Fast Running Blog

Having recently developed stress fractures, I have been reading up on them and wanted to compile some of the discussion from the original thread into one post, as the thread has been inactive for some time and when I went to reply, it was recommended that I start a new one. This includes what I view as the highlights of the original thread as well as some potentially helpful research I have done and some links. My goal is to give some information and potentially some reassurance to anyone who later comes to the board with the worry of stress fractures or a diagnosis. When you have to stop running, you find that you have tons of time per day suddenly free, and I like to spend it researching my condition (and daydreaming of trail runs to come, someday...)

Presentation:
Stress fractures are in general most common in the lower leg and foot. In runners, they are most commonly found in the tibia or the metatarsals. Mine are near the midpoint of both tibias, but a previous poster experienced them right at the top of her tibias, near her knee. Sometimes they are unilateral, sometimes not. The people who experienced them in both legs tended to have tibial fractures. I think only one person said they had fractures in two totally different places (Toby Barlow; heel and tibia).

They are sometimes mistaken for shin splints in the early stages, however it is important to note that the two injuries are NOT the same. For me, the difference became clear when after refereeing a girls' high school soccer game: I came off the field stumbling and in tears from the pain, finally realizing after weeks of pain that it couldn't be shin splints. Quadraballer experienced something similar. I have had shin splints, but the fractures distinguished themselves by eventually becoming MUCH more painful. In runner terms: it was obviously Bad Pain.

Diagnosis:
At least three runners noted that it took 6 weeks from the onset of pain until the actual diagnosis. My sports doctor told me that an x-ray does NOT always show a stress fracture, unless it is to the point where the bone is actually cracking through (like that poor girl who collapsed during a race). In my case, what WAS visible on the x-ray was a slight bump that could also be felt by running my fingers down the inside edge of my tibia. I was told that the bump was formed around the fracture as my body tried to heal it. Two months later, the bump is gone. A bone scan was most cited as the way to positively determine a stress fracture. My doctor stressed that if the fracture gets to the point where it is clearly visible on the x-ray, surgery is almost certainly required. He himself had such a surgery in high school for a football injury. I'm not sure whether that's true for everyone; I think he was kind of trying to scare me.

Recovery:
I was told that bone remodelling takes about six weeks, but that stress fractures actually can take somewhat longer because they are so small that it is difficult for one's body to get enough blood to them. My doctor mentioned that an air cast is often used, but did not put me in one. He instructed me to do NO running for six weeks. Others had different experiences, such as James Wizenz who couldn't run for 4 months, or (I think) Allie, who ran sooner than I. As for me, two months after diagnosis I am still experiencing pain. My doctor stressed that the 10% rule, which we all know but many of us ignore, is very important when recovering from a stress fracture. He agreed with Pete Pfitzinger (see below) that "If you have pain in the area that was injured then you have not healed sufficiently to run." (whoops, I'll stop) There are a lot of injuries that you can still run on before they're totally healed-- sprained ankles come to mind-- but stress fractures aren't one of them.

Josse mentioned runners who run through stress fractures and others who take time off. I'm not sure how you'd run through them, but I believe that it happens and I suspect that it has a LOT to do with how early you catch them. Stress fractures start out really, really tiny, and are made worse through time. My unprofessional suspicion is that people often keep running on stress fractures for at LEAST several weeks. Personally, I ran until I was literally unable to run without limping and bursting into tears. I do not cry a lot.

On a less medical note, I think this makes stress fractures particularly frustrating for runners and other athletes. My soccer friends are giving me all kinds of crap about 1) how long it's taking, 2) how strict the recovery is (like some others, I was told not to bike or use the elliptical machine), and 3) the fact that I am walking and standing like an uninjured person and not wearing a brace or cast. This is really frustrating, especially when you feel like you are otherwise so healthy-- before my diagnosis, I was stronger than I've ever been, and now it's like the muscles are going to waste. I'd read that I shouldn't even lift weights for my legs until I was healed, which really leaves me with nothing except swimming. Just a note for those who follow after: I feel you. It's horrible.

If you haven't already, for the love of God, when you start running again get fitted for some shoes that suit your stride. The longer I run, the more I realize that my pronation, though slight, ends up getting blamed for every single injury. Whether it's orthotics or Vibrams or the Pose method or whatever, I can't stress (har har) enough that it's important to think about the mechanics of how you run. I know you know this, just wanted to throw it in.

Women: Obviously this is not relevant to everyone, but I include it because stress fractures are more common in women then men, particularly among runners. This is due, as you might imagine, to the fact that women have a more difficult time absorbing calcium. I don't know about you, but my mom shoved calcium pills down my throat from menarche until I moved out of her house, and has been bugging me to take them ever since. There does not, however, seem to be a consensus in the medical community about how many women, if any, should be supplementing with calcium. I'd encourage you to research it or ask your doctor. Personally, I am lactose intolerant, which complicates the issue. Anyway.

Another huge problem, according to my doctor, is that many women runners are amenorrhoeic, often due to low body fat and/or a diet too low in fats. He informed me that amenorrhoea affects the female athlete's ability to absorb calcium, and that irregular menstruation is the number one risk factor for stress fractures in women runners. He also sort of accused me of having an eating disorder, which I found irritating, as you might imagine, but that's neither here nor there. The important take-away is that amenorrhoea is harmful to your body! I have heard that girls with amenorrhoea caused by eating disorders often suffer from osteoporosis, and not just because they were getting little to no calcium from their diets.

Controversial but important: He also told me that forms of birth control that result in amenorrhoea cause the same effect. I consulted a gynecologist out of curiosity, who confirmed that Depo-Provera (http://en.wikipedia.org/wiki/Depo-Provera) ("the shot," which causes amenorrhoea in 55% of women) has been definitively linked to bone loss. She disagreed, however, with the claim that the hormonal IUD has the same effect, citing a study. (http://humrep.oxfordjournals.org/content/25/5/1158.long) She also noted that any birth control method that does not cause amenorrhoea will absolutely not produce bone density loss (BDL). I know birth control is a touchy subject, but I don't want my fellow runners getting hurt, and I don't think enough people know this.

As with osteoporosis, family history is something to consider here.

General comment: For what it's worth, my doctor told me I was the "textbook case" for stress fractures, which was also irritating. He joked that he should photograph my legs and feet for a literal textbook. I'll alert you to what that means, in case you, too, are textbook:

- female
- amenorrheic
- slight pronation
- recent increase in activity (super intense soccer season of playing on two teams as well as refereeing several days a week)
- recently suffered from Achilles tendonitis (two years ago, left Achilles)-- apparently this is also a symptom of pronation and bad shoes
- crappy shoes (five-year-old cleats-- I know, I know, I threw them out last month)

In conclusion, I think April G's final post on the last thread pretty much sums it up: "to anyone with stress fractures I would say take the time off, come back slow, and it's all gravy." I'm not there yet, but it sounds true. My additional note would be that it's important to remember that if you've had stress fractures once, you are more likely to have them again. If you have no idea why they happened, sit down and look at your training program, look at your diet, look at your shoes. Happy running!

Helpful links:
A basic description of stress fractures at OrthoInfo (http://orthoinfo.aaos.org/topic.cfm?topic=a00112)
Stress Fractures in the female athlete, at U. Wisconsin Health (http://www.uwhealth.org/sports-medicine/stress-fractures-in-the-female-athlete/13070)
Risk Factors for Stress Fractures in Track and Field Athletes, American Journal of Sports Medicine (http://ajs.sagepub.com/content/24/6/810.full.pdf+html) (full article requires membership, but even the abstract is helpful)
Bone remodeling period (http://en.wikipedia.org/wiki/Bone_remodeling_period) (Wikipedia)
NCBI article on the Female Athlete Triad (http://www.ncbi.nlm.nih.gov/pmc/articles/PMC546077/)

Some come-back-to-running websites originally posted by Toby Barlow:
http://pfitzinger.com/labreports/9wkH2O.htm
http://www.pfitzinger.com/labreports/stressfracture.shtml