Stress Fracture – Lower Limb
Lower LimbOverview
A stress fracture is a partial or complete fracture resulting from repetitive microtrauma and cumulative loading rather than a single traumatic event, commonly affecting weight-bearing bones of the lower limb such as the tibia, fibula, metatarsals, and femur. These injuries typically develop in athletes or individuals engaged in repetitive high-impact activities and represent a continuum of bone injury from stress reaction to complete fracture. Early recognition and appropriate management are critical to prevent progression and complications.
Pathophysiology
Stress fractures result from an imbalance between bone remodelling demands and the bone's ability to adapt to repetitive loading. During normal bone remodelling, osteoclasts remove old bone while osteoblasts lay new bone; however, when loading exceeds the bone's adaptive capacity, microscopic cracks accumulate faster than they can be repaired. The tibial shaft and proximal fibula are most commonly affected, followed by metatarsals and femoral neck—each with varying healing timelines and complication risks.
Patient Education
Stress fractures require a period of relative or absolute rest from the aggravating activity; gradual return to loading activities following medical clearance, along with identification and correction of underlying biomechanical or training errors, is essential to prevent recurrence.
Typical Presentation
Site
Anterior or medial tibial shaft (most common), fibular shaft, second metatarsal, femoral neck, calcaneus, and occasionally the acetabulum or ilium in distance runners and endurance athletes
Quality
Focal, well-localised sharp or aching pain; described as 'bone pain' rather than muscular; may have a gnawing quality at rest
Intensity
Variable from 2–7/10 depending on stage of fracture; typically begins mild and insidious, worsening with continued activity; may be absent at rest initially but progressively worsens with activity
Aggravating
Running, jumping, hopping, high-impact activities, weight-bearing activities, rapid increases in training volume or intensity, training on hard surfaces, inadequate recovery between sessions
Relieving
Rest, cessation of the provocative activity, ice application, elevation, immobilisation, non-weight-bearing status
Associated
Localised tenderness on palpation, possible mild swelling or oedema over the fracture site, pain on hopping or single-leg stance, pain on impact-loading activities, visible muscle atrophy if chronic, altered gait pattern
Orthopaedic Tests
Test descriptions are written with AI assistance from standard clinical texts. Where a test lists Sources, its description has been checked against them; those sources are independent and do not endorse OsteoKit. Accuracy figures and grades (A–D) appear only when checked against the published study; tests without one are marked “No accuracy study”.
Further reading: full test procedures are described in standard clinical examination texts, e.g. Magee & Manske, Orthopedic Physical Assessment (7th ed.), and Cook & Hegedus, Orthopedic Physical Examination Tests: An Evidence-Based Approach (2nd ed.).
Tuning Fork Test (Vibration Test)
Procedure
Strike a 128 Hz tuning fork and place its base on the bone over the painful area.
Positive Finding
Increased, sharp pain at that spot.
Sensitivity / Specificity
Reference: Schneiders AG, Sullivan SJ, Hendrick PA, Hones BD, McMaster AR, Sugden BA, et al. The ability of clinical tests to diagnose stress fractures: a systematic review and meta-analysis. J Orthop Sports Phys Ther. 2012;42(9):760-71.
Interpretation
Supports a stress fracture. It can miss fractures, so a negative test does not rule one out when the history fits. Range across two studies in a 2012 systematic review (Schneiders et al.) against imaging; the results could not be pooled. The authors concluded that the tuning fork should not be used on its own to diagnose or exclude a stress fracture; imaging is needed.
Fulcrum Test
Procedure
Patient seated with the legs over the edge of the plinth. Place your forearm under the mid-thigh as a fulcrum and press gently down on the knee.
Positive Finding
Sharp pain in the thigh, sometimes with apprehension.
Interpretation
Used to screen for a femoral shaft stress fracture in runners. A positive test needs imaging. A negative test does not rule one out. A 2012 systematic review of clinical tests for lower-limb stress fractures (Schneiders et al.) found accuracy studies only for therapeutic ultrasound and the tuning fork. No study of this test was found, so no figure is shown. Imaging (MRI, or X-ray once healing has begun) confirms a stress fracture.
Percussion Test (Tap Test)
Procedure
Tap gently over the bone away from the painful area, or along the long axis of the limb.
Positive Finding
Pain at the suspected fracture site.
Interpretation
Supports a stress fracture but is not reliable on its own. A 2012 systematic review of clinical tests for lower-limb stress fractures (Schneiders et al.) found accuracy studies only for therapeutic ultrasound and the tuning fork. No study of this test was found, so no figure is shown. Imaging (MRI, or X-ray once healing has begun) confirms a stress fracture.
Single-Leg Hop Test (Functional Hop Test)
Procedure
Patient performs single-leg hopping in place or hops forward in a straight line for 10–20 repetitions on the affected limb while monitoring for pain reproduction.
Positive Finding
Reproduction of pain or inability to complete the task due to pain in the affected limb
Interpretation
High sensitivity; a negative hop test must NOT be used to exclude a stress fracture. High sensitivity has been reported only for medial tibial stress fracture in small studies, and specificity is poor — a positive hop test occurs in roughly half of patients with medial tibial stress syndrome. Critically, the test has no validated role in excluding HIGH-RISK stress fractures: femoral neck, anterior tibial cortex, tarsal navicular, medial malleolus, base of the fifth metatarsal, and the sesamoids. In those sites a missed diagnosis risks progression to complete fracture, displacement and avascular necrosis, so persistent load-related bone pain warrants imaging regardless of hop test result. This is consistent with the fulcrum and tuning fork entries on this page, which also state that a negative result does not exclude fracture. Positive result suggests the lesion is mechanically provoked by impact loading; must be correlated with imaging given moderate specificity. A 2012 systematic review of clinical tests for lower-limb stress fractures (Schneiders et al.) found accuracy studies only for therapeutic ultrasound and the tuning fork. No study of this test was found, so no figure is shown. Imaging (MRI, or X-ray once healing has begun) confirms a stress fracture.
Palpation for Focal Bone Tenderness
Procedure
Palpate along the bone (tibia, fibula, metatarsals, navicular) looking for a single tender spot.
Positive Finding
Tenderness at one small spot on the bone, often with swelling.
Interpretation
Focal bone tenderness with pain that has built up with activity strongly raises concern for a stress fracture; offload and refer for imaging. Stress fractures of the anterior tibia, navicular, femoral neck, base of the second metatarsal and proximal fifth metatarsal are higher risk and need prompt referral. Groin pain with activity in a runner may be a femoral neck stress fracture and needs urgent imaging. A 2012 systematic review of clinical tests for lower-limb stress fractures (Schneiders et al.) found accuracy studies only for therapeutic ultrasound and the tuning fork. No study of this test was found, so no figure is shown. Imaging (MRI, or X-ray once healing has begun) confirms a stress fracture.
Single-Leg Stance Test (Modified Weight-Bearing Tolerance)
Procedure
Ask the patient to stand on the affected leg for up to 30 seconds.
Positive Finding
Focal bone pain on standing.
Interpretation
Pain with standing suggests a more irritable injury; offload and refer for imaging. Not a diagnostic test.
⚠ Red Flags
- •Severe unrelenting pain at rest suggesting displaced fracture or reflex sympathetic dystrophy
- •Signs of compartment syndrome: severe pain out of proportion, pain on passive stretch, paresthesia, pallor, pulselessness
- •Femoral neck stress fracture with displacement risk—sudden severe pain with inability to bear weight
- •Fever, systemic illness, or constitutional symptoms suggesting infection (osteomyelitis)
- •History of significant trauma with severe swelling suggesting acute fracture rather than stress fracture
- •Pulsatile mass or vascular compromise suggesting vascular injury
- •Neurological deficit or cauda equina symptoms
⚡ Yellow Flags
- •Excessive training volume or obsessive exercise behaviour suggesting compulsive overtraining
- •Disordered eating patterns, extreme weight loss, or amenorrhoea indicating Relative Energy Deficiency in Sport (RED-S)
- •Perfectionism, high anxiety, or competitive pressure contributing to overtraining
- •Social isolation or withdrawal from non-sporting activities
- •Fear-avoidance beliefs about returning to activity causing deconditioning
- •Catastrophising about prognosis or likelihood of recurrence
- •Poor adherence to rest recommendations or premature return to activity despite medical advice
Osteopathic Techniques
Refer first
A suspected stress fracture needs a confirmed diagnosis, usually with MRI because X-rays are unreliable, and relative rest before a gradual return to activity. High-risk sites (femoral neck, anterior tibia, navicular, talus, sesamoids, and the 1st and 5th metatarsals) are prone to non-union and often do not respond to conservative care. Refer before using manual techniques on the limb.
- Reference bookMay & Marappa-Ganeshan · StatPearls 2023
Rehabilitation Exercises
Ankle plantarflexion and dorsiflexion active range of motion
Hip flexion, extension, and abduction active range of motion (supine or standing with support)
Standing calf stretch (gastrocnemius and soleus) against wall
Supine hamstring stretch using strap or towel
Hip flexor stretch (modified Thomas position) kneeling or supine
Supine glute sets and quad sets (isometric contractions)
Supine bridge hold (progressing to single-leg once weight-bearing permitted)
Clamshell exercises (side-lying hip abduction with knee bent)
Standing hip abduction with resistance band (non-affected leg initially)
Single-leg stance with upper limb support (once weight-bearing cleared)
Supine pelvic tilt and core engagement breathing exercises
Pool walking or aquatic therapy (non-weight-bearing initially, progressing to walking and running in water)
Referral Criteria
- •Any suspicion of stress fracture with inability to exclude on clinical grounds—refer for imaging (X-ray, CT, or MRI) for definitive diagnosis
- •Femoral neck or pelvic stress fractures—refer for specialist orthopaedic evaluation due to risk of displacement and complications
- •Stress fracture with evidence of compartment syndrome—urgent referral for surgical fasciotomy
- •Non-union or delayed union (no radiological evidence of healing after expected timeframe)—refer for orthopaedic specialist and possible surgical intervention
- •Signs of infection or systemic illness—refer to general practitioner or emergency department
- •Recurrent stress fractures despite appropriate management—refer for bone health assessment, metabolic screening (calcium, vitamin D, hormonal profile), and investigation of Relative Energy Deficiency in Sport
- •Inability to tolerate weight-bearing or severe functional limitation—refer to physiotherapy specialist for graduated loading protocol
- •Patient with suspected eating disorder or RED-S—refer to medical doctor, registered dietitian, and sports physician for coordinated care