Ask The PT: How Do I Recover From A Stress Fracture?

Physical therapist Janice Morra explains how to safely return to running after a stress fracture (and how to workout in the meantime).

Before running after a stress fracture, let alone ramping up training to what you were doing before you were injured, you must let the bone heal. Like breaks from singular traumas, a stress fracture is a break in a bone. Stress fractures, on the other hand, result from overuse, or repetitive overload. From length of recovery to pain level, four factors influence whether you stay healthy when you begin to run again.

Healing a stress fracture

foot, bone, stress fracture, running, injuriesHow long a bone takes to heal from a stress fracture depends on the bone. To figure out how much time you need to recover before running, check out these healing times for common stress fractures, but be sure to consult with your health care provider to make sure you’re ready:

Toe (metatarsal): 6-8 weeks

Heel (calcaneus): up to 12 weeks

Thigh (femur): 18-20 weeks

Hip, pelvis, or spine: 18-20 weeks

After a stress fracture is diagnosed, early care may or may not include immobilization of the location with a cast or brace, but it definitely shuts down all exercise and much activity. After time completely “off” (as in no running, cross-training, jumping, or other high-impact activities), recovery allows for limited activities with little to no weight-bearing. As the fracture shows signs of solid healing, some partial weight-bearing exercise may be allowed: stationary biking, swimming, pool running, non- or limited weight-bearing weight lifting and strengthening programs.

Evaluating the runner

Once a runner has been cleared to start physical therapy, I want to know more about their lifestyle and running habits. First, especially in younger, growing runners, I ask about diet and nutrition. Then we discuss their running habits, recent changes in training, bone density test results (if any), and their history with running shoes. These factors are important not only for a healthy recovery and return to running after their stress fracture, but also to prevent injuries down the road.

Next, I evaluate their biomechanics, at first as they walk and again when they are able to run. We identify areas of stiffness and weakness. Often, these imbalances cause stress fractures. That’s why I address them. We work on the links while the runner is healing.

How to exercise while a stress fracture heals

With the exception of spinal, pelvic and hip fractures, which tend to require two to three months of solid recovery with no activity, some non-weight-bearing upper body strength and core work can build fitness while a stress fracture heals. As long as the fracture site is protected, runners can start strength and flexibility programs early in their recovery.

Before returning to running, spend up to 2 weeks on a stationary bike and pool running. Work up to the higher impact of an elliptical trainer, which is still lower impact than running because both feet are on the pedals at all times. Add a more advanced core, hip, and lower body strengthening program with body weight training. For example, rotate between exercises like this:

    • Planks
    • Push ups
    • Pull ups
    • Single leg balance and dead lifts
    • 2-footed hops and jumps

If the recovering runner doesn’t feel any pain after 2 weeks of these activities, then I do the single leg hop test. I look at the runner’s ability to hop on one leg (on the side of the body with the healing fracture): is it painful? Are her hips, pelvis, and knees level when she lands? Then, I check running shoes for old wear patterns as well as whether the pair is an appropriate model with adequate support, cushioning, and other factors. Finally, I evaluate running form for biomechanical efficiency.

How to start running

Once the single leg hop test is painless, you’re ready to run. Warning: the bone needs time to adjust to the stress that occurs during running — four times the force of your bodyweight! So start with a walk/jog program. My preference is to err on the side of caution: no pain before, during, after, or the next day after your first jog. Some minor bone sensitivity is normal, as well as some muscular and joint aches and pains, especially as you progress through training. Follow this 8- to 12-week program to return to running:

Weeks 1 – 8: Alternate days of the following walk/jog exercise with cross training (bike, swim, elliptical or other low-impact activities). Take 1 day completely off. Continue core work and hip strengthening. Ice after activity.

Weeks 9 – 12+: Alternate walk/jog days with 1 to 2 days of cross training.

Week 1: Walk 2 min. Run no more than 1-2 min. Repeat for 20 min. total walk/jog.

Week 1: Walk 2 min. Run no more than 1-2 min. Repeat for 20 min. total walk/jog.

Week 2: repeat above

Week 3: Walk for 2 min. Run 3 min. Repeat for 20 min. total walk/jog.

Week 4: Walk 2 min. Run 4 min. Repeat for 20 min. total walk/jog.

Week 5: Walk 1 min. Run 5 min. Repeat for 20 – 25 min. total walk/jog.

Week 6: Walk 1 min. Run 6 min. Repeat for 20 – 25 min. total walk/jog.

Week 7: Walk 1 min. Run 7 min. Repeat for 25 – 30 min. total walk/jog.

Week 8: Walk 1 min. Run 8 min. Repeat for 30 min. total walk/jog.

Week 9: Walk 1 min. Run 8 min. Repeat for 30 – 40 min. total walk/jog.

Week 10: Walk 1 min. Run 10 – 15 min. Repeat for 30 – 45 min. total walk/jog.

Week 11: Run for 30 – 45 min.

Week 12: Run for 30 – 45 min.

Have a question? Send your questions to: AskThePT@run.com

NOTE: Due to the volume of mail, we regret that the physical therapist cannot answer every email.

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Comments

  1. Juli says

    Hi. I was so happy to read this. I had a stress fracture in my heel. Wore a cast for three weeks and had it removed on 8/7. I did a 9 day round of steroids. I bruised the bone right after the cast came off but didn’t refracture it. I still feel pain in my heel, but my podiatrist gave me the green light to do the elliptical and spinning classes. I’m concerned as I still feel pain in my heel. Sounds like that may not be unusual based on your time line above. Dying to get back to running. Also wondering if I should change what shoe I use to something more cushioned in the heel. Used to run in Asics Kayanos. Podiatrist gave me heel cups to use too.

    • Vicki says

      Hey Juli,

      I have a stress fracture in my heel too from running! Only 3 weeks? I am in a walking boot. I really hope it doesn’t take 12 weeks. Does it really take 12 weeks? Or is that 12 weeks that you should wait until you start running?

  2. The Run.com Team says

    Thanks for your comment, Juli!

    One key to recovery is patience, which can be hard when you’re antsy to run. Kayanos have great heel cushioning; try them out with the heel cups from your podiatrist. Be sure to check in with the podiatrist about pain, and don’t forget to take recovery days from the cross training activities as well.

  3. carlos says

    My doctor told me I could start jogging lightly but I jogged and I can feel it when touched. When I run or walk there is no pain. But when I apply pressure I can feel somewhat of a bruise. Why is this happening?

    • Janice Morra says

      The most difficult thing to deal with can be the residual bone soreness. And it can be bad in the beginning – remember, the bone needs to build up tolerance to the 4X body weight stress of running again and this can take up to 1 yr to go away (sometimes longer)…..that’s why I do a slow return to run.

  4. Nancy says

    I have an acute femoral shaft stress fracture. I was going to try the elliptical but it sounds like this May be too much:(
    Is it ok if I feel an occasional twinge while working out? I do while water running. Is bike better to start before elliptical?

    • Janice Morra says

      1. When you say “acute,” are we speaking in terms of length of time? You have to respect the fracture healing process. many MD’s I work with wouldn’t allow any activity at all for the first 4-6 weeks to allow for the bone healing to begin.
      2. Any water activity needs to be thought out (or better yet, done under the care of a physical therapist): water can act as an assistance or resistance to exercise. these properties come into play with regards to the healing time line. If you’re just swimming or running, this can be considerably more “forceful’ on the healing bone than you realize!
      3. I believe the first activity after the initial period of rest should be stationary cycling with minimal resistance/higher RPM.

      If you aren’t under the guidance of an orthopedic and/or sports physical therapist , then maybe you should consider finding one. A plan can be formulated based on your specific situation.

  5. Sara R says

    I had a metatarsal stress reaction about 10 weeks ago. I have started back running 1 minute run/1 minute jog for 12 minutes every couple of days. I have some slight ache around the site when I walk around during the day, but only occasionally. Is this the bone tenderness that is OK to feel and continue running?

    • Janice Morra says

      Hi Sara,
      Yes. I usually advise icing the area for 10 minutes in the early stages of recovery — and hopefully you’re in the correct shoes and/or insoles or orthotics.

  6. Milan says

    Hi! I was diagnosed with a stress fracture to the third metatarsal. After 4 weeks with a boot, I got approval to slowly begin a run/walk program. I’m so nervous about letting my foot heal though and was wondering if maybe just walking, but at an incline would be better. Which activity do you think would work best to get my heart rate up while being a lower impact for my foot – walk/jog at 0 incline or walking only but alternating the incline 0-10? Thanks for any advice you can offer!

  7. Charles says

    I’m at a special forces selection school, I was a d1 swimmer and not use the the amount of running. November 20th i was diagnosed with a grade 3 tibial stress fracture. Since then I stayed off of it. Crutches for 10 days, then December 20th started a running ramp up similar to yours. I did a 3 mile run on a treadmill at a 8:30 mile pace with no pain. 12 weeks into resting we began doing hill sprints and 400m sprints to “listen” to the bone it began flaring up. This Monday we went for a 3 mile trail run and 1 mile into I began to feel the same mimicking feeling and stopped.
    I have a deadline by march3rd to return to training, what would you suggest?
    Has the bone healed? Or am I sliding back into a bad place again?
    Anything helps I stay up all night worrying about this.
    Thanks

  8. Elise says

    Hi. I sustained two stress fractures on May 11 during a 10km race downhill. One on oubic ramus and one on acetabulum. Running is so of the radar but wondering if you have seen anyone with this? Right now I started swimming with a pull buoy and doing upper body stuff. I can tolerate a bit of floor work on that leg plus squats and planks are pain free. I progressed to a cane this week and can walk ok without but just feels better with that bit of extra support. So frustrated at the thought of such a long recovery time. I am seeing a hip Ortho next week for some guidance hopefully. I assume to let pain be my guide and was considering trying my bike in the trainer on the weekend just to see how it feels.
    Do you ever see these fractures healing fully before 20 weeks? As anxious as I am to run it is so far off the radar but simply walking or cycling would be great and I am keen to pool run too.
    Any thoughts are so welcome . I am so bummed and shocked at the sudden onset.
    Thanks

    • Erin says

      Hi,
      I’m a varsity soccer player and I started feeling pain in my hips about October of last year, it was only a little pain so I shook it off until about march 2013 when it started to get to the point where ithurt all of the time, even with rest. I was misdiagnosed for about 3 months, I saw countless doctors from the same place and they couldn’t find anything wrong with me, anyways, I went to a different place and they discovered that I had 2 stress fractures in my pelvis (the growth plates) and I rested for about 8 weeks. Went back about a week ago and the x-rays show that I’m healed. Doctor said I could gradually get back to activity levels over a slow period of time. Soccer season starts back up August 18th and we run ALOT… I’ve gotten back to walking and jogging a bit, but it still hurts a lot to walk or jog, I’m not sure if I’ll beready for the season.. The doctor says ifit continues to hurt to set up a bone scan in 2 weeks, so my question is, is this just healing pain? Should I be concerned? And will I be ready to start soccer in late August?

Trackbacks

  1. […] My stress fracture is getting better! I’m on week 5 of 8 of rehab. Swimming has been amazing, and I’ve hit the point where I can jump without any pain. Jumping sounds risky, but it’s not. A friend was concerned I’m hurting myself but before attempting a stressful activity, it’s important to know your body. If I was feeling pain this morning, I wouldn’t jump and wouldn’t recommend jumping. I’m preparing my foot to run again, in which I will be putting 4x my body weight on my feet with each strike I make. I need to ensure that we’re making progress. This is the advice I’m following: http://blog.run.com/blog/training/ask-the-pt-how-do-i-recover-from-a-stress-fracture/ […]

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