Stress Fractures in Athletes

Foot health and proper care are at the forefront of prevention and treatment of common stress fractures.

© 2009 Rich

Athletic competition and exhibition have been a staple of our culture since inception. Whether it is cheering on our favorite sports team, enjoying a night out at the ballet or participating in our first marathon, these unique skill sets bring people together. Though each athletic talent is distinct in its purpose and following, their participants can share common pains when they leave the stage, field and concrete.

Common fractures

According to Dane LaFontsee, CPed and president of the Pedorthic Footwear Association, there are five main stress fractures that most commonly afflict athletes. Stress fractures of the tibia, fibula, second or third metatarsal, calcaneous, and Jones or fifth metatarsal fractures can sideline professional and amateur athletes.

“One of the major factors in stress fractures of the lower limb is improper biomechanics of the foot,” Michael Forgrave, CPed (C), said. “For example, if your foot pronates then the forefoot must splay to ‘get out of the way,’ this will put more stress on the metatarsals, which can lead to stress fractures. Pronation can also lead to stress fractures of the tibia and fibula as more stress is placed on the muscles that attach in these areas, like tibialis posterior and tibialis anterior.”

These five fractures, along with others that stretch beyond the scope of the foot and ankle, do not discriminate between sports or activities.

“The injury area is dependent upon the mechanics required by the sport and whether that athlete can produce those mechanics properly,” Forgrave said.

Some activities are more prone to a specific fracture but no one is immune.

“I see [stress fractures] most in runners and dancers and I attribute that to their high tolerance of pain and their ability to just keep working through no matter how painful it is,” LaFontsee said. “Runners just want to run and dancers just want to dance.”

He also cited impact and ill-fitting footwear for causes of injury that can eventually lead to stress fractures. Improper training shoes or poor choice of footwear when not training leave the athlete with little to no protection from injury.

“I see [stress fractures] in soccer players because they are often in a shoe that isn’t very supportive,” LaFontsee said. “In the [dancing] world, I see many Celtic dancers. That clog shoe puts a great deal of stress on the metatarsal area. Also, female ballet dancers have to dance on their toes in a pointe shoe so that creates problems.”

Gender discrepancies

The prevalence of stress fractures in men and women varies due to a number of factors, but overall, women suffer the brunt of the injuries.

“I see a lot more injuries with the female athlete than I do with the male athlete,” LaFontsee told O&P Business News. “When I see a male stress fracture it is usually impact-related or [related to] a weakness that the athlete has had for a number of years.”

LaFontsee, who works with collegiate and professional athletes as well as professional dancers, identified several reasons for this discrepancy.

“We attribute that to diet, to amenorrhea and just the simple fact that women, if they are having their menstrual cycle, lose a lot of calcium,” LaFontsee said. “Also, guys don’t care if they are a few pounds overweight so we’ve got a dietary problem with that as well.”

Forgrave also treats a larger number of female athletes than male athletes for stress fractures.

“There are several reasons this may be true. One is that females have a greater ‘Q’ angle — the angle between the greater trochanter, the midline of the patella and the tibial tuberosity. This will set up the lower limb to compensate for this greater angle,” he said. “Women are also not as muscular as men. The muscle will help the bone adapt to stress. It is not to say that men don’t get stress fractures, they are just not as frequent.”

Competition level and age

High school athletes are often busy with athletics year round giving their bodies little time to adjust to changes.

“A lot of times you see it at the lower levels like in the high school female athlete,” Randy Stevens, CPed, CFo, said. “They might be playing three seasons of soccer and they are on harder indoor surfaces or they are playing on an outdoor surface like artificial turf. Those are oftentimes contributing issues.”

Through his work with college athletes, LaFontsee understands the stress that young athletes take on when they leave high school and pursue a sport in college.

“It’s like going from college to the pros. It’s a huge jump,” he said. “They might spend a couple of hours each day afterschool [training] in high school. When they get to college level, they can spend 4 to 5 hours a day [training]. I will see more stress-related fractures in the early part of that college time than I will later.”

Many athletes, especially in collegiate and professional sports where the stakes are raised, push too hard without realizing the damage they could be incurring on their bodies; damage that could end their careers if they are not careful.

“One of the major causes of stress fractures is the concept of too much, too soon,” Forgrave said. “Athletes feel that they must do more so they increase the stress or volume at too rapid a rate.”

Age plays a large role among the older populations as well.

“In women there is usually a loss of calcium in the bones and this may also hold true for men,” Forgrave said. “[Also] as we lose some of our muscle mass we don’t necessarily have the support system around the bones that we need.”

Bodies biomechanically change as we age and can not tolerate the same stresses as they once did.

“I work with a lot of athletes in their 40s, 50s and 60s and they are still trying to run but their bodies are starting to say, ‘I can’t take this anymore,’ so we might see some stress-related injuries at that point.”

Stress Fractures 101

According to the American Academy of Orthopaedic Surgeons (AAOS), a stress fracture is an overuse injury that occurs when muscles become fatigued and are unable to absorb added shock. The inability to absorb the shock forces the muscle to transfer the overload of stress to the bone causing the fracture.

In addition to proper footwear, AAOS offers some additional tips on ways to prevent stress fractures. For instance, when starting a new sport, AAOS recommends setting incremental goals. This will gradually build up a resistance and not place too much stress on any part of the body. Also, AAOS recommends alternating activities when you can. This can be difficult for competitive athletes, but for the novice, mixing up varying activities can alleviate the stress on the body.


Warning signs

No matter the experience or age level of an athlete, it is important to know and understand the warning signs of a serious medical problem and take action before the condition worsens.

One good rule for every athlete is that any kind of pain is an indication of a problem.

“It may be minor at first, like a dull toothache,” Forgrave explained. “It will occur with activity but disappear after. This can lead to bigger problems if it is not addressed. With any lower limb discomfort a pedorthist or related health care professional should be consulted.”

Also, with a little investigating, athletes can figure out right away if there is another problem to be concerned about by simply looking at their training shoes.

“Do they wear their shoes out prematurely? Does the shoe distort quickly?” Forgrave asked.

These could be signs of a larger problem.

LaFontsee also offered some helpful signs to watch out for.

“If [pain] always occurs at the same point [in training] or if there is a point at which their body is saying ‘this hurts’ and it continually happens, that tells me the body is not able to protect itself,” he said. “When the body weakens due to fatigue, the technique falls apart and that is when the athlete is in jeopardy.”

No matter the circumstances, it is recommended that professional medical attention is sought at the first sign of any problem.

“You don’t want to wait. Too many athletes don’t want to let their coaches know. If they are training they blow it off and don’t address the issue right away,” Stevens said. “I’ve known people who have had metatarsal head pain and they’re training for a marathon and they get couple weeks out from the marathon and it really becomes painful. Then they go to the physician and then they find out they have a third metatarsal stress fracture and are not able to run in the marathon. It’s not from overtraining but from neglect of the recognition of a problem to see the physician and let them address the issue and keeping it from getting as far advanced.”


“Nobody wants to take time away from their sport particularly if their livelihood depends on it,” Forgrave said. “Most athletes will accept a 6-week holiday from their sport if it means that they will not hurt. Usually a stress fracture requires 6 weeks of non-weight bearing activity.”

Depending on the injury, Forgrave suggested using the pool or stationary bike as a means for light training during down time.

“If the athlete must perform, then the first thing that must be addressed is their feet as this will probably be a major cause of the stress fracture,” he said. “Stress fractures are a bony response to stress, so you must find the cause of the stress and fix that. The second thing is that the athlete must be in their prescribed footwear during waking hours. In some instances, that may mean putting them in a rockered removable cast when they are not being active. This also means that they may be unable to practice but would be available to compete.”

In all cases, Forgrave stressed the importance of reducing the area of stress.

“For the tibia and fibula, I would probably use a foot orthotic that would reduce the amount of pronation and provide shock absorption,” he said. “With metatarsal stress fractures and Jones fractures, a metatarsal pad placed proximal to the metatarsal heads would support the shafts of the metatarsals thereby reducing the stress on them. With a calcaneal stress fracture, I would put lots of padding in the heel of the orthotic and reduce any calcaneal eversion. This is the type of injury that requires immobilization and crutches. This athlete should not compete.”

Shoe modification

Shoe modifications are also something that can relieve the stress on the foot of those athletes cleared to participate on some level.

“For a ballet dancer, I can modify the shoe to give them a lot of shock absorption and create a little bit of an arch so I can protect that mid-foot,” LaFontsee said. “But I get them in an athletic shoe with a good strong orthotic and I require them to wear that as much as possible – even around the house so we’re going to treat that injury when they are not necessarily practicing their sport.”

For soccer players and figure skaters, LaFontsee does not have the option to modify the shoe because they are too tight. For these populations he focuses on their everyday footwear and makes sure they wear them as much as possible.

“I create an orthotic that is going to protect the area they has a fracture,” he said. “If you’ve got a fracture in the second metatarsal of the foot, I don’t want you in a shoe that bends nicely at the forefoot. I want you in a really strong-soled shoe.”

Stevens also recommends the use of devices as much as possible but admits that 100% of the time is an unachievable ideal.

“Wear the devices whenever you can and that helps to biomechanically keep you in line,” he said. “Naturally the more you wear them the better and the more stable you are going to stay.”

LaFontsee tries to put the seriousness of foot health into the forefront of his patients’ minds.

“You need to keep your foot protected as much as possible,” he said.” The way I try to relate that … to an athlete is to say that your foot is your instrument and if you were a member of a famous orchestra and played a Stradivarius violin which is worth over $100,000 or if you were part of a rock band and your guitar was one of the Gibson or Les Paul guitars, would you just put it in a paper bag and carry it around? Or would you put it in a really good, strong protective case? Your foot is your instrument. Put it in a good, strong protective case.”


Proper footwear is at the top of the list of ways to prevent stress fractures. While it might sound easy to achieve, there are often obstacles in the way of this ideal. In a perfect world, practitioners would have the chance to be more proactive in working with stress fractures as opposed to reactive.

LaFontsee does have the opportunity to intervene ahead of an injury. Through his work with the Marquette University basketball teams, he evaluates the players and looks for potential problems.

“The problem with both the professional athlete and the collegiate athlete is that they both have shoe contracts,” he said. “Those shoe contracts are wonderful for the University but your foot doesn’t work the same way as somebody else’s foot.”

That is when LaFontsee puts his pedorthic magic into action.

“We have to make a bad shoe good for the person who’s foot doesn’t work as well in that shoe,” he said. “We have to give them a good home base where the foot knows where it’s at all the time and that could be just a protective orthotic or an over-the-counter device. It doesn’t have to be something custom but it does have to be something that is protective.”

Forgrave empathizes with LaFontsee as he also encounters the same difficulty with shoe contracts.

“Making sure that their foot biomechanics are proper can pay huge dividends,” he said. “Make sure that the shoes they wear are the proper ones for them and their feet, regardless of their contract obligations.”


As unfortunate as a stress fracture injury is for an athlete, this is also an opportunity to educate your patients for the future.

“Don’t ignore symptoms,” Stevens stresses to patients. “The only way we, as practitioners, know what’s going on with you is through communication. We’ve all got to work together to head off these probable causes that could create these situations when it comes to stress fractures. It ends too many [careers] and it can become chronic.”

While it is not a practitioner’s intention to scare the patient, it is also important that they understand what could happen if stress fractures or health care provider instructions are ignored.

“The athlete must understand that they are at risk of a full fracture if they don’t follow their health care provider’s instruction,” Forgrave said. “Educate the athlete to listen to their body. The body gives subtle messages that you are doing damage to it. I feel one of the major problems with any athlete is the ability to distinguish between good pain and damaging pain. For example, many runners who are not trained by a professional coach will get training programs off the Internet. What they don’t realize is that these training programs are merely guidelines. If you are tired or had a bad day at the office, you don’t have to follow the program to the letter. Always listen to your body.”

As practitioners, the greatest reward is helping your patients succeed.

“It’s the happiest moment when you see an athlete succeed who you worked with,” Stevens said. “We are here to serve the patient and meet their needs. That’s the reward of it all.”

Jennifer Hoydicz is the managing editor of O&P Business News.

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