What is a Stress Fracture?
Tiny cracks in bones are called stress fractures, and they're caused by doing things like jumping up and down or running a lot, which puts a lot of force on bones.
When stress reaction occurs, the bone is breaking down and becoming weak. However, the bone has not yet broken. This usually happens after 3-4 weeks of not exercising.
A stress fracture is a fissure that has occurred in the bone. It might need a boot for stabilization. The usual length of time for non-running exercise is 6-8 weeks.
Though they are different, many doctors will use the two interchangeably to ensure you understand that the bone needs rest. This is largely because they can't say this chronic and repetitive bone stress.
You can prevent stress fractures from happening by following these steps. Most stress fractures are preventable if you take the proper precautions. Follow these steps to avoid stress fractures.
Tibia, metatarsals, fibula, and femur fractures are the most common type of running stress fractures. The second and third metatarsals of the foot receive the most impact when you push off to walk or run, making them very susceptible to fractures.
This text is discussing how the lower leg can become weakened from underfueling and overtraining, due to the impact it absorbs from each foot strike.
Most stress fractures are treated without surgery, so the recovery process is mostly up to you.
What Does a Stress Fracture Feel Like?
Many runners experience foot pain at some point and wonder what the cause is. It could be a tendon, a bruise, or a stress fracture.
There is localized pain with a stress fracture that gets worse with running over time.
You may notice a small pain in your foot/ankle/shin/hip while running, but if the pain gets worse over time, it may be a sign of a more serious issue.
If you feel pain in a specific area and it is on a bone, it is likely that you have a stress fracture.
- Try backing off for a few days.
- If you return without pin pointed pain, it may have been a tight or overworked muscle.
- If not, then go get an x-ray – ASAP. It’s better to catch it as a fracture before you turn it in to a full break.
- A break will require more time to recover and stress fractures don’t magically heal by ignoring them.
7 Keys to Running After a Stress Fracture
There are many reasons why running after a stress fracture is difficult, and not just because of the physical aspects.
The array of emotions many runners will feel as they get back into the sport can be all over the map:
- Worried about the potential of re-injury
- Discouraged over potentially losing fitness
- Excited to be running again
Remember that it will not be easy to start running again after a stress fracture, just because you put on your shoes and walk out the door. You will have to deal with many emotions first.
The first few times out after being cleared to run after a stress fracture can be tough for a few reasons:
#1 Phantom Pains After Stress Fracture
You will feel all the sensations happening in your body and be worried that each is a new injury.
Trust me, you’re fine.
- focus on your breath
- take in the scenery
- enjoy the fact that you’re running
- try not to be paranoid about every little sensation
#2 Go Short, Go Slow
You should take it slow when you start running again after a stress fracture. Remember, the fracture happened after running many miles, so if you try to do too much too quickly, you might cause the fracture to come back.
- keep your first runs short (and short is relative, it depends on how long you’ve been out and what your mileage was like before the injury)
- ensure your intensity is low (again, relative)
- allow your body to re-adapt to the demands of running (act like a beginner!) – all of your joints, muscles and tendons need that time
- seriously act like a beginner, use run/walk, follow the Couch to 5K plan if you need guidelines
#3 Work Through Mental Fears of the Loss of Fitness
If you've been sidelined with a stress fracture, you may have lost some of the fitness you've worked so hard to build up.
We all know that running is just different than other exercises, and if you haven't been able to run for a while, it can be frustrating to feel like you're not as good as you used to be.
- For the first several runs after coming back from a stress fracture, just enjoy the fact that you are running again and that you can do so without pain.
- Remember that you will regain fitness faster than the first time you tried to get there because your body and mind know what is possible.
- Checkout this full guide on how much fitness you lose with time off
Within the next few weeks, you will be able to return to the level of activity you were at before the injury. As difficult as it may be to be patient, it is the best way to prevent another stress fracture.
#4 Pre-Hab and Re-hab Like It’s Training
I can't overstate how important it is to work with a physical therapist who specializes in sports. A general PT focuses on getting you out of pain and walking again, but a sports PT is focused on helping you get back to your pre-injury level of activity as quickly as possible.
Once they assign you PT exercises, do them.
If they give you 5 exercises to do 3 times a day, you should do them. These movements will help you recover and prevent future running injuries.
Feel free to inquire about exercises you can do from your physical therapist, such as biking, swimming, or yoga. Once you know any limitations, make sure to adhere to them.
Rushing the recovery isn’t worth the setback.
#5 Strength Train Consistently
Although we are aware that running promotes good health and stronger bones, many people do not realize that strength training is also essential for generating stronger bones.
Multiple studies have found that strength training can help to improve bone density, even in those with osteoporosis.
Wait to place weight on your injured leg, and in the meantime, start weight training with your upper body and core. Strength training for runners helps with endurance, improves posture, improves speed, and will help prevent other injuries.
Once you are ready to start adding strength to the leg again, the physical therapist will give you guidelines.
- Start with body weight only movements
- Consistently utilize single leg movements, this will help ensure your stronger leg doesn’t compensate after injury
- Add in mini-bands
- Finally you MUST lift weights – the studies show the bone building occurs from lifting heavy things, not just your body weight.
#6 Focus on Inflammation Reduction
During the recovery process, there may be some discomfort as the body adjusts to getting back to the intensity of running. Our goal is to help the body adjust and ease the mental fears associated with soreness.
Some inflammation is necessary after a workout in order to see results.
BUT we want to control chronic inflammation from high stress or pain without using NSAID's.
- Herbs For Muscle Recovery – easy things you can add like tea to feel good
- Anti-inflammatory Meals – Foods that are going to assist in recovery
- CBD Oil for Runners – This was a game changer for me after knee surgery. Maybe largely because it improves sleep.
#7 Return to Running Program After Stress Fracture
Now is not the time to be careless and take chances like we might with some races. You want to follow a plan that is structured and will help you return to running without pain.
Phase 1
- Eliminate all weight bearing activities until cleared by your Doctor
- Start doing the strength training for upper body and core immediately
- Ask if you are cleared to do Aqua Jogging or Pool Running – this is a phenomenal way to keep your fitness and will be really useful during the rebuild
Phase 2
- Begin doing cross training like a stationary bike, rowing or swimming once cleared
- Continue doing strength training, only start adding in any lower body approve by Physical Therapy
- If there is pain, stop, reverse and go back to phase 1.
Phase 3
About six to eight weeks after you start following the plan, you'll be ready to begin running.
- Start with a short 20 minute run/walk session
- After every session evaluate any appearance of pain and go back to phase 2 if it appears
- Continue walking daily and slowly increase the number of runs each week
- Then slowly increase the volume of time running vs walking
- Don’t add speed work back to your plan until you have at least a few months of completely pain free running
The following are must dos to prevent future stress fractures from running:
How to Prevent Running Stress Fracture?
If you continue to run, is it likely that you will experience the same issue with a stress fracture again?
No!
There are ways to reduce your chances of getting a stress fracture, although it is not possible to prevent all of them. If you have never had one before, there are still things you can do to reduce your risk.
1. Increase Mileage Slowly
A good rule of thumb is to increase your total mileage by no more than 10% per week. However, if you have had a stress fracture, you should be even more cautious and conservative for the first month or two.
I know its frustrating to see yourself progressing at such a slow rate, but at least you're still running and not dealing with another stress fracture.
2. Mix Up Running Surfaces
Running on surfaces like asphalt or concrete is more difficult on your body than running on softer surfaces like trails or grassy fields.
Softer surfaces are better for runners because they are more forgiving and can help prevent injuries.
3. Get Off the Treadmill
I don't like running on the treadmill, but some people do and that's okay.
You may not believe it, but there is a connection between running on a treadmill and getting stress fractures.
The way your feet hit the ground while running on a treadmill is quite similar with each step, unlike when running on other surfaces where there may be differences due to changing terrain, turns, etc.
Why does this matter?
This allows the forces on your bones to be dissipated through a much wider range of the bone, which makes for stronger bones. When your feet are hitting the ground slightly different with every step, the point of maximal stress on your bones is different with each step. This allows the forces on your bones to be dissipated through a much wider range of the bone, which makes for stronger bones.
However, when you run on a treadmill, your feet continually land in the same way, which can create force concentration on the same area. If you have the opportunity to run outdoors or on an indoor track instead of a treadmill, it is advised that you take it!
4. Check Your Shoes
The last time I got a new pair of shoes was a few months ago. As my shoes break down, they provide less and less cushioning when I'm running.
A pair of running shoes typically lasts between 300 and 500 miles, but this varies depending on the runner and the type of shoe.
If you are running multiple times a week, it is a good idea to rotate multiple pairs of running shoes. This has several benefits, including allowing the foam to fully decompress before wearing them again, resulting in maximal shock absorption.
The store where you got your shoes may be able to tell you if you are rolling your foot based on the wear patterns on your shoes. This could be causing extra stress on your body.
SIGNS & SYMPTOMS OF A RUNNING STRESS FRACTURE
A stress fracture is a type of injury that can affect any bone in the body, but is more likely to occur in the bones that bear weight (such as the bones in the legs and feet) in people who run frequently.
Common areas include:
- 2nd and 5th metatarsals
- Tibia
- Fibula
- Navicular
- Neck of femur
DIAGNOSING STRESS FRACTURES
Subjective history plays a big role in diagnosing stress factors. This is the story the patient tells you.
The runner will struggle through a couple of weeks, with worse times and higher levels of fatigue. However, if they can stick with it, they will start to see their performances improve again #### There is a common story among runners that involves a change in training. This could be a sudden increase in mileage, or adding in a new plyometric program that increases intensity. The runner may struggle for a couple weeks with worse times and more fatigue. However, if they stick with it, they will eventually start seeing their performances improve again.
Simplifying things can often lead to a change in the way we do things. Sometimes, it is as easy as a change in our shoes.
The pain usually associated with a fracture is localised to the area of the injury. There may also be some swelling. In the early stages, pain is felt when putting weight on the injury and is worse with movement. As the condition gets worse, the pain is present even when resting and often worse at night.
The physical tests that can help with diagnosis are touching in and around the painful area (palpation) and impact tests. With palpation, you would expect the pain to be localized and not widespread. With impact tests, the patient jumper and stamps, and you are looking to see if the patient's symptoms are reproduced. These tests are often used as objective markers to measure progress. If the patient is pain-free, it is a good sign that progress has been made.
MRI is the best way to diagnose stress fractures using images.
HOW TO MANAGE A STRESS FRACTURE
Usually, the first step is to take a break from the activity that’s causing the stress on the bone. If you've been diagnosed with a stress fracture, the next step is to figure out how to manage it. The first step is usually to take a break from the activity that's causing the stress on the bone.
Not all stress fracture are made equal, so at this stage, I have a few things going through my mind:
- Is it a high risk fracture?
- What are pain levels like? and how irritable is it?
- What is the quality of the bone like in the first place?
- Biomechanical factors
IS IT A HIGH RISK STRESS FRACTURE?
A stress fracture with a high risk of non-union or delayed healing is classified as high risk. Any area that has a poor blood supply or risk of developing into a full fracture can be classified as high risk.
A fracture that is classified as high risk is typically managed with either surgery or a more aggressive form of conservative management.
High risk fractures include:
- Neck of femur: Tension side (In certain fractures you get a tension side and a compressive side. In the compressive side, as the name suggests, the bones are being pushed together so actually favours union and healing, whereas the tension side is repeatedly being pulled apart, so it can be difficult for that area to heal and unite).
- The patella
- Medial malleolus
- The base of the 5th metatarsal
- Navicular
- Sesamoid bones of the big toe
PAIN LEVELS & IRRITABILITY?
If you have a stress fracture, you need to figure out if it is high or low risk. Most running stress fractures are low risk. You can use how much pain you are in and how much activity it takes to make the pain worse to figure out how much you need to rest.
The area needs to heal in order for us to feel better. Our body already has the wisdom to do this, we just need to give it the right environment. This means not putting pressure on the injured area.
If you have a lower risk stress fracture, you only need to stop doing activities that cause pain. You should keep the strength and health of adjacent body parts by doing other exercises for other joints, the other leg, or upper body while you wait for the injured area to heal.
You may continue your training regime by participating in other activities that do not cause pain. Some common examples are cycling and pool running. I am a big fan of deep water pool running, as it allows you to keep good running mechanics while still reaping the benefits of a run, without all the strain.
If you work out with enough intensity, you can still do a lactate threshold workout while aqua-jogging in the pool.
If you understand stress fractures and are not at risk for one, you can still do a lot to maintain your fitness or even improve it.
