Foot Stress Fractures: What They Are, Why They Happen, and How Physiotherapy Helps You Recover Safely

Foot pain that gradually worsens with running, walking, or jumping isn’t something to ignore. One of the most important causes of progressive load-related foot pain is a stress fracture; a small crack or bone overload injury that occurs when tissue can’t keep up with the demands placed on it.

These injuries are common in runners, dancers, recreational athletes, military recruits, and people who suddenly increase their activity.

What is a Stress Fracture?

A stress fracture is a tiny crack or severe bone bruise caused by repetitive stress, not a single traumatic moment. Stress fractures sit on a spectrum, from mild stress reactions to complete stress fractures, and are classified as low-risk or high-risk depending on the location and healing potential.

Common Types of Stress Fractures in the Foot

Low-Risk Locations

These usually heal well with conservative management:

• 2nd–4th metatarsals

• Calcaneus

• Cuboid

• Cuneiforms

  
  

High-Risk Locations

These have poorer blood supply or high mechanical load:

• Navicular

• Proximal 5th metatarsal (Jones region)

• Sesamoids

• Talus

• Base of 2nd metatarsal (Lisfranc region)

• Medial malleolus

  
  

High-risk sites require much stricter management and sometimes surgical review.

How Do Stress Fractures Happen?

Stress fractures occur when bone is loaded faster than it can recover.

Everyday Causes:

• Sudden increase in running or step count

• Training on hard surfaces

• Worn-out or minimalist shoes

• Jump-heavy workouts (HIIT, skipping, box jumps)

• Long hours of walking or standing

• “Too much, too soon” in a new exercise program

  
  

Clinical Contributors:

• Insufficient muscle shock absorption

• Biomechanical overload (e.g., increased forefoot loading)

• Poor ankle dorsiflexion

• High or low arches

• Low bone density

• Vitamin D deficiency

• RED-S / low energy availability

• Altered gait mechanics due to calf or hip weakness

Common Signs and Symptoms

Typical Symptoms:

• Gradual onset of a very specific, pinpoint area of pain

• Pain increases with weight-bearing activity

• Pain improves with rest

• Localised tenderness when pressing the spot

• Possible swelling

• Pain when hopping or running

• Eventually, pain can occur at rest if ignored

  
  

Clinical Signs Physiotherapists Look For:

• Focal bony tenderness

• Pain with hopping or single-leg loading

• Altered gait (antalgic pattern)

• Swelling or periosteal thickening

• Pain during loading, not necessarily during passive movement

• Red flags: night pain, pain at rest, inability to hop

Management of Low-Risk vs High-Risk

Stress Fractures

One of the most important distinctions in foot stress fracture care is differentiating low-risk from high-risk locations. This completely changes the management plan.

Management of Low-Risk Sites

1. Relative Rest (Not Complete Rest)

Low-risk fractures usually allow activity within pain limits:

• You can often walk normally.

• Avoid high-impact exercise until symptoms settle

  
  

2. Footwear & Load Modification

• Supportive, cushioned shoes

• Avoid hard ground

• Temporary orthotics or stiff-soled shoes for forefoot fractures

  
  

3. Short-Term Offloading

• CAM boot for 2–4 weeks if walking is painful

• Ice, elevation early on

  
  

4. Gradual Reloading

Physio-guided reintroduction of:

• Calf strengthening

• Intrinsic foot muscle training

• Gait retraining

• Low-impact cardio

Pain guidelines:

• 0–3/10 pain during activity is acceptable

• No worsening the next day

  
  

5. Return to Running: Usually 6–10 Weeks

Criteria:

• Pain-free walking

• Pain-free hopping

• No tenderness over fracture site

• Strength symmetry

  
  

Low-risk sites rarely require specialist involvement.

Management of High-Risk Sites

1. Strict Offloading

High-risk fractures usually demand:

• CAM boot for 6–8+ weeks

• Often non-weight-bearing with crutches

• No impact loading until cleared

  
  

2. Early Imaging & Medical Referral

High-risk sites require:

• MRI or CT early

• GP or sports physician involvement

• Orthopaedic consultation if needed

Example:

• Navicular fractures commonly require 6 weeks non-weight-bearing.

• Jones fractures are notorious for non-union and often require surgical review

  
  

3. Longer Rehabilitation Timeline

High-risk sites require slower progression:

• Offloading phase: 6–10+ weeks

• Gradual return to weight-bearing

• Impact training delayed until clinical and possibly radiological healing

  
  

4. Biomechanics & Strengthening

During offloading, physio focuses on:

• Hip/glute/core strength

• Non-weight-bearing cardio (swim, bike, rowing)

• Foot intrinsic activation when load becomes safe

• Gait retraining later in rehab

  
  

5. Bone Health & Nutrition Screening

More common in high-risk cases:

• Low energy availability (RED-S)

• Vitamin D deficiency

• Low bone mineral density

  
  

Referral to GP or dietitian may be recommended.

6. Return to Running: Typically 10–16+ Weeks

Criteria are stricter:

• Pain-free hopping

• No tenderness over fracture site

• Full strength

• Imaging may be required (navicular, 5th metatarsal, talus)

  
  

Differential Diagnosis: Conditions That Mimic Stress Fractures

Not all foot pain is a stress fracture. Physiotherapists will also consider:

1. Plantar Fasciitis

• Pain at heel or arch

• Worse in the morning

• Not as focal as a stress fracture

  
  

2. Tendinopathies

• Achilles, tibialis posterior, peroneal

• Pain with movement rather than pinpoint palpation

  
  

3. Morton’s Neuroma

• Burning or numbness between toes

• Neural symptoms rather than bone pain

  
  

4. Sesamoiditis

• Pain under big toe

• Soft tissue irritation, not bony tenderness

  
  

5. Midfoot Sprains / Lisfranc Injuries

• Pain in midfoot after twist or trauma

• Swelling and difficulty weight-bearing

  
  

6. Bone Bruise

• Similar but often linked to a specific overload incident

  
  

7. Arthritis or Joint Synovitis

• Diffuse joint pain, stiffness, swelling

  
  

Foot stress fractures are common, but if diagnosed early and managed properly, the prognosis is excellent. The key is understanding whether your fracture is low-risk or high-risk, because the treatment, timeline, and precautions differ dramatically.

Physiotherapy plays a crucial role, from early diagnosis and offloading, through strength and gait retraining, to a safe and confident return to sport.

If you’re dealing with persistent, pinpoint foot pain that worsens with impact, it’s worth getting assessed sooner rather than later. Early intervention can prevent a small stress reaction from becoming a much more serious fracture.