Stress Fractures in Runners

For runners, the dreaded diagnosis of a stress fracture (particularly in the foot) can result in not being able to train or race.

This causes much disappointment over months of discipline and hard work. Stress fractures are caused by overuse and repetitive activity and are commonly found in runners and athletes who participate in soccer and basketball.

Refraining from running and high impact activities for an adequate period of time is an important aspect to recovering from a stress fracture in the foot. Returning to running too quickly can delay the healing process as well as increase your risk for a complete fracture (which would take even longer to recover from).

Stress Fractures in Runners

What Are Stress Fractures?

Stress fractures are a unique type of bone fracture as they rarely occur due to a specific trauma. Stress fractures typically occur due to a silique of events that leads to the bone not being able to handle the stress of your activity (such as running) which results in a crack in the bone.

Stress fractures are common in the foot, typically in the smaller metatarsal bones, but they can occur almost anywhere (particularly in weight bearing or load bearing bones). For runners, stress fractures most commonly develop in the foot, but are also known to occur in the tibia (the main load bearing lower leg bone) and in the hip (in the neck of the femur). On average, stress fractures in the metatarsal bones and the tibia tend to heal the easiest whereas factures elsewhere can be more problematic. Although the main focus will be on the foot, many of the following guidelines would be useful regardless of the area injured.

Initially, you might barely even notice the pain associated with a stress fracture, but the pain tends to worsen with time. The tenderness usually originates from a specific spot and decreases during rest. As the injury worsens, the pain tends to spread out and become more diffused with a focal area of tenderness. You might have swelling around the painful area. In some cases, the entire foot may begin to swell.

Stress fractures typically occur as the bone is subjected to a new unaccustomed force without enough time for recovery. Bone adapts gradually to increased loads through remodeling, a normal process that speeds up when the load on the bone increases. During remodeling, bone tissue is destroyed, and then rebuilt. This is a similar process in muscle tissue. When the load and/or volume of activity are too much for the bone, a fracture will occur.

Risk Factors

In most cases, it’s not one specific risk factor that leads to the stress fracture, but a combination of risks and events that lead to the injury. Diagnosis is usually through X-ray. However, an acute injury may not initially show, so a second X-ray may be needed after a week or so to confirm the diagnosis.

See List of Risk Factors

  • Certain sports. Stress fractures are more common in people who participate in sports such as track and field, soccer, basketball, tennis, dance or gymnastics. High repetitive impact sports tend to have the most stress fractures. (Sorry, but that includes running.)
  • Increased activity. Stress fractures often result from increasing the amount or intensity of an activity too quickly. For example, people who suddenly shift from a sedentary lifestyle to being more active (increasing training volume significantly) or those who rapidly increase the intensity, duration or frequency of training sessions. This also includes tapering up mileage too quickly.
  • Gender. Women are more likely to develop a stress fracture, especially those who have abnormal or absent menstrual periods (known as amenorrhea).
  • Foot problems. People who have flat feet or high, rigid arches are more likely to develop stress fractures. Worn or poorly fitting footwear or high heels can also contribute to this issue. For runners, transitioning too quickly from a more built up running shoe into a minimalistic style can be a factor.
  • Osteoporosis. Osteoporosis or osteopenia causes weakening in the bones that makes it easier for stress fractures to occur.
  • Prior stress fractures. If you have experienced one or more stress fractures, you’re at a higher risk.
  • Poor nutrition. Lack of Vitamin D, calcium, Vitamin K, and magnesium can make bones more likely to develop stress fractures. Generally poor eating habits are also a factor.
  • Hard surfaces. Spending long periods of time or training on hard surfaces, such as concrete, can increase your risk.
  • Smoking. Smoking leads to poor blood flow and affects the body’s ability to heal and recover.
  • Obesity. The heavier you are, the more forces that ultimately go through your foot. Depending on how you are exercising, your particular footwear and the surface which you walk or run on can contribute to increasing your risk factors.
  • Gait abnormalities. Alterations to your normal mobility (from either another injury or a change in your body) that affect how you typically move. The change in mobility, along with your activity level, can be enough to overload the bone. Particularly, when other risk factors are present.
  • Low stride frequency. A low stride frequency means that you are hitting the ground and pushing off harder than if you were running with a higher stride frequency. It’s typically best to attempt to maintain a stride frequency of at least 180 steps per minute regardless of your running pace.

A bone scan or MRI tends to be the most useful to determine if there is a stress fracture injury to the bone. In the case of a poorly healing bone, the use of a bone stimulating electrical device may be recommended by your physician.


Initial Treatment

Non-weight bearing or limited weight bearing for four to six weeks is a very common course of treatment along with cessation of running activities. This amount of time allows the body to initiate the healing response while reducing the stress on the injury site. If you continue to stress the site of injury, the fracture can worsen and require more invasive treatments. Treatment should to be taken seriously as a stress fracture left untreated can lead to a non-union of the bone (requiring surgery to repair) or more rarely, avascular necrosis (where the bone begins to die).

Crutches, a walker or a Roll-A-Bout knee scooter can be used while you have weight bearing restrictions. A walking protective boot is also typically used to protect the injury site.

As with many injuries, the initial treatment for a stress fracture in the foot is PRICE (Protection, Rest, Ice, Compression, and Elevation).

  • Protection. Wear a walking boot, and limit weight bearing on the foot.
  • Rest. Limit any activities that cause pain. Depending on the severity and your personal health status, this can last from two to eight weeks. Those with diabetes usually take a significantly longer period of time to heal.
  • Ice. Use ice as needed for pain and edema control. The rule for icing is to apply ice no more than twenty minutes per hour. Do not place the ice directly against the skin, especially if you are using a gel pack style. A bag of frozen peas can be ideal. Individuals with poor circulation or impaired sensation should take particular care when icing.
  • Compression. If swelling is present, utilize a simple ACE wrap around the foot and ankle to help with the swelling and pain. Start at the toes, and work up the leg. Take care to not apply the ACE wrap too tightly as over squeezing the foot can be irritating.
  • Elevation. Use pillows to position the foot above the level of your heart to help reduce swelling. This would be an excellent time to apply ice, too.

In general, the application of heat, cold, or over the counter (OTC) topical agents, such as Arnica Montana (an herbal rub) or Biofreeze, may help you to manage pain and stiffness.

I’m not a fan of anti-inflammatory medications as there is research indicating that such medication may actually slow the rate of bone healing. If you are unable to control the pain with the above mentioned products, then you may want to consider other over-the-counter (OTC) non anti-inflammatory medications or prescription pain medications. Please speak to your physician for additional pain management advice.


Addressing Your Risk Factors

After you have initiated PRICE and the pain and swelling has decreased, address any risk factors (if and when possible).

  • Stop smoking. If you smoke, please stop. It not only affects your bone density, but it has negative effects on every other body system. It also increases your risk of cancer and heart disease.
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  • Nutritional management. Address any nutritional deficits. This includes having adequate levels of Vitamin D3, Vitamin K1 and K2, magnesium, and healthy fats.
     
    Vitamin D3 is critical to the absorption of calcium, through the intestinal wall, which is important for bone health. Although calcium is a critical component of bone health, I cannot recommend extra supplementation because of the potential cardiac risks to over supplementation. A healthy varied diet will typically supply adequate calcium levels (assuming that adequate Vitamin D3 levels are present for absorption and that you are avoiding drinking soda). Vitamin D3 is also a critical nutrient in maintaining a healthy immune system.

    Research indicates that Vitamin K can help to reduce bone loss by helping the body regulate osteoclast function with in the bone. An osteoclast is a type of bone cell that breaks down bone tissue. These very important cells are integral in maintaining proper bone density and insuring an appropriate amount of calcium in the blood stream. Without adequate calcium, many critical cell functions can be affected (including heart function). Both Vitamin K1 and K2 have been proven to reduce the risk of fractures, including hip and vertebral.

    Vitamin K, found in green leafy vegetables, has anti-coagulation benefits. If you take blood thinning medications, your physician will need to know how much you consume on a regular basis.

    Magnesium is a critical component of bone health and health in general. Magnesium helps the body to regulate calcium levels. This has a positive effect on bone health and also has been proven to reduce the risk of kidney stones.

    I also use magnesium as a sleep and recovery aid. I consume it at night to help me sleep. Magnesium can also reduce muscle soreness, cramps, and/or spasms. You can take Mag Glycinate in pill form or by eating foods higher in magnesium such as spinach, artichokes, and dates.

    Most people are deficient in the amount of magnesium they consume on a regular basis. I recommend beginning with a dose of 200 mg (before bedtime) and increasing the dose in 100 mg intervals as needed. I would caution you that taking too much magnesium can lead to diarrhea. Mag Glycinate in its oral form is the most highly absorbable. Although not quite as absorbable, Thorne Research Magnesium Citrate is also a fantastic product.

    If you’re female (and especially if you suffer from amenorrhea, abnormal or absent menstrual periods), then consuming adequate levels of fats is pertinent. Adequate levels of Omega-3 fatty acids and other healthy fats (primarily from plant sources such as avocados and coconut or olive oil) are critical in order to insure that your body has what it needs for proper hormonal support. Amenorrhea can be a sign that your diet is lacking in adequate high quality fats as well as a sign of overtraining.

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  • Avoid soda and distilled water. Excessive soda intake (particularly diet soda) has been linked to poor bone density. The exact cause isn’t entirely clear. Many theorize that the acidic nature of the soda along with the chemicals and additives cause increased osteoclast activity in the bones. This releases more calcium into the blood stream in order to help fight the negative effects of soda consumption. It’s clear that too much soda is bad for your health and bones. Similarly, distilled water is water that has been leached of all other nutrients and minerals. Drinking too much distilled water can leach needed nutrients out of the bones. This may also be true for heavy coffee drinkers.
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  • Weight management. It’s important to manage your weight effectively. Excessive body weight can cause additional stress on the body. Whenever possible, work toward optimizing your health. This includes maintaining a healthy body weight. The heavier you are the more stress forces present throughout the lower extremity.
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  • Follow a suitable training program. As you train for your next race, it’s important that you find the right training program for you. Are you a novice or an expert? How is your running base? What kind of terrain do you mostly train on? These and many more factors need to be determined. I highly recommend that you work with a running coach to help find the right training plan for you. Coach Angie has many fantastic training plans.


Rehabilitation

Initially in the rehabilitation process you will need to keep with whatever restrictions were given by your physician. If possible, you will want to maintain your fitness the best you can. Most of the time, you might be allowed to participate in an aqua jogging program. This is probably the best way for you to maintain your cardiovascular fitness while avoiding weight bearing during your healing time.

Once you’re cleared by your physician to initiate exercise and activity, it’s time to progress your rehabilitation. The proper cross training program will be critical to insure that you are able to taper back into your running program without issue. For detailed descriptions and photos of potential helpful exercises, please refer to Foot Foot Stress Fracture Rehabilitation Exercises. (If you’re already working with a rehabilitation professional, such as a physical therapist, consult with him or her prior to starting my recommended rehabilitation exercises.)

  • Strengthen your foot and ankle complex. Weakness in the foot and ankle muscles (as well as the smaller foot intrinsic muscles) can lead to excessive strain on the tissues on the bottom of the foot including the plantar fascia. I recommend initiating a complete ankle/foot strengthening protocol. Please refer to Ankle Resistance Exercises Using the Elastic Exercise Band.
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  • Improve your balance. Poor balance is often associated with muscle weakness in the foot and ankle as well as weakness in the knee and hip musculature. Weakness and balance deficits can lead to poor foot mechanics, which ultimately can lead to a stress fracture, metatarsalgia or a myriad of other injuries. Improving your balance can help to reduce the risk of metatarsalgia and is an important part of the rehabilitation process.
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  • Add an orthotic. Often times, the stress fracture occurred due to alterations in foot mechanics or an old or poorly fitting shoe or orthotic. If you are recovering from a stress fracture, consult with a podiatrist or a physical therapist that specializes in orthotics to determine the proper orthotic or shoe for you.
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  • Did you progress too quickly into a minimalistic shoe? The standard built up shoe offers more foot support and padding than most minimalistic style shoes. If you attempted a quick progression, this may have contributed to the injury. Unless you are a child or teenager, expect a safe transition to take at least three months. A slow transition will allow your body to adequately adapt to the new stresses.
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  • Weight training. Once you’re cleared by your physician, initiating or returning to a weight training program is critical to the development and maintenance of strong bones. Weight training (particularly barbell training) loads the skeleton progressively over time, which can decrease bone loss and increase bone mineral density. It also positively affects the hormones, such as human growth hormone (HGH) and testosterone, needed to improve bone density and muscle strength. Barbell training is the most effective method due to the progressive load on the skeletal system, and the muscle pull being exerted on the bone, which also stimulates bone formation.

    The key to maintaining and improving bone density is always progressive axial skeletal loading and the associated pull of muscles against the bone during activity (particularly, strenuous activity). Examples of such exercises include squats, lunges, and dead lifts.

Conclusion

It’s critical that you to slowly progress back into running and other high impact activities. It’s equally important that you address any of these risk factors in order to help reduce the risk of re-occurrence. If you have experienced one or more stress fractures, you’re already at a higher risk. As you taper up activity, monitor for signs of swelling and pain. If symptoms occur, taper down the intensity. Continue to work in a pain-free range in order to strengthen around the injury site.

If you don’t experience a significant relief as you progress into your rehabilitation, please consult your medical professional. I recommend a physical therapist that specializes in feet or who works with athletes for the treatment of stress fractures. The American Physical Therapy Association (APTA) offers a wonderful resource to help find a physical therapist in your area. You may also consider consulting with a podiatrist.

For additional information on common running injuries and how to self-treat, please visit www.thePhysicalTherapyAdvisor.com.

Disclaimer:  This article is for general informational purposes only and does not constitute the practice of medicine or other professional health care services, including the giving of medical advice. No health care provider/patient relationship is formed. The use of information on this blog or materials linked from this blog is at your own risk. The content of this blog is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Do not disregard, or delay in obtaining, medical advice for any medical condition you may have. Please seek the assistance of your health care professionals for any such conditions.

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