How Do Stress Fractures Heal?

Stress Fracture Protocols

0:27 How Do Stress Fractures Heal?
2:11 When Can I Run?
2:43 Low vs High-Risk Injuries
4:41 RED-S and the Athlete Triad
6:29 How Do I Start Running After a Stress Fracture?

When we develop a bone stress injury, what happens is there's an imbalance between the damage that occurs and our body's ability to remove that damage. Then we begin to experience some pain, and eventually we get an image that says that we have a stress fracture. What's the process that our body goes through to heal that stress fracture, and what can we do to make sure that we heal it to the best of our abilities? There's two different processes that work together to allow our body to heal a stress fracture. The first one is called targeted remodeling. This happens through two different cells, our osteoblast and our osteoclast. Our osteoclasts break down the bone that has been damaged.

Now to envision this, let's zoom in on the fracture. We can envision the osteoblast and osteoclast acting like a small tube of superglue. Very, very precisely, it's going to go and it's going to fill in the specific injury site, it's going to make it super solid, but it's going to take some time to make sure we don't have superglue all over everything. Now, we have a second process that helps with this, and that's called global remodeling. It's a bigger process that's less specific. I want you to imagine I have some putty and I'm going to fill in this crack, but I'm not going to take my time. I just want this thing over with, I'm going to slap some putty down. It's going to heal. And then eventually over time, it'll get back to its normal formation. These two processes work together, very specific remodeling, and then more global remodeling that happens in a much quicker fashion.

This global remodeling, because it's faster, because it's not as specific, is part of the reasons why sometimes people will say, "Well, I had a stress fracture right here, and I still have a bump there." That's a normal thing. One of the downsides about global remodeling is that it is affected to a greater degree by our hormones. With many bone stress injuries, hormones are a component of why that injury happened in the first place. So if our hormonal function is not exactly where we want it to be, it could affect how that bone is going to heal from a global standpoint. All right, so that's a general process for how this happens. But how long is this going to take, because all I want to do is get back to running? We have two types of bone in our body. We have cortical bone and we have cancellous bone.

Cortical bone is more present at the end of long bones. It's more sturdy in nature. Cancellous bone, or spongy bone, is more present in our spine, in our pelvis and in the proximal aspect of our hips. It's important to designate these types of bone because we get stress fractures in both of these bone types and they heal at different rates. We categorize bone stress injuries into high, medium, and low risk. A big reason why we do that is because different bones are made up of different percentages of cortical and cancellous bone. Bones that are more cancellous or spongy in nature are generally higher risk because they have a harder time healing, they take longer, and often, there's more things that have gone into why that injury happened in the first place.

Injuries to cortical bone tend to heal a lot quicker. That's why someone with a metatarsal stress fracture or a stress fracture of their tibia tends to get back to running quicker than someone that has a sacral stress fracture or a femoral neck stress fracture. Cortical bone, we can return to running quicker. Spongy bone, we have to take a longer time. It takes between four weeks to three months for our cortical bone to completely turn over. That's a lot different than spongy bone. Spongy bone can take around 200 days to completely turn over and recover.

To get diagnosed with a stress fracture, you're going to need an MRI. On that MRI they're going to tell us the location of the stress fracture and they're going to grade it. There's a few different ways to grade stress fractures. This table is helpful here. If we have a stress fracture that is a higher grade, it's going to take longer for that bone to heal. If we have a stress fracture that is a lower grade, we're going to be able to return to running quicker. The grade of the image is going to affect when we can return to running. The bone that's affected is going to affect when we can return to running. We see that low-risk bone stress injuries tend to return to running at about 13 weeks after an injury. When we look at those high-risk sites, we see that it tends to be about 24 weeks to return to running.

[cheyenne]

Its taken me a whole year to return to running after a femoral neck stress fracture. I went from running 7 miles daily to hardly being able to walk within a week. I pushed off seeing a doctor for two months, I thought It would heal on it’s own, then went another two months before I got a MRI to properly diagnose me. One thing I saw that was true for me was that with femoral stress fractures the pain often comes when you’re lifting the weight off the injured leg.

[svatekzprahy]

you're so much more helpful than anyone else

[Jordan-lrbi]

I started running on week 5 from injury, an MRI (taken on week 3) showed a grade 2 tibial stress fracture. 2 weeks back running now, still not completely pain free but I'm slowly improving/ not getting worse. Reduced mileage to 25% and am mostly on grass.

[ziyakhan]

Thanks for this! Not a runner, but i play squash. I had an "associated transverse oblique undisplaced" stress fracture of the left central and anterior acetabulum diagnosed in May 2022 from an MRI done in January 2022. Worst part? The doctor said he suspected a hip impingement in January, and recommended light exercise. Come May 2022, I was ordered bed rest and crutches. As of December 2022, still can't walk painlessly but hey, no more crutches!

[Theblazegod-lu]

I am a cricketer. Recently i rolled my ankle and i later came to know that it was a stress fracture.
Is there any specific nutrition that should be in the diet so that healing process doesn't slow down
Its been 9 weeks and the pain has reduced a bit . Hoping i return back quicker and stronger.

[lauracanna]

Nearly 5 months post lower tibia stress fracture and I still walk with 1 crutch. I hope my physio will build a programme for me to go back into running in the future and strengthen my bones..

[JeewaOx]

Very helpful video. Had an acl reconstruction and lower back stress fracture. Long term injuries.min 1 yr to return

[LynnDeatherage-qk]

I fracture my scrum and tailbone took a very long time. But the lower leg very well.

[SlavicRatnik]

You def know your stuff, I have a FnNSF injury grade 3 initially but now its a grade 4 on the MRI scale, you helped me understand my injury more than my surgeon that really wants me to get surgery, I do not want to get surgery, we'll see how things go. Want to get back into running and lifting weights. Another question arises too, if there is a push pull going on in the femoral neck whats happening with the FN when bodyweight squatting, barbell squats, deadlifts and clean/power cleans?

[אבינועםשחר-הי]

Very realistic and helpfull. Injuries are very very frustrating for sport junkeys. This video puts things in perspective.

[leaffaninoc]

I would welcome an understanding of your recommendations regarding recovery for tennis and pickleball players. How should we come back from a stress fracture in the femoral head/neck area? Not fun!

[ramyanaidu]

Screening CT demonstrates undisplaced linear lucency noted involving the posterior cortex of tibia in the distal one third. Undisplaced fracture - ?Stress etiology...this was the observation in MRI..

What does this mean? Is this high risk or medium?

[davidcoomber]

Why do they start playing music in these video’s

[Alex.]

Grade 4 distal tibia stress fracture
Healing "very satisfactorily" at 5 months
8 months can I start running?

[maggiequintero]

Hi, I was recently diagnosed with ischiofemoral impingement. Bone marrow edema with the right femoral neck and intertrochanteric region extended to the lesser trochanter compatible with the séquela of a stress fracture. What does this all mean. I have an appt next week but can’t wait too long. Thoughts?

[juliavautier]

Hi! I was diagnosed with a tibial stress fracture back in September doctor told me to wait 6 weeks and slowly get back. At 6 weeks I could tell was not healed so tried again at week 8 still not feeling good. So waited another month and started at week 12th still felt some runs. Decided to take little more time off, went back week 16th it felt fine, so started to slowly progress. Now it has been almost 7 months and I still feel
sometimes, is it possible that it isn’t 100% healed or it is normal to be sore after running? I am so frustrated! Thank you!

[neomonnahela]

Found the video very helpful. I had a stress fraction last year at the left side of my shin. The doctor said it would take 6 weeks, then I could start running slowly again. Then it healed, I felt no pain. Now recently I've been feeling slight pain in the same area. Gonna take it super super slow this time. Injury is a bih😢

[NieterHereNorThere]

Diagnosed with a grade 2 in October. Took 6 weeks off. Started building back slowly, but I started workouts too soon. Back on the shelf in January. I don't plan on running again until March. My question is, is it normal to experience mild pain following easy runs during the recovery process. As in, should I completely shut it down if there is any pain again, or is that just a normal part of the healing process?

[tommymurta]

I sustained a grade 4 femoral shaft stress fracture at the end of February. Haven’t ran since. I’ve been using crutches, non weight bearing, and plan to stop using them after the end of week 4.. which is in a few days. Is this wise? I am doing PT starting next week and don’t plan to run unless they allow me to.

[sttz]

My ct scan showed I had a subtle stress injury on my great toe, is that a big issue ? I been resting it and thinking about it getting a mri
Or just ignore it but possible turn to a bigger thing .