Stress fractures

Last updated: June 29, 2023

CME information and disclosurestoggle arrow icon

To see contributor disclosures related to this article, hover over this reference: [1]

Physicians may earn CME/MOC credit by reading information in this article to address a clinical question, and then completing a brief evaluation, in which they will identify their question and report the impact of any information learned on their clinical practice.

AMBOSS designates this Internet point-of-care activity for a maximum of 0.5 AMA PRA Category 1 Credit(s)™. Physicians should claim only credit commensurate with the extent of their participation in the activity.

For answers to questions about AMBOSS CME, including how to redeem CME/MOC credit, see "Tips and Links" at the bottom of this article.

Summarytoggle arrow icon

A stress fracture is a fracture of structurally normal bone due to the coalescence of microfractures caused by repetitive activity. Risk factors include female sex, calcium deficiency, and highly repetitive activity. Clinical manifestations include pain that worsens with activity and improves with rest and tenderness over the affected bone. High-risk stress fractures are stress fractures in locations (e.g., lateral femoral neck, anterior tibia, 5th metatarsal) that are prone to complications (e.g., fracture progression, nonunion). Stress fractures may be managed based on a clinical diagnosis, but x-rays are typically obtained for confirmation. Because x-rays are often normal, an MRI is indicated if there is a concern for a high-risk stress fracture. Treatment is mainly conservative and focuses on cessation of the inciting activity, but high-risk stress fractures are managed as acute fractures, with immobilization, avoidance of weight-bearing activities, and referral to orthopedics.

Epidemiologytoggle arrow icon

  • Common injury in athletes; accounts for ∼ 10% of all sports-related overuse injuries [2]
  • Most commonly affected regions in both children and adults: [2][3]

Epidemiological data refers to the US, unless otherwise specified.

Etiologytoggle arrow icon


Normal bone develops a fracture as a result of bone remodeling due to repetitive microtrauma. [5][6]

Risk factors [6][7]

The female athlete triad syndrome is associated with an increased risk of stress fractures. [2]

Classificationtoggle arrow icon

Stress fractures are classified based on the risk of stress fracture complications. [2][6][7]

Low-risk stress fractures

High-risk stress fractures

Clinical featurestoggle arrow icon

Diagnosticstoggle arrow icon


A preliminary clinical diagnosis guides early management, but imaging of the affected region is indicated for confirmation. [2][12]

Stress fractures may often not be visible on plain films, particularly during the first 2–3 weeks of disease onset. Repeat x-ray and/or MRI is often required. [12]

Laboratory studies [15]

Differential diagnosestoggle arrow icon

The differential diagnoses listed here are not exhaustive.

Treatmenttoggle arrow icon

Initial management of stress fractures is typically conservative. Surgical management is reserved for refractory cases and high-risk stress fractures (e.g. anterior tibia, proximal 5th metatarsal, patella, talus, superolateral femoral neck), which are prone to fracture progression, delayed union, or nonunion.

Low-risk stress fractures [10][12]

Up to one-third of low-risk stress fractures do not heal with conservative management. Refer patients with refractory fractures to orthopedic surgery. [6]

High-risk stress fractures [2][12]

High-risk stress fractures should be managed like acute fractures. [2]

Complicationstoggle arrow icon

We list the most important complications. The selection is not exhaustive.

Calcaneal stress fracturestoggle arrow icon

Calcaneal stress fractures are most commonly found in individuals who run, jump, and/or march for extended periods of time (e.g., athletes, dancers, soldiers). For acute fractures of the calcaneus, see “Calcaneal fractures.” [17]

Etiology [17]

  • Repetitive microstress to the calcaneus (e.g., weight overload, increase in physical activity)
  • Inadequate footwear and activity on hard surfaces increase risk.
  • See also “Etiology of stress fractures.”

Clinical features [17]

  • Heel pain on activity (e.g., weight-bearing activities, walking on hard surfaces)
  • Point tenderness on palpation of the posterior calcaneus
  • Swelling, warmth, and/or ecchymosis of the heel (uncommon)
  • Positive calcaneal squeeze test: pain elicited by mediolateral compression of the heel between thumb and index finger


Differential diagnosis of chronic heel pain

Treatment [17][18]

Calcaneal stress fractures are considered low-risk and can usually be managed conservatively.

Calcaneal stress fractures are often misdiagnosed as soft-tissue injuries and undertreated. [17]

Tibial stress fracturetoggle arrow icon

Tibial stress fractures result from activities that put excessive force through the tibia and are classified as either low-risk or high-risk for complications depending on the location of injury. For acute fractures of the tibia, see “Tibial fracture” and “Fractures.” [2][4]

Etiology [2][4][7]

Clinical features


Differential diagnoses [4]

Depends on the location of the pain, e.g.:


See also “Treatment of stress fractures.”

Initial management [4][7][15]

Activity modifications for athletes and optimal time to return to play should be determined in consultation with a specialist, as these decisions can affect recovery time and the need for surgery. [7]

Low-risk stress fractures of the tibia [7]

High-risk stress fractures of the tibia [2]

Metatarsal stress fracturestoggle arrow icon

Metatarsal stress fractures are common with repetitive load bearing, hence they are also known as march fractures. For tuberosity avulsion fracture and Jones fracture of the 5th metatarsal shaft, see “Fractures.” [2]


  • Excessive repetitive force through the foot from:
    • General exercise (e.g., running, walking, dancing) [7]
    • Sports that cause tension on the plantar-lateral side of the foot (e.g., soccer, basketball, football) [2]
  • Specific risk factors include:
    • Anatomical features of the foot or leg such as tibia vara and low arched feet [2][19]
    • Fatigued muscles during long, intense physical activity [4]
    • Change in terrain or physical training routine [4]
    • History of recent trauma [4]
  • See also “Risk factors for stress fractures.”

Clinical features

Diagnostics [5][15]

Differential diagnoses [4][7]

Management [2][4][7]

See also “Treatment of stress fractures.”

Initial management [4][7][15]

Low-risk stress fractures of the metatarsal shaft

Sports and physical activity can generally be resumed when weight-bearing activities are no longer painful. [4]

High-risk stress fractures of the metatarsal shaft

Refer to a specialist (orthopedic surgeon or sports medicine) for consideration of surgical management (e.g., with intramedullary fixation). [2][15]

Referencestoggle arrow icon

  1. Weber JM, Vidt LG, Gehl RS, Montgomery T. Calcaneal stress fractures. Clin Podiatr Med Surg. 2005; 22 (1): p.45-54.doi: 10.1016/j.cpm.2004.08.004 . | Open in Read by QxMD
  2. Sherman SC. Simon's Emergency Orthopedics, 8th edition. McGraw Hill Professional ; 2018
  3. Tu P. Heel Pain: Diagnosis and Management. Am Fam Physician. 2018; 97 (2): p.86-93.
  4. Bencardino JT, Stone TJ, Roberts CC, et al. ACR Appropriateness Criteria ® Stress (Fatigue/Insufficiency) Fracture, Including Sacrum, Excluding Other Vertebrae. J Am Coll Radiology. 2017; 14 (5): p.S293-S306.doi: 10.1016/j.jacr.2017.02.035 . | Open in Read by QxMD
  5. Saunier J, Chapurlat R. Stress fracture in athletes. Joint Bone Spine. 2018; 85 (3): p.307-310.doi: 10.1016/j.jbspin.2017.04.013 . | Open in Read by QxMD
  6. Patel DS, Roth M, Kapil N. Stress fractures: diagnosis, treatment, and prevention. Am Fam Physician. 2011; 83 (1): p.39-46.
  7. Wu M, Fallon R, Heyworth BE. Overuse Injuries in the Pediatric Population. Sports Med Arthrosc. 2016; 24 (4): p.150-158.doi: 10.1097/jsa.0000000000000129 . | Open in Read by QxMD
  8. Bedoya MA, Jaramillo D, Chauvin NA. Overuse Injuries in Children. Topics in Magnetic Resonance Imaging. 2015; 24 (2): p.67-81.doi: 10.1097/rmr.0000000000000048 . | Open in Read by QxMD
  9. Matzkin E, Curry EJ, Whitlock K. Female Athlete Triad. J Am Acad Orthop Surg. 2015; 23 (7): p.424-432.doi: 10.5435/jaaos-d-14-00168 . | Open in Read by QxMD
  10. McInnis KC, Ramey LN. High‐Risk Stress Fractures: Diagnosis and Management. PM&R. 2016; 8 (3S): p.S113-S124.doi: 10.1016/j.pmrj.2015.09.019 . | Open in Read by QxMD
  11. Walls R, Hockberger R, Gausche-Hill M, Erickson TB, Wilcox SR. Rosen's Emergency Medicine 10th edition- Concepts and Clinical Practice E-Book. Elsevier Health Sciences ; 2022
  12. Kahanov L, Eberman L, Games K, Wasik M. Diagnosis, treatment, and rehabilitation of stress fractures in the lower extremity in runners. Open Access J Sports Med. 2015: p.87.doi: 10.2147/oajsm.s39512 . | Open in Read by QxMD
  13. Guermazi A, Roemer FW, Crema MD. Imaging in Sports-Specific Musculoskeletal Injuries. Springer ; 2015
  14. Hegazi TM, Wu JS. Musculoskeletal MRI. Springer Nature ; 2019
  15. Patel DR. Stress Fractures: Diagnosis and Management in the Primary Care Setting. Pediatr Clin North Am. 2010; 57 (3): p.819-827.doi: 10.1016/j.pcl.2010.03.004 . | Open in Read by QxMD
  16. Brewer RB, Gregory AJM. Chronic Lower Leg Pain in Athletes. Sports Health. 2011; 4 (2): p.121-127.doi: 10.1177/1941738111426115 . | Open in Read by QxMD
  17. Kiuru MJ, Niva M, Reponen A, Pihlajamäki HK. Bone Stress Injuries in Asymptomatic Elite Recruits. Am J Sports Med. 2005; 33 (2): p.272-276.doi: 10.1177/0363546504267153 . | Open in Read by QxMD
  18. $Contributor Disclosures - Stress fractures. None of the individuals in control of the content for this article reported relevant financial relationships with ineligible companies. For details, please review our full conflict of interest (COI) policy:.
  19. Warden SJ, Burr DB, Brukner PD. Stress fractures: Pathophysiology, epidemiology, and risk factors. Curr Osteoporos Rep. 2006; 4 (3): p.103-109.doi: 10.1007/s11914-996-0029-y . | Open in Read by QxMD
  20. ACR–SPR–SSR Practice parameter for the performance of radiography of the extremities. Updated: January 1, 2018. Accessed: May 30, 2023.

Icon of a lock3 free articles remaining

You have 3 free member-only articles left this month. Sign up and get unlimited access.
 Evidence-based content, created and peer-reviewed by physicians. Read the disclaimer