Stress fractures in runners and how to treat them

Meet Joe – Joe is a middle-aged accountant from the Northern Beaches who recently attended the Fixio physiotherapy clinic with left shin pain.

Joe started running 6 months ago to “lose weight” and one of his New Year resolutions for 2021 is to run his first half marathon. During the last 6 months Joe has been running sporadically from Dee Why to Curl Curl, a distance of about 6km. Since the start of 2021 though, Joe decided to run from Dee Why to Manly 3 times a week, a 17km round trip. Joe found the increase in k’s difficult, but pushed through some minor hip and ankle pain because he wants to run that half marathon.

Examining, evaluating and diagnosing an injured runner

Musculoskeletal physiotherapists use a comprehensive assessment of the entire mid-lower body to accurately diagnose shin splints and stress fractures in runners.

Things like:

  • Activity history
  • Posture
  • range of motion
  • foot type
  • footwear
  • flexibility
  • strength
  • functional movement patterns
  • walking and running gait

Are examined and measured to give your physio a holistic view of the zones causing you pain.

What are stress fractures?

In normal healthy bone, increased stress and physical loading can cause some deformation and microdamage. Stress fractures have 3 stages[1]:

Stage 1 – Fracture initiation, which occurs at the site where the load stress is concentrated in a specific spot

Stage 2 – Fracture propagation occurs when physical loading is pushed past the level at which bone can be repaired or new bone can be laid down in the area.

Stage 3 – The final stage is a complete fracture with symptomatic presentation to our Fixio physio.

What are the symptoms of stress fractures for a runner?

People with stress fractures of the lower leg will commonly have:

  • pain in the lower leg that comes on during exercise
  • an ache in the front part of the lower leg that may continue after exercise
  • pain on both sides of the shin bone
  • tenderness or pain along the inner part of the lower leg
  • mild swelling in the lower leg as it progresses

How are stress fractures treated by physiotherapy?

Because risk factors for stress fractures include faulty biomechanics, abnormal bony alignments, incorrect footwear and other physical factors, it’s important that stress fracture treatment is broad ranging.

Usually, a 3-phase (acute, subacute, and chronic) treatment approach is beneficial for runners with a stress fracture. [2]

At our Fixio clinic, Joe underwent treatment to increase joint mobility, flexibility, dynamic control and we went through a video running gait analysis and participated in gait retraining to address his hip and ankle impairments.

The acute phase focuses on rest and interventions to relieve symptoms, whereas the subacute phase focuses on progressing weight bearing tolerance.

How can I avoid stress fractures and shin splints?

You can’t completely eradicate any chance of suffering stress fractures, but there are steps you can take to minimise your risk:

  • wear comfortable running shoes that fit well and offer good support
  • avoid exercising on hard, slanted or uneven surfaces
  • increase exercise intensity and length gradually
  • warm up and stretch before exercising
  • don’t just push through the pain, listen to your body.

Shin splints and stress fracture are not injuries to leave unattended. Physiotherapists see too many patients who have caused themselves ongoing pain and discomfort simply due to not having the issue seen to earlier. If you are suffering from increasing pain or stiffness in your legs and shins it is prudent to make an appointment with your local Fixio physio to have a full evaluation of the injury.


[1] Kaeding CC, Miller . the comprehensive description of stress fractures: a new classification system.

J Bone Joint Surg Am. 2013;95:1214-1220.

[2] Liem BC, ruswell HJ, Harrast MA. Rehabilitation and return to running after lower limb stress ractures.

Curr Sports Med Rep. 2013;12:200-207.


How physiotherapy can treat overuse injuries in tennis players

With the Australian Open just around the corner, we’ve been hearing a lot about tennis players lately. Today we’re going to be looking at overuse injuries in tennis players, but not the kind of Instagram or Twitter overuse we’ve become accustomed to.

Why are tennis players susceptible to overuse injuries?

Tennis play is a mix of overhead motions, quick starts and stops with short explosive bursts of motion, and a dynamic exchange of intricate strokes and serves.[1] Athletes are susceptible to a variety of injuries because of these repetitive stresses.

Tennis is a demanding sport on both the lower and upper body, with overuse injuries of the shoulder, elbow and knee making up around two-thirds of all tennis injuries.

Muscle activation during the serve and forehand is focused on the subscapularis, the pectoralis major, and the serratus anterior.[2] A common overuse injury in tennis players is rotator cuff tendonitis.

The backhand involves largely the middle deltoid, supraspinatus, and infraspinatus.[3] This repetitive loading of the rotator cuff, particularly the supraspinatus and infraspinatus, leads to overuse injury due to the repetitive eccentric muscular activation. Wrist extensor activity is heavy in all strokes, which could help explain this joint’s predisposition to injury.[4]

Common tennis injuries:

It is important for your physio to understand the chronology of your symptoms, prior injuries, biomechanics, training schedule and roundabout time spent practicing types of strokes.

Your Fixio physio will ask you a number of questions on your first visit to help work out the root cause of your injury and any other exacerbating factors. This allows us to help build a profile of the injury and lets us get stuck into creating your personalised recovery program.

Please try and think of these things[5]:

  • When your symptoms began
  • If any motion or activity makes the pain better or worse
  • Any recent direct injuries

Depending on what your physio deems is necessary for your recovery, you will receive any combination of the following treatments:

  • Hands on treatment
  • Dry needling / acupuncture
  • Joint mobilisations
  • Trigger point release
  • Myofascial release
  • Scar tissue management
  • Stretching
  • Active rehabilitation
  • Pilates
  • Strength training
  • Posture retraining
  • Muscle re-education
  • Goal setting sessions

Top tips for avoiding tennis injuries

  1. Use the right equipment
  2. Take breaks
  3. Exercise
  4. Stretch
  5. Warm-up and warm-down
  6. Practice
  7. Get a biomechanical assessment from your physio

Whether you’re a beginner or an advanced player, tennis is a very physically demanding sport. At Fixio, we understand tennis players and the intricacies of overuse injuries and can help you get back on court feeling strong and pain free ASAP.

Make a booking to speak with us on (02) 8964 4086 or send an email to info@fixio.com.au.

[1] Kovacs MS. Applied physiology of tennis performance. Br J Sports Med. 2006;40:381–5 discussion 386.

[2] Kovacs M, Ellenbecker . An 8-stage model for evaluating the tennis serve: implications for performance

enhancement and injury prevention. Sports Health. 2011;3:504-513.

[3] Ryu RK, McCormick J, Jobe FW, et al: An electromyographic analysis of shoulder function in tennis players. Am J Sports Med 16:481-485, 1988

[4] Chow JW, Carlton LG, Lim YT, et al Muscle activation during the tennis volley. Med Sci Sports Exerc 31:846-854, 1999

[5] Manske R, Ellenbecker . Current concepts in shoulder examination of the overhead athlete. Int J

Sports Phys Ther. 2013;8:554-578.


What is Patellofemoral pain syndrome?

Do you suffer from:

  • a sore knee when running
  • Increased pain after squatting movements and walking up and down stairs
  • Pain after sitting for a long time with your knees bent
  • The feeling of grinding or clicking sound in the kneecap when you bend and straighten your knee
  • Kneecap region that is tender to the touch?

You may have Runner’s Knee, AKA – Patellofemoral pain syndrome.

What is Patellofemoral pain syndrome?

Patellofemoral pain syndrome, commonly known as Runner’s Knee is one of the most common knee complaints seen by Fixio physios. Patellofemoral pain syndrome can be found in both the young active sportsperson and the elderly and if not treated properly, can hang around for years.

Patellofemoral pain syndrome is pain felt behind and around your kneecap, where your patella (kneecap) meets your thigh bone (femur). This joint is known as your patellofemoral joint.

What causes Patellofemoral pain and what are the symptoms?

In musculoskeletal physiotherapy, the most common reasons for runner’s knee are overuse, muscle performance deficits, and trauma. Patellofemoral pain is what’s known as a heterogenous condition, meaning that not everybody that suffers it will have the same symptoms.

The symptoms of runner’s knee are notorious for looking like other conditions and over the past few years there has been an influx of new treatment guidelines that has changed the way physiotherapists treat Patellofemoral pain. It is important to see a musculoskeletal physio who has plenty of clinical experience with the injury and is constantly updating their skills. These experts are best placed to make an accurate diagnosis so you can move onto the recovery phase.

If you have:

  • Sudden or severe pain in the knee
  • Heard a loud pop or snap during sport or exercise
  • Swelling in the knee after feeling pain
  • A feeling of looseness in the joint
  • An inability to put weight on the joint without pain, or any weight at all

These could all be symptoms of Patellofemoral pain syndrome.

 Figure 1 Schematic overview of potential pathways to elevated patellofemoral joint (PFJ) stress, a proposed contributor to patellofemoral pain.[1]

Do I need surgery?

Most likely no. People with patellofemoral pain syndrome alone do not need surgery. Be patient, and keep exercising to get better. Runner’s knee can be hard to treat. Some people get better quickly, but for others it might take six weeks or even longer for your knee to feel better.

How do musculoskeletal physiotherapists treat Runner’s Knee?

Thankfully, non-operative treatment provided by an expert physio is effective for most patients.[2] Each treatment program is designed specifically to combat the root cause of your patellofemoral pain.

Once we have identified the cause of your pain and any underlying functional improvements we can work on, your physio will be able to guide you through your bespoke program. Physiotherapy may include exercises to make your hip, core, and knee muscles stronger and more flexible. Squats, quadriceps exercises, leg raises, climbing, and leg presses can be good since they target these specific areas.

Common treatments for patellofemoral pain include:

  • Exercise therapy with hip and knee exercises
  • Short-term tailored patellar taping
  • Patient specific education in relation to biomechanics and exercise therapy
  • Advice on loading programs

Will the pain come back?

Patellofemoral pain syndrome can come back.

The simplest advice for keeping runner’s knee at bay includes trying not to overstress your knees and listening as closely as you can to your body. You can do this by:

  • Losing weight if needed
  • Warming up before running
  • Increasing your activities gradually
  • Wearing good running shoes

If your knees are painful, take a break from activities that cause a lot of pounding on your legs, like running, volleyball, or basketball.

Instead, try swimming or another low-impact activity. As your knees feel better, you can slowly go back to your normal sports.

Make an appointment to see us at Fixio Physio for more information of Patellofemoral pain syndrome and what can be done to overcome it.


[1] Powers CM, et al. Br J Sports Med 2017;0:1–11. doi:10.1136/bjsports-2017-098717

[2] Kannus P, Natri A, Paakkala T, et al: An outcome study of chronic patellofemoral pain syndrome. Seven-year follow-up of patients in a randomized, controlled trial. J Bone Joint Surg 81A: 355–363, 1999


21 physiotherapy tips for a healthy 2021

On behalf of the team at Fixio I’d like to give a big thanks to our clients for your support during an interesting 2020 and we are looking forward to getting stuck into a big 2021.

To start the year off with a bang and get your physiotherapy goals off on the right foot, here’s 21 tips from us at Fixio.

  1. You don’t need a Doctor’s referral to see a musculoskeletal physio

This is a BIG one. As physiotherapists are primary care providers, you can come in and see us without seeing your GP first. No waiting, no delay – get that dodgy knee looked at today.

  1. Physiotherapy is something you do, not something you get – do your homework

Make time for physio prescribed exercises at home. Your physio will know if you haven’t done your homework. They design exercise plans for your body’s abilities and needs. If you don’t work on your body at home, you’ll likely be returning again and again for the same issues.

  1. Look after your little niggles before they become big problems – it won’t get better if you don’t stop hurting it.
  1. Get a good night’s sleep!

Sleep is so important for recovery and musculoskeletal pain is notorious for being worse at night, creating a self-perpetuating loop of poor sleep that exacerbates your pain and discomfort.

  1. Get a massage. 

Massage therapy techniques accentuate the effects of physiotherapy, aid muscle relaxation as well as promote recovery. Give it a try; it will leave you feeling great!

  1. Get up and move!

Simply standing up every 30 minutes and having a 10 second stretch can make an immense difference to how you feel. When watching TV, get up and stretch every time the ads come on.

  1. See your Health Professional

Too many patients I see in our clinic tell me that they have had their injury for weeks or months before doing anything about it. Remember – the longer an injury is with you, the harder it is to fix. If you have a pain or problem get an assessment done immediately with your physio.

  1. Pay attention to what you are doing, many injuries occur when people are distracted, tired or in a rush.
  1. Drink plenty of water.

Better hydration means more frequent trips to the bathroom and to fill up your water bottle. Congratulations, you’re getting up and moving more.

  1. Make your home office a safe and healthy place to work

If you’re new to working from home due to COVID19, the good news is that you don’t need to go out and buy thousands of dollars of ergonomically designed knick knacks to save your body from developing chronic pain. https://fixio.com.au/2020/05/15/is-working-from-home-hurting-you-try-these-easy-tips/

  1. Don’t neglect back pain

Back pain is so common, that around 70 to 90 percent of Australians will face it in their lifetime. It’s important to act on back pain sooner rather than later because the issue can progress and worsen in time and because it can also be a sign of a more serious musculoskeletal condition.

  1. Stretching IS important

The ugly cousin of cardio and weight training, stretching is often the forgotten fitness element. Poor old flexibility tends to get neglected in people’s training routines as it’s nearly invisible unless you are an Olympic gymnast.

  1. Get your technique right in the gym

One of the most common reasons for injury in health and fitness programs is poor exercise technique – make sure you get good instruction on the correct technique for all of your exercises before you get serious and increase the weights.

  1. Slow & steady wins the race:

Build your running km’s up slowly. We often see people trying to run 50km per week after only training for a few months and they wonder why their body is hating it.

  1. Hydrate

Have another drink of water – keep those joints lubricated, deliver nutrients to cells, improve your sleep quality, cognition, and mood.

  1. Go for a walk in nature

Research from Nippon Medical School in Tokyo showed that a simple nature walk changed blood flow to the brain, helped facilitate a state of relaxation and increased the number of natural painkillers the body produces to battle inflammation.

  1. Listen to your body

Minor aches and pains are normal to experience with sport and exercise. However if pain persists longer than weeks or starts to impact on your sport, exercise or everyday life then it is important to address the issue ASAP.

  1. Get your technique checked out by a sports physio

Lots of people seem reluctant to ask for help from their Physio or Health Professional about their running technique or technique in the gym. The better your physio gets to know you and your training, the easier it will be for them to help you manage any injuries and keep them at bay in the future.

  1. Invest time in preventative exercise – AKA Prehab

Prehab essentially follows the same rules as rehab but with one key advantage. You don’t have to be injured. Prehab involves working to prevent that injury from occurring in the first place or strengthen an area before surgery.

  1. Take some time for physical self-care

Healthy body, healthy mind isn’t a saying for nothing. Focusing on activities that help you to stay physically fit and healthy is especially important during challenging times. Whether it’s walking, swimming, biking, working out at the gym or along with a Youtube video, or even doing chores at home, you’ll feel better for it

  1. If you have any questions, or nagging injuries; give us a call on (02) 8964 4086
    or send an email to info@fixio.com.au.
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