Stress fractures are common overuse injuries in athletes. They usually occur during periods of increased training, creating a disruption in the normal bone repair processes. There are both intrinsic and extrinsic factors, whether biomechanical as well as biochemical, placing the athlete at risk. In most cases the diagnosis is primarily clinical, sometimes indicating imaging. Treatment focuses on relative rest to maintain symptom-free and progressive activity to tolerance. Stress fractures in the athlete have generally an excellent prognosis to return to sport with little risk of complications. There is, however, a type of stress fracture that possesses a higher risk of fracture progression, delayed union, as well as non-union, making it a challenge to treat conservatively. High-risk stress fracture sites are the neck of the femur (tension side), anterior tibia, patella, medial malleolus, talus, tarsal navicular, proximal fifth metatarsal, and great toe sesamoids. These sites have in common that they induce high tensile loads and low blood flow. High-risk stress fractures require more aggressive management, with complementary diagnostic image use to make an accurate early diagnosis and to initiate immediate treatment. Management of these stress fractures includes non-weight-bearing immobilization, and withdrawal from sport, with a gradual return to physical activity. In some cases, surgical intervention may be needed. To avoid delay in diagnosis and achieve an effective treatment outcome, it is crucial that the clinician has a high suspicion of this injury type.