Last reviewed: September 29, 2026

Yes. A normal X-ray does not rule out a stress fracture, especially early on.

A stress fracture is a small crack in a bone caused by repeated loading, such as running and jumping. Early on, the bone is swollen but the crack may not show. According to the American Academy of Orthopaedic Surgeons, the X-ray may look normal at that stage.

A review of imaging studies found that X-rays detected between 12% and 56% of leg and foot stress fractures. MRI was the most accurate test. In a study of 80 teenage athletes with shin pain, every X-ray was first read as normal. MRI still showed a bone stress injury in 127 of the 160 shinbones scanned. The X-rays that did show changes were mostly from the more severe injuries.

Shin splints cause pain along the inner edge of the shinbone and are diagnosed mainly by examination. When shin pain does not improve with treatment, the doctor may check for a stress fracture. MRI can help tell the two apart.

Girls are at higher risk. In a review of 180 studies, female athletes had more than three times the risk of bone stress injury of male athletes in the same sports. The Academy names cross country, gymnastics and outdoor track as the highest-risk sports for girls. In one college study, distance runners had a much higher rate than athletes in sports where body weight matters less. Boys get stress fractures too.

Not eating enough for the amount of training raises the risk. Doctors call this relative energy deficiency in sport, or RED-S. The International Olympic Committee says it affects both girls and boys. In a study that followed 259 girls and young women, those who trained 12 or more hours a week, restricted their eating and played a sport that values leanness had the highest rate. Nearly half of them got a bone stress injury.

Most stress fractures heal with rest and a gradual return to sport. A few sites heal poorly because of the forces on the bone and a weaker blood supply. These include the hip, the kneecap, the front of the shinbone, the inner ankle and certain foot bones. They need prompt evaluation, often time off the leg, and some need surgery. In adults, one review found a faster return to sport after surgery for two of these foot fractures, but the evidence was weak. Little of this evidence comes from children.

In a trial of more than 5,000 female Navy recruits, calcium and vitamin D supplements lowered the rate of stress fractures during basic training from 6.6% to 5.3%. These were adults, not children.

In general:

  • If pain continues after a normal X-ray, ask your child’s doctor whether more imaging is needed.
  • Hip, groin or midfoot pain in a runner may need prompt attention.
  • Ask whether your child is eating enough for the amount of training.
  • After a stress fracture at a high-risk site, or more than one, ask about a check of nutrition and bone health.

Drafted with AI assistance from published sources, reviewed and edited by Babak Sheikh, MD.

Sources:

This is general information about what published research shows. It is not medical advice and it is not about your situation. Reading it does not create a doctor-patient relationship with me. I am a retired orthopedic surgeon and I do not see patients. Talk with your own doctor before changing anything about your care. If something feels suddenly or seriously wrong, get medical care promptly rather than waiting.

This page is provided as is. I make no guarantee that it is accurate, complete or current, and medical evidence changes. Use of it is at your own risk.

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