ARTICLES, TIPS, TRAINING & GENERAL ADVICE

Stress Fracture Q & A

by Brad Hefta-Gaub, December 30, 2007

I have done a lot of research on stress fractures. As an athlete who has suffered from two stress fractures, I have made it my mission to find out what causes stress fractures and how they can be prevented I hope by sharing my findings and what I’ve learned through the healing process I am able to educate others. I am not a medical doctor, so please take my comments as feedback from a patient, and do not consider anything I say to be medical advice.
Stress fractures in your hips - I don’t even want to imagine how painful this is, but these types of stress fractures are apparently common among long distance runners. My quick net research seems to suggest that older runners and female runners are at significantly greater risk for this type of injury.

You can get partial stress fractures on either the top (tension fracture) or the bottom (compression fracture) of the “femoral neck” (the ball part of the ball and socket hip joint); or you can have a break that goes all the way through the femoral neck called a displaced fracture. Displaced fractures are particularly problematic because they can lead to avascular necrosis (the injury that our friend Floyd Landis had his hip replacement surgery to repair).

Pain in your shins - A very common injury for runners is shin splints. We’ve all heard the term, and most of us probably would assume that any pain in your shins is shin splints. That’s what Lance Armstrong thought as he trained for his first New York City Marathon. Unfortunately, sometimes pain in the lower legs can actually be something much more serious, namely a tibial stress fracture.
Tibial stress fractures can be become very serious because athletes may assume that the pain “is just shin splints” and they will be advised by their friends and fellow runners to “just tough it out”. People trying to work through this pain, can often end up with a tibial stress fracture. Determining whether shin pain is a shin splint or a more serious stress fracture is something that should be left to your medical professional. In all of my “research” on the topic, the distinction appears to be rather subtle, with tibial stress fractures being a much more serious injury.
Pain in the top of your foot and toes - can be a sign of a metatarsal stress fracture. These types of injuries apparently often go unreported. In fact, I suspect that I may have had a mild stress fracture in my left metatarsal bones as well as my calcaneus stress fracture. I suspect that my wife may have received this injury as well when she trained for and completed the 3-day Walk. This injury can be caused by osteoporosis or a foot deformation (e.g. tailor’s bunion), abnormal foot structure and mechanics (e.g. overpronation), and increased hill or speed running.
Pain in your heel - Another common injury for runners is plantar fasciitis. Most of us would assume that pain in our heels is plantar fasciitis. When I got my first heel injury, everyone I knew said, “Oh you just have plantar fasciitis, rest a day or two and you’ll be fine!” Of course, I didn’t feel better in a day or two, and as I got more worried about my injury, I did more research and discovered the primary distinguishing symptom being “pain related to lateral compression”.
Basically, if you squeeze the sides of your heel, and it hurts, then your pain is probably not plantar fasciitis… you probably have a calcaneus stress fracture. When I got to my doctor for the first visit to discuss my heel pain, I explained my self diagnosis. He hummed “oh really….” and gave me a full exam. And then he announced, “Yep, I think you were correct, you have a stress fracture.” The key symptom was this pain with lateral compression.

I got my first case of calcaneus stress fracture a year ago in my right heel. I had been training for my first marathon, and had ramped up pretty quickly. I fell into the trap of over training because I had a very high fitness level from cycling, and assumed that since I wasn’t tired, and my muscles weren’t getting sore, that I was giving myself enough time to recover. Although I certainly won’t compare myself to Lance, I suspect that he may have fallen into the same trap. But with running, unlike cycling, you are putting a tremendous amount of force on your feet, legs, and hips. Your bones and connective tissue also needs time to recover.

After getting an official diagnosis, I was determined to recover quickly. I stayed on crutches for a week and minimized my standing, walking, and weight baring for a total of 4 weeks. I didn’t run at all during this time. I stayed fit with cycling, in particular spin class. In 4 weeks I felt great, and was eager to get on a treadmill so I returned to the doctor and he was very surprised that I had made a full recovery. But he cleared me to run, and he encouraged me to “listen to my body”. As a result, I was really afraid to do much running. And my run training from last year shows it. I basically only ran on average 2 hours a week, and at most 6 hours in only 2 of my training weeks coming up to my Ironman. Ultimately, I am convinced that this moderate running prevented another injury, but didn’t really address the underlying cause for my stress fracture.

My second calcaneus stress fracture was in my left heel. I got it almost a year after my first. And again, it was probably from over training (and the underlying structural problems with my feet). After my Ironman, I wanted to start training for next year, and in particular, improve my run time. So I trained to run the Seattle Marathon, and I ramped my training to an average of 3.3 hours a week, but again, with doing no more than 4.75 hours in any one week. Upon diagnosing my second stress fracture, my doctor focused more on my holistic medical history. And from that he reached a new conclusion for the source of my problems.

Possible Root Cause: Poor Foot Mechanics

Considering the following history of injuries: 2 calcaneus stress fractures (one in each heel), very fast recovery from the first, a strained hip flexor after resuming more serious run training, and a mild case of hip bursitis. Also considering the following non-injury medical history: high arches, tailor’s bunion on both feet, history of being overweight, high dairy consumption for must of my life, no family history of bone breaks. All of these fractures lead my doctor to believe that the source of my “stress” causing these stress fractures is an underlying flaw in the anatomy of my feet. Namely that my high arches are causing poor shock absorption and hip strain. Fix the arches fix the other problems.
My doctor sent me to a local sports medicine rehab clinic. This has offered significant insight for me. The time I have spent with my physical therapist has been great. She has done serious gate analysis (watching me walk and run from all angles) and determined not only what structural issues in my feet need correcting, but she has also identified which muscles of mine are overly tight (and need a good stretching routine). These tight muscles can also cause problems in gate and stride, and can in fact lead to more stress fractures. Your muscles can actually be strong enough to break your bones. Don’t we all suspect this is what happened to Barry Bonds?

Recovery

A lot of people have asked the question “What kind of exercise can I do while I have this stress fracture?” I guess I’m lucky that I had a good doctor, because I felt like he and I had a good candid conversation about my training goals (and my need to exercise and stay fit) and he was helpful in suggesting which of my training activities he felt I could safely continue while my stress fracture was healing. The simple rule was if you could do it on day 1 without any pain at all, then it was probably ok to do throughout your recovery. Some activities that you might think of as non-weight baring, like swimming and cycling, certainly were good after about week 2, but even those activities will put stress on different parts of your body. It’s going to depend on where your stress fracture is, and how aggressive you are about training.

I wanted to heal quickly, so I didn’t do any activity that would cause any pain. I found that swimming the first week was still too painful. As I would kick, the muscles in my legs would pull on their connections to the calcaneus, and it would hurt. So I avoided swimming until week 2. I suspect that swimming would be very difficult with a hip stress fracture, tibial stress fracture, or a metatarsal stress fracture; because swimming kicks are full leg kicks and would cause stress to be placed on any of these muscle bone connections.

Light spinning was fine, but I couldn’t “stand up” on a spin bike, and I couldn’t put a lot of tension on the wheel or else, again, my muscles would stress the heel. I suspect that this would be particularly true of a hip and tibial stress fractures.

Weight training like squats, lunges, leg presses, would be very painful and significantly impact recovery if they were done prematurely. This is one reason that I suggested isometric strength training as a possible alternative.

Stress Fractures Due to Sudden Trauma

A Rock Climber I know believes he got a stress fracture from jumping down 6 feet and landing on one heel. He said he was experiencing pain from lateral compression and suspects a calcaneus stress fracture. This certainly sounds like a calcaneus stress fracture to me. In fact, I did find one article that suggested that these types of stress fractures are common among construction workers. I guess falling off of a ladder is an occupational hazard.
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Sources:
Academy Of Orthopedic Surgeons
American Academy Of Family Physicians

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