How Women Runners Can Avoid Stress Fractures

Women are twice as likely to develop stress fractures from running as men. Physicians and runners give tips on how to minimize risks and recover from injury.

As Carol Owens entered her 40s, she was looking for ways to stay active, and turned to running. Using her experience as a physical therapist at Magee Rehabilitation Hospital-Jefferson Health, she took a diligent approach, allowing her body to get used to the exercise. Over the course of four years she signed up for races, progressing from 5Ks to 10Ks, until she felt ready for a half marathon. Her training regimen was going well, but then four weeks before the race, she started to feel some pain in her hip. Though Carol ultimately finished the race, by the time she returned home, she could barely walk up the stairs. It turned out to be a stress fracture in her hip.

“I was really surprised. I thought I did everything right,” she laments. “It’s been a slow recovery, and I’m returning to running cautiously. But honestly, I’m scared of getting injured again.”

woman rejoicing after finishing a race

Carol Owens, at the finish line of her half marathon.

A stress fracture is a tiny crack in the bone in a runner’s ankle, leg and sometimes pelvis. It’s a painful injury that impacts 20% of all runners and can sometimes take months to heal from. Not only are more women running than men – 54% of all runners are women according to a 2018 National Runner survey – but because of differences in anatomy, body composition, and metabolism among other factors, women are also at least twice as likely as men to develop stress fractures. Unfortunately, information on how to best prevent and treat stress fractures in women is still lacking.

Jefferson researchers recently undertook a pilot project surveying women runners of a broad range in age and skill level, to better address this information gap. We spoke to the lead researcher, Therese Johnston, PT, PhD,  Professor in the Department of Physical Therapy, and runners who participated in the study for tips on how women can reduce their risk of injury.

Start Slow to Avoid Injury

“Many people think running is easy, you just put on a pair of shoes and hit the ground,” says Dr. Johnston. “But there’s a lot more to it. The mechanics of running put an enormous amount of stress on parts of your body that may not be used to it. People may think, ‘I’m fit, I do a 45 minute spin class,’ but the demands of running are very different.”

Dr. Johnston says it’s important to ramp up slowly. “Several women in our study who suffered a stress fracture said that they increased their mileage and/or speed too quickly,” she says. “It depends on what kind of regimen they followed. Some followed established protocols, and others followed random ones online that turned out to be too advanced for a beginner runner.”

Beginners may also benefit from The Run-Walk method, which involves alternating short run segments with short walks. Even more advanced or elite runners find that the run-walk method allows for better recovery and prevents injury. Dr. Johnston, who is an athlete herself, says her coach used the method when she was training for the challenging IronMan race. “I was surprised with that approach, given my fitness level,” she says. “But honestly think I would have injured myself or not even have been able to do the IronMan if my coach had not taken a conservative approach to my training.”

woman wearing sunglasses and running

Dr. Therese Johnston at a half-IronMan race.

Fuel Your Body with the Right Nutrients

Two-thirds of the study participants with stress fractures reported that they had nutritional deficiencies. “Because of our metabolism, women can develop nutrient deficiencies when doing intense physical activity, often without realizing it,” says Dr. Johnston. She suggests focusing on getting sufficient calcium, iron, protein, Vitamin D, fruits and vegetables, and dairy, and not to skimp on calories, especially if you’re training for a race.

“Looking back, I could have definitely paid closer attention to my nutrition,” Carol laments. “Even though I’m not running competitively, it’s still important for an everyday runner to fuel the body with the right nutrients. But find foods that work well for your digestive system.”

Cross Train for Strength and Stability

Inadequate nutrients can impact energy, bone strength, and even lead to menstrual irregularities. In fact, the study found that women with stress fractures had lower hip bone mineral density and reported irregular periods when they were training heavily.

“Screening for bone density is usually done only in post-menopausal women,” explains Dr. Johnston, “but our research shows that the bone can be affected even pre-menopause. So we may be missing important clinical indicators for stress fractures.”

With the risk of decreased bone strength in women runners, Dr. Johnston emphasizes the importance of cross-training. Many of the study participants with stress fractures knew that doing strengthening and stretching exercises like weight-lifting, yoga, swimming, etc. was important, but they found it hard to make time for it in their running schedule. “It’s understandable, but in order to avoid injury, it’s critical to include cross-training in your regimen,” she says. “Resistance band exercises like lateral and monster walks can improve hip strength and provide more stability to runners.”

The link between menstrual changes and bone strength is unclear, but the study suggests that women runners should keep track of any menstrual irregularities during heavier training times and report these changes to their physicians.

Pay Attention to Your Shoes

One of the study participants, C.C Tellez, started getting into running after college and in the last 5 years has become a competitive runner, vying for a national ranking.

“When I first started running, I had very little information on things like proper footwear,” she says. “It wasn’t until I went to my local running store that I got properly measured for a running shoe. I ended up discovering that an injury I had been suffering with was because my shoes were too small. I hadn’t even thought of that, and it wasn’t something my doctor asked about either.”

woman at athletic event

C.C Tellez, just after completing a race.

Don’t Push Through Pain

“Experiencing an occasional ache or pain is normal with running,” explains Dr. Johnston, “But when it persists or feels different, pay attention to it.”

In the study, women without stress fractures reported using pain as a warning signal, while women with stress fractures were more likely to push through serious and long-lasting pain.

“I think women – and men – are not great at listening to their bodies,” says Carol. “If a patient of mine had described the type of pain I had before my race, I would have told them to ease off. But I was so determined to finish that race.”

Join a Running Club that Fits Your Goals

C.C started her own running club as a way to provide a safe space where people could discuss injuries or pain that they were experiencing. “Running clubs are a great source of camaraderie and community,” she says. “I found so many resources and tips just from talking to other runners. Everyone really looks out for each other and can tell you if something looks off about your form.”

“Many of our study participants were part of running groups and found them to be instrumental in creating fulfillment from the exercise,” says Dr. Johnston. “But it’s very important to find a group that matches your fitness levels and goals. Some women pushed themselves too hard to keep up with the group, which ended up being counter-productive.

People may think, ‘I’m fit, I do a 45 minute spin class,’ but the demands of running are very different. It’s important to ramp up slowly. – Dr. Therese Johnston

Find the Right Doctor and Know What to Ask for

Historically, and for a number of complex reasons which include implicit gender bias, women’s health concerns are sometimes dismissed by doctors, especially when it comes to pain. In a 2014 survey by National Pain Report of nearly 2,400 women with a variety of chronic pain conditions, 91 percent reported that they felt that the healthcare system discriminates against female patients. Women are also more likely to be told that their pain is “psychosomatic,” or all in their head, according to the survey.

“When I was experiencing pain in my foot five years ago, I first saw a podiatrist,” recalls Dr. Johnston. “Being a physical therapist, I knew something was wrong, but he discounted me completely. I persisted and didn’t leave the appointment until he ordered an MRI. He finally did and it showed a stress fracture. I’ve heard so many similar stories from other women runners. At least I know what questions to ask and how to advocate for myself. So many women don’t.”

Dr. Johnston suggests being as assertive as you can, trust your instincts, and don’t be afraid to seek out another physician when needed.  “There are great physicians out there who understand women runners,” she reassures. “It also really helps to go to a doctor who has experience running themselves.”

In fact, after months of hip pain and a misdiagnosis, C.C was referred by Dr. Johnston to Dr. Jeremy Close, associate professor in family and sports medicine, who worked on the study with Dr. Johnston and is a fellow runner. “Because he knew first-hand some of what I was experiencing, I didn’t have to convince him,” C.C explains. “He pushed for an MRI, and I finally found out the source of my pain was a stress fracture.”

“So many women in the study said that it’s not that their physicians didn’t care, they just didn’t get it,” says Dr. Johnston, “Some women were told ‘Just stop running, switch to a different exercise’,” she adds.  “I don’t think physicians realize how impactful that statement can be for these women who are on a path to wellness. Running is more than just an exercise, it’s about the community and accomplishing goals. That’s why it was so important to do this study.”

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