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FIFA Diploma in Football Medicine: Stress Fractures

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Stress fractures are tiny cracks in bones that are due to a failure of the bones to absorb repetitive loads. Things like running, jumping, landing, and direct contact to a bone can cause this injury. Think of what happens when a pebble strikes your car’s windshield.

  Stress Fracture

This loading results in structural fatigue of the bone, causing pain, performance impairment, and potentially a complete fracture. Bone is a constantly changing. After the stress fracture occurs, the bones immediately starts to repair. Studies in soccer have shown that stress fractures can cause significant time necessary for full recovery and return to play.

Causes and Risk Factors

  • Increasing the amount or intensity of an activity too quickly (most common). For example, immediately progressing from 1 – 2 practices per week to 4 – 5 practices per week. Think intensity, duration, frequency of training sessions.
  • Inadequate recovery time between sessions and/or seasons
  • Switching to a different playing or running surface (typically a harder surface)
  • Wearing poorly fitting or old shoes
  • Restricted joint motion, decreased flexibility, and muscular weakness
  • Poor nutrition, especially in female athletes. Low levels of Vitamin D and inadequate amounts of minerals and protein in the diet are factors.
  • Problem with the bone, e.g. osteoporosis
  • Young female athletes who experience menstrual difficulties are at risk of stress fracture, especially later in life. This is typically caused by poor nutritional habits.

What you can look for:

  • Most common locations: shin, foot, heel, spine (spondylolysis), thigh bone (femur)
  • Tenderness when putting pressure (touching) area
    • Shin – feel from the bony prominences on the inside and outside of ankle all the way up the shin to the knee
    • Foot – the little toe side is the most common area, feel all bones on the top of the foot
    • Heel – feel all around the heel including the bottom
    • Thigh – groin pain
    • Spine – back pain
  • Hopping on the injured side leg will usually increase the pain

Examination procedures (what the doctor does)

  • X-ray – changes in the bone take time to occur so an X-ray taken early on may not show much
  • CT (CAT Scan) – this will show the area, but must be used judiciously because of the increased cancer risk from the radiation
  • Bone Scan – this requires an injection of a “radio-labeled isotope” which is a small amount of radioactive material that will collect in the area. This test is very sensitive meaning it will detect even a small problem, but it is not specific, meaning the test does not distinguish between a stress fracture or tumor or infection.
  • MRI – this test can be useful, but like the bone scan, may not be specific to stress fracture.
  • DEXA Scan – this test is used to determine bone density. A low bone density would predispose the athlete to stress fracture.


  • Relative Rest – modified activity like pool work
  • Bone health – see a dietician or endocrinologist
  • Biomechanical errors in running technique – see a running gait analysist/biomechanist
  • Inappropriate/excessive loading (training) – see a strength and conditioning coach
  • Footwear/poor foot mechanics – see a podiatrist
  • Medication: There are no pharmacological therapies that will clearly enhance healing     
  • Oral contraceptives – “oral contraceptive treatment is not effective in increasing bone mineral density or reducing stress fractures. 9,11”
  • Anti-inflammatory medication - It is important to stress to the player that this is not to be used to allow them to continue to train. This will obviously permit further loading and make their problem worse. One should ideally attempt to avoid the use of oral non-steroidal anti-inflammatory medications as these may impair bone healing.
  • Discuss any form treatment, especially medication, with your doctor
  • Braces are for activity modification while recovering and not for continued use.
  • Surgery is reserved for the worst case scenario when all other types of treatment have failed
  • Sample rehabilitation program


Stress fractures may be prevented by understanding and reducing modifiable risk factors, especially those involving strength, surfaces, footwear, nutrition, and female hormonal issues.

FIFA Podcast on Stress Fractures

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The above information is intended solely for the general information for the reader. The contents of this article are not intended to offer personal medical advice, diagnose health problems or for treatment purposes. It is not a substitute for medical care provided by a licensed and qualified health professional. Please consult your health care provider for any advice on medications and medical conditions.