How do you tell the difference between a soft tissue injury and a stress fracture?

So how do you tell whether your injury is ‘just’ soft tissue or a more serious stress fracture? Physiotherapist Bryony Short explains how to evaluate the symptoms

Runner holding their ankle

Been struck by a niggling leg injury, but unsure quite what you’ve done and whether you need to see a physio? Here we look at how to differentiate between a soft tissue injury and a stress fracture and how best to treat them both…

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How do I know if it’s a soft tissue injury?

If your symptoms are widespread and achy in nature, rather than a sharp pain, it could be a simple soft tissue injury. Generally, soft tissue injuries will respond well to the following:

  • Ice therapy (15 mins a day, 2-3 times per day)
  • Anti-inflammatories
  • Stretching exercises
  • Prescriptive loading exercises from a physiotherapist
  • Offloading (no running)

How do I know if it’s a stress fracture?

However if you’re also experiencing the following, it could be a stress fracture, one of the most common worries for athletes:

  • Pain at rest
  • Significant increase in severity of pain with impact (weight-bearing > walking > running)
  • Pain at night time
  • Focal pain at a specific site along the bone

What is a stress fracture?

Stress fractures will occur when the force, or load, applied to the bone exceeds the bones ability to withstand it. It’s different to a ‘regular’ fracture because it is not the result of a high velocity force being applied to the bone and thus ‘breaking it’, it is more like a very painful very ‘pinpoint’ bruise to the bone.

The presentation of a stress fracture will vary depending on which stage of the ‘bone stress continuum’ the patient may be in.

The three stage symptoms of stress fractures

Periosteal inflammation

Pain spread along the bone (not focal) pain with impact but settles with rest.

Bone marrow oedema

Symptoms worsening in severity. Can start to get night pain & pain at rest.

Stress fracture

Very localised pain pain exacerbated by weight-bearing and high impact. Can include pain at rest and at night. Can present with swelling and redness.

How to diagnose a stress fracture

This can be quite tricky due to the location of the injury, i.e. pain at the front of the shin could be a tibial stress fracture or simple shin splints. Equally pain in the foot could be a metatarsal stress fracture or metatarsalgia. It’s therefore essential that a patient receives a very thorough assessment.

It’s not necessarily only the physical examination that will identify the stress fracture, but a more detailed verbal assessment of the history and the presentation of the injury.

Generally, a stress fracture will occur with an increase in the volume of training or style of training, i.e. if a patient dramatically increases their mileage week after week or changes the terrain that they are running on (from treadmill to road).

If your physiotherapist suspects a stress fracture they will then need to request a series of imaging for the injury to confirm this diagnosis (x-rays, MRIs and potentially sometimes CT scans). The management of stress fractures varies greatly depending on their location and severity, often the cure being complete rest from any activity.

However if you have any concerns at all, like with any health issue, seek medical advice from a qualified medical practitioner, whether that’s a doctor or physiotherapist.    

How to prevent run injuries 

In my opinion though, prevention is the best cure. I am constantly telling my runners to ‘train smart, not hard’. Four out of five runners with an injury will have incurred their injury due to a ‘training error’.

This means you have made a mistake in the way you have carried out your training. Typically, this can be a sudden increase in the amount you are running (i.e going from 5k three times per week to 10km four times per week).

It can also be due to an imbalance in your high and low-level intensity training. It can often be due to an uneven spread of training across the week i.e. doing all your runs on the weekend. Commonly it can also be due to inadequate rest and recovery.

It might sound so simple, but training sub-optimally in this way can be hugely detrimental to your health and can be a recipe for developing stress fractures! So please do sit down and PLAN your running calendar. Here are some handy tips I give my runners:

  • Physically write or print out a training diary and plan and use this to keep you going off piste.
  • Work backwards from your event and schedule your runs according to the number of weeks you have available.
  • Consider the 10% rule: incrementally increase your run distance each week by 10% to avoid training error.
  • Think about scheduling three runs in per week, with the long run being the weekend.
  • Schedule in and honour the rest days!
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Top image credit: iStock/Getty Images Plus/Izf