These are NO joke.
I'm sure you've heard horror stories of the dreaded walking boot, really long rehab times, and even re-injuries.
And you so desperately don't want this to be you!
The good news: it doesn't have to be.
I promise.
Yes, even the scary return-to-run process doesn't have to be terrifying.
Let me skip to the good part real fast:
Getting back to running is all about slow, gradual, pain-free running.
Yea.
It's that simple.
But I'm jumping ahead of myself (what else is new...).
Let's talk about what to expect from your rehab process.
Let's talk about your comeback after this foot stress fracture!
Because often, it's way less scary and a lot more manageable when you have a plan.
Or at least a couple bullet points even if you don't have the full picture.
Let's dive in, running fit fam.
Low Risk vs. High Risk?
First thing's first…
You're going to need to clarify with your healthcare provider (PA, Ortho surgeon, physician, podiatrist, whomever diagnosed you) whether you have a low risk or a high risk stress fracture.
The difference?
It gets technical because the rating depends on which surface of the bone is fractured, which bone is involved, etc.
Examples of high risk: superior cortex of the femoral neck and the anterior (front) cortex of the tibia.
The point is:
If you have a high risk stress fracture, this blog post isn’t for you right NOW. You've got a different rehab journey to go on before you get to the following stages we'll talk about below.
But when it comes to low risk BSI's (bone stress injuries) and stress fractures, things might not be as bad as you think.
There's actually more evidence coming out about how you *might* be able to skip the ugly boot! (but more on that later…)
Examples of low risk: tibial and metatarsal BSI's that occur on the compressive surfaces of the bone, namely the posterior and dorsal cortex.
See how this gets detailed and nuanced pretty fast, even with a LOW risk bone stress injury? That's why we're going to have the major disclaimer/come-to-Jesus meeting…
DO NOT REHAB A STRESS FRACTURE ON YOUR OWN.
No way.
No how.
And…I will not help you rehab a stress fracture over an email correspondence or IG DM. You can ask questions; please do! (Because knowledge is power…and that's how you Dare to Train Differently.)
Is all that pretty blunt and harsh sounding?
It is. (mid-western "ope" and apology for sounding so mean)
But it's because YOU deserve the BEST!
You deserve excellent medical care.
You deserve to have a healthcare team on your side that walks with you through this rehab process.
And you deserve to run pain free.
So please, don't do this alone.
With the not-fun part out of the way, let's talk more about what you CAN do, even with a foot stress fracture.
Phase 1. It's All About Load
Straight talk: you have a fracture line in a toe-bone.
Not great, duh.
And it needs to heal.
Which means, just like in running, it needs some recovery time.
Which can mean needing to be off the injured foot for a little bit of time, but maybe not as long as initially thought.
Hear me out…
"low-risk tibial (shin bone) and metatarsal (toe bones) BSIs should be managed using an optimal loading approach. There is no need for a prolonged period of strict protected weight bearing (eg, 6 to 8 weeks in a walking boot).
Optimal loading of a low-risk BSI respects the underlying pathology and is based on symptoms rather than time…"
Did you actually read that last sentence?
Not just the blurb about not wearing the boot...don't hear what I DIDN'T say. If you need to wear the boot, or not wear a boot but use crutches or a cane…then use them! The first step in recovering from this stress fracture in your foot is to get you walking again, as normally as possible, without pain!
Because first you walk…then you run, right? ;)
Can I walk with a stress fracture in my foot? Won't it hurt my foot?
Let's say you get the green light to start walking on that foot again.
Now is the time when we need to double down on optimal loading:
"Optimal loading…is based on symptoms rather than on time…Any pain, either with activity or at rest, indicates that the pathology has been mechanically and/or chemically irritated and that loading must be modified. Pain does NOT automatically indicate BSI recurrence, but it does indicate the loading must be immediately modified to avoid delayed healing and/or reinjury."
This rule right here.
Tattoo it on your forehead.
Put it on sticky notes around the house.
Whatever you have to do.
But this is the fastest way to get better:
being able to walk normally without pain and RESPECTING when your body does send you symptoms. This is your body's way of communicating with you, "hey, we need to back off a touch. I'm not broken again, but I'm not 100% better yet. We're still under construction."
Making sense so far?
So how do we make this happen?
Time to break out those super cushy, soft running shoes with a mild roll plate in them! Because those will become your foot's best friend, encouraging natural, efficient gait mechanics but with the support like your walking on clouds.
And say "bye felicia" to your minimalist shoes for a while because those will just "increase metatarsal load…in the early, painful stages of recovery [and]…would necessitate slower-progression through a return-to-run program."
So am I allowed to take any prescribed pain meds?
You can, as long as these aren't masking symptoms/messages your body is trying to send saying you're over doing it. A great time to take prescribed pain medication is at night because sleep is your most powerful recovery and healing tool. It's literally the time when your body stitches itself back together. And when pain keeps waking you up at night, it's hard to recover well.
Phase 2. How to not lose your mind during recovery: EXERICSE!
There's no denying it: you've worked hard for your aerobic endurance!
And you don't want to lose it.
And you're also getting ants in your pants because you can't run.
So what do you do?
How do I keep up my cardio (and not go crazy) during recovery?
"Athletes with a low-risk BSI can maintain cardiopulmonary fitness during initial load reduction using:
Cycling
Swimming
deep-water running
and/or other forms of cross-training.
Watch for any symptom provocation at the site of the BSI to ensure optimal healing…Cross-training workloads can include a combination of high-intensity interval training and more endurance-type protocols…"
Will continuing to workout hurt my recovery?
Now before your eyes glaze over from reading too much science-speak, pay attention to this next part:
"cross training workloads…should be monitored to ensure optimal energy availability to support BSI healing, particularly in athletes displaying signs of relative energy deficiency in sport (RED-S)."
What this quote is saying:
You're not trying to set PR's right now while you're healing from a stress fracture.
Your energy right now should be going towards healing, NOT trying to make up for lost time. Staying active and still working out is fantastic for continuing to create an environment for healing and bringing nutrients and oxygen to damaged tissues, but it also takes energy to recovery from a workout in general. So be smart.
Phase 3. Stay Strong; Maintain Muscle Mass
We'll keep this one relatively short and sweet.
Strength training is a must for runners in general. And it's even more important for runners recovery from BSIs and then returning to run.
That being said, there are 2 parts to this section.
Part 1: strength work you can easily do
Upper body work in a long seated or tall kneeling position
Core work in positions that don't create symptoms in your injured foot
Any other workout or sport activities that follow these same rules
Part 2: strength work for the injured foot that you NEED a healthcare provider for
This means any leg strength, calf work, foot exercises, etc you name it
these should be prescribed by the appropriate healthcare provider (i.e. do NOT guess and piece yourself back together from Dr. Google.)
Why?
"Athletes recovering from a low-risk metatarsal BSI should wait until bone tenderness resolves prior to initiating resisted weight-bearing plantar flexion due to the large bending moments experienced by the metatarsal diaphysis."
In other words, we don't want to delay your healing; we want to speed it up if possible! But that requires patience, skill, and experience.
But that doesn't mean you're just doing to sit on the PT mat with a bag of ice on your foot. Nope, nope, nope!
"Intrinsic foot strengthening…and knee flexor and extensor and multiplanar hip strengthening, may begin early in rehabilitations for a metatarsal BSI. Ankle dorsiflexion range of motion can decline rapidly following loss of normal gait in athletes with a metatarsal BSI, resulting in early heel rise and increased metatarsal loading in return to running. Early maintenance of dorsiflexion range of motion" exercises are also suggested.
So don't think there's no work to be done!
It's important to keep the rest of the team players in shape, especially further up the kinetic chain, such as glute and hamstring strength and ensuring your ankle maintains full mobility.
Phase 4: Your Favorite Phase
You guessed it…return to running!
So when can you start to run again?
You get approval from your physician
Your PT, AT, rehab provider etc thinks you're ready
And "a return to run program [can be initiated] once an athlete is pain freeduri ng activities of daily living for at least 5 consecutive days."
But what does return-to-run look like?
It's going to look a little different for every one because it's all about bone workload.
Bone workload:"can be defined as the interaction between how many times and how hard a bone is loaded"
What the heck does this mean for runners?
"for loads relevant to running, it has been estimated that a 10% increase in tissue loading (stress/strain) halves the number of loading cycles before failure"
I know, I know, enough of the big science-y words…but we're making a point here.
It's this:
Don't take this recovery lightly. But at the same time, understand how strong your body is and the healing it IS capable of! It just requires the right environment, and luckily, because of research studies, physical therapists, exercise physiologists, etc we KNOW what to look for and what your return to run should look like.
Here are the answers you're looking for:
"Because bone damage increases more rapidly with increases in loading magnitude, it is theoretically safer to increase training volume before intensity…In a probabilistic model, running the same distance but with a decrease in speed, from 3.5 to 2.5 m/s, reduced tibial BSI likelihood by half.
Therefore, prescribe high-speed running bouts judiciously, and temporarily reduce running volume when increasing volume of high-speed running
"most return to run programs begin with achieving pain-free, dedicated walking before gradually substituting increasing time increments with jogging (50% of usual pace) and then running.
Progression through a return to run program is guided by symptom provocation both during and after a session, NOT by running performance…measures of perceived exertion are NOT appropriate when guiding return to run programs.
Remember: getting back to running isn't about building your cardio again; it's actually about managing load.
Remember phase 1? It's all about loading the bone the right amount to make it stronger, encourage healing, without over doing it.
THE REAL ANSWER YOU WANT:
"For now, we suggest that clinicians use a combination of gradual increase in workload (eg, 5-10% weekly increase in RUN TIME) and close monitoring for any symptom provocation when guiding the return to run process after BSI."
Final Thoughts
There's waaaaay more to say about stress fracture and bone stress injury recovery and rehab, but for now, trust the process.
And trust your body.
It's carried you this far.
And it IS strong! And it IS capable.
And you can make an amazing comeback.
Last point:
A big part of recovery that "no one" talks about is the mental aspect of feeling symptoms or pain throughout this process.
If you only take away 1 piece of information from this entire blog post (or all of my blog posts!), know this:
Pain is your body's way of talking to you, of getting you to stop and pay attention.
Sometimes it's telling you "hey, no really, don't run on this foot! Something's not right!
Other times…it's just talking.
Letting you know things aren't 100% yet, but it's also not the end of the world.
Things just are.
Symptoms and pain don't always mean there's damage occurring.
Again, sometimes…it's just our bodies talking.
What are you going to say back to it?
Until next time, running fit fam.
Dare to Train Differently,
Marie Whitt, PT, DPT // @dr.whitt.fit
P.S. Want evidenced based, science backed exercises to avoid and prevent stress fractures in your feet? Click here to check out my Stronger Feet Workshop!
References
Warden, S., Davis, I., & Fredericson, M. (2014). Management and Prevention of Bone Stress Injuries in Long-Distance Runners. Journal Of Orthopaedic &Amp; Sports Physical Therapy, 44(10), 749-765. doi: 10.2519/jospt.2014.5334
Warden, S., Edwards, W., & Willy, R. (2021). Optimal Load for Managing Low-Risk Tibial and Metatarsal Bone Stress Injuries in Runners: The Science Behind the Clinical Reasoning. Journal Of Orthopaedic &Amp; Sports Physical Therapy, 1-28. doi: 10.2519/jospt.2021.9982