ligament injuries) and the management of injuries in cyclists, runners and rowers.

Lia has competed in many sports including swimming, rowing, cycling, triathlon and hockey.