My patient, Frank, came to the clinic a few weeks ago to show me where his foot hurts.

Frank is a firefighter and a runner, 45 years old. He told me he’s been training for a 5K race in Austin that will take place next month.

I asked him where he ran every day, and he described a park nearby with a running track that slopes towards the center of a playing field.

Over the past few weeks, he said, he’d been going there every day and running for an hour or more.

He showed me his running shoes, which are worn and don’t offer much support. He doesn’t always have time to follow a good diet, he confided, and he had been diagnosed with osteoporosis (loss of bone density) a while back.

After a physical exam and studying the results of a CT scan, we arrived at a conclusion.

He seemed surprised when I said the pain could be caused by a stress fracture. « But, Doctor, I’m not doing anything differently, » He protested. « I just increased my workout to prepare for this 5K. »

While he wasn’t doing anything unusual, the combination of poor foot support, repetitive pounding and poor nutrition had conspired to produce a hairline crack in the second metatarsal bone in his right foot.


It’s not just runners who suffer stress fractures. Patients with rheumatoid arthritis; those who spend long hours on their feet; and people with metabolic bone disease or neuropathy are also vulnerable to this condition. Diabetics may not be aware they have stress fractures if the nerves in their feet are damaged.

There are 26 bones in your feet, and most of the time they do their job without complaint. The five long bones in the mid-foot area, called metatarsals, are most prone to hairline fractures. These are bones that connect the ankle to the toes.

What happens is that tiny cracks, so fine they may not show up on x-rays, can start to affect these bones. The patient begins to notice pain and swelling, and the foot may feel tender when he touches a certain spot. The more he tries to continue the activity that’s causing the problem, the worse it gets.

The first mention of stress fracture in the medical literature is from thousands of years ago, when Aristotle described the condition. Nowadays, we perform a physical exam, asking the patient about his medical history and lifestyle. An MRI, CT scan or bone scan are used to confirm the diagnosis.

Stress fractures are more frequently seen in females than in males. About half of all stress fractures are diagnosed in athletes. The medical recommendation is often just what the patient does not want to hear: Change your routine for a while to let the injury heal. In other words, drop out of the game.

We may also prescribe crutches or a special boot to protect the foot until the bone can heal, and medication to relieve pain and swelling.


Unfortunately, most people don’t realize they have a stress fracture until it’s too late. The onset of pain is gradual. It increases when the patient is engaged in whatever activity has caused it, and it is relieved by rest.

One way to protect yourself again this type of injury is to avoid working out when you are tired. Fatigued muscles tend to transfer more load to the bones.

Another protective measure is good footwear. It doesn’t pay to squeeze the last mile out of your running shoes. Buy shoes with ample cushioning and support.

If osteoporosis is a factor, it can be treated by adding calcium and vitamin D to the diet. One study showed that female soldiers had fewer stress fractures after they started taking nutritional supplements.

But the major cure is stress relief— in other words, relieve yourself of the activity that is causing the stress fracture. Although it’s not always welcome, this may be the best advice we can give.