Stress Fractures | Symptoms & Causes

What causes stress fractures?

Stress fractures are an overuse injury caused by repetitive stress — usually to the shin bone (tibia) or foot bones but also to the hip (femoral neck) — over a period of time without enough rest to give the bone enough time to heal.

Muscles adapt to stress — that’s how they become stronger. But they also need to rest and rebuild between the episodes of stress. When a muscle gets repeatedly overtaxed with the stress of impact (running, quick cutting, pivoting), it can transfer that stress to the bones of the foot or lower leg.

What factors can contribute to young people getting stress fractures?

Stress fractures can occur if a runner or athlete:

  • is experienced but is overtraining (often occurs late in the sports season) 
  • resumes hard training too soon after a lay-off 
  • increases the duration or intensity of training too quickly 
  • trains on hills 
  • is a novice who begins training too hard before she’s conditioned 
  • runs on surfaces that are too hard or uneven
  • runs in improper or outworn footwear 
  • has flat feet (fallen arches), which unevenly distribute the stress from impact 
  • has poor running mechanics 
  • has tight muscles 
  • is an anorexic individual, whose bones are already deprived of nutrients, brittle and vulnerable to injury; this profile occurs often in runners and gymnasts

What are the symptoms of stress fractures?

Pain and/or inflammation in the foot or lower leg can be symptoms of stress fractures. The pain tends to intensify in stages:

  • At first, the injury may hurt mildly when the child plays her sport. 
  • As more trauma occurs, the child will experience constant pain when she’s playing. 
  • At the end stage, the child has constant pain in her foot or lower leg, even when she’s not playing. At that point, the affected area will have sustained a significant amount of damage.

Female athletes are more vulnerable to a stress injury

Occasionally, an adolescent girl runner or gymnast (or other athlete) might have an eating disorder, which will result in a cascade of problems. An anorexic or bulimic girl can lose her period (amenorrhea) and suffer bone density loss (osteopenia or osteoporosis). Her bones can become brittle and thus vulnerable to injury and fracture. It’s important for teenage girl athletes to maintain healthy, vitamin D- and calcium-rich diets.

Why is there an increase in overuse injuries?

Youth and teen participation in organized sports has grown to about 35 to 40 million kids across the United States. Not surprisingly, the incidence of sports injuries has also grown—and statistics suggest that 30 to 60 percent of student athletes will have an overuse injury at some point in time. In one Sports Medicine practice at Children’s, for example, at least half of the young patients have an overuse injury.

How can parents and coaches help kids avoid stress fractures and other overuse injuries?

Parents and coaches have a great deal of influence—for better or for worse. Parents and coaches should emphasize moderation in training and should restrain the zeal with which they push youth and teens.

Coaches should:

  • become certified
  • learn and use proper training techniques
  • avoid assigning too many repetitive drills—the overwhelming cause of overuse injuries
  • teach proper running mechanics and other sport-specific motion techniques

Physical education departments should make sure that the surfaces of tracks and fields are in good shape, and that proper equipment, footwear and protective gear are used for each sport.

Our Sports Medicine specialists advise:

  • warming up and stretching before practice
  • resting at least one day a week 
  • cross-training/alternating sports: It is usually unwise for a child or teen to specialize in just one sport. Multi-sport athletes tend to get fewer overuse injuries than those who specialize in just one sport.
  • alternating exercises during practice: By alternating exercises, the athlete is less likely to experience an injury—and over the long term, her muscle memory will actually improve.

Are there other guidelines and resources for injury prevention and safer training?

The American Academy of Orthopaedic Surgeons (AAOS) has issued comprehensive guidelines for helping to prevent sports injuries. Below is an excerpt from the AAOS recommendations:

Use proper equipment.

  • Replace athletic shoes as they wear out. 
  • Wear loose-fitting clothes that are light enough to release body heat. 
  • In cold weather, dress in removable layers.

Warm up.

  • Warm up to prepare to exercise, even before stretching.
  • Run in place for a few minutes.
  • Breathe slowly and deeply, or gently rehearse the motions of the exercise to follow.


  • Stretch slowly to the point of muscle tension.
  • Hold each stretch for 10 to 20 seconds, then slowly release.
  • Inhale before each stretch, exhale on release.
  • Do each stretch only once.
  • Never bounce on a fully stretched muscle.

Drink water.

  • Drink enough water to prevent dehydration, heat exhaustion and heat stroke.
  • Drink 16 ounces (one pint) of water 15 minutes before exercising, another 16 ounces after cool-down.
  • Drink water every 20 minutes or so while exercising.

Cool down.

  • Cool down for twice as long as warm-up.
  • Slow down motion and lessen intensity for at least 10 minutes before stopping completely.


  • Schedule regular days off from exercise, and rest when tired.
  • Fatigue, soreness and pain are good reasons to not exercise.