Two words a runner NEVER wants to hear.
It immediately conjures up images of ugly walking boots, scrapped race plans for months and months, and weeks on end of going back and forth between different doctor appointments, trying to get a straight answer about when you can finally get back to running.
I hear you, running fit fam.
Stress fractures can be scary.
But there is a silver lining to all this.
Yup, or did you already forget?
Around here, we Dare to Train Differently.
Which means…knowledge is power.
The more you know about stress fractures
what they are
how they happen
what they feel like…
The less scary they are.
Because when you understand how your own amazing, marvelous body works, you begin to appreciate it more.
And listen to it. And then understand what it's trying to tell you. Yes, even when it comes to stress fractures (both preventing and recovering from them). So let's start building that foundation today in this blog, running fit fam. That way, your never caught unaware.
Let's dive in.
Where do long distance runners get stress fractures and/or bone stress injuries (BSIs)?
"50% occur in the tibial diaphysis (the long, middle part of your shin bone)
The majority of other bone stress injuries occurring in:
the femur (your upper leg bone)
Fibula (your outside shin bone)
Calcaneus (your heel bone)
Metatarsals (the toe bones in the wide part of your foot)
Tarsals (your actual little toe bones, the ones you can wiggle)
However, BSIs in the pelvis (hips) and lumbar spine (low back) also occur in runners and should not be overlooked"
But let's back this up…did you notice the words "bone stress injuries"?
That was on purpose.
There is a difference between stress fracture and bone stress injuries.
We don’t hear about the other one a whole lot…and we should. Because BSI's eventually lead into….you guessed it…stress fractures.
What is a stress fracture and what causes one?
Short answer: a process.
Here me out.
What is a bone stress injury (BSI)?
Like a stress fracture, a BSI is an overuse injury
" A BSI represents the inability of bone to withstand repetitive mechanical loading, which results in structural fatigue and localized bone pain and tenderness. Bone stress injuries occur along a pathology continuum beginning with stress reactions, which can progress to stress fractures and, ultimately, complete bone fractures"
Did you catch all that?
Bone injuries happen on a spectrum.
Stress fractures don't *typically* just appear one morning. They start as a bone stress injury, progressing to a stress fracture, potentially evolving into a full blown fracture.
Don't freak out and leave!
Stay with me!
Remember my smart-ass answer? what is a stress fracture? A process.
Because it is. Let's keep going.
How is a bone stress injury different from a stress fracture?
" Accumulating microdamage may coalesce to initiate the BSI pathology continuum, which includes stress reactions, stress fractures, and, ultimately, complete fracture. Stress reactions are characterized by increased bone turnover associated with periosteal and/or marrow edema, whereas stress fractures have the addition of a discernible fracture line"
Putting all of this together: Running is a high impact sport. You're literally pounding the pavement mile after mile after mile after….
And your bones are partly responsible for absorbing that load (your muscles play a large roll too). These bone stress reactions happen because a runner has accumulated too much bone damage, too quickly for their body to effectively repair it. And over time, this damage builds up, starting that continuum.
A Stress fracture:
"actual cortical disruption", meaning, there is actually a fracture line present in the bone. The bone isn't necessarily broken in half, but it has a crack in it.
A bone stress reaction:
think of it like a "bone strain." there's damage done to the bone; it's inflamed and it's cranky but there's no overt signs of a fracture because...there isn't one.
The name of the game here: the sooner a bone injury can be diagnosed as a stress REACTION rather than fracture, the better the recovery.
However, that part isn't easy. Or clear cut. Hence the "how" of how runners run themselves into a stress fracture.
But luckily, there are some patterns so we can look out for.
So here's what we do know…
What are the signs you have a BSI or a stress fracture? What do they feel like?
To make this process easier, run your symptoms through this checklist:
1. Has this discomfort or pain been coming on gradually and with activity (aka running)?
2. Take an honest look at pain. Does the following describe what you're experiencing?
At the beginning, your "pain is usually… a mild, diffuse ache that occurs after a specific amount of running and at specific times during the running gait cycle"
(read: a certain part of your stride)
Your pain doesn't go away with the warm up or at any time during your run. It only stops once you end your workout.
"As the initial pain often subsides soon after running is complete and is not present during rest, it is often ignored at first."
You find that when you try to train through it, your "pain may become more severe and localized, and occur at an earlier stage."
(Read: you're starting to notice that your pain happens sooner and sooner during your runs).
Your find that your pain sometimes also lasts longer after your workout is done and starts to show up with general activity like walking.
Maybe you've even gotten to the point where pain stops you from running altogether, or you start to feel increased symptoms in the evening, and/or it wakes you up at night.
3. Let's test it.
Sitting down, if you poke the EXACT area that aches while running, does it hurt?
If you stand on the leg that hurts and you hop on 1 leg, does that hurt?
There's something you should know though...
These tests can be positive if you shin splints. (Stick around for the end of this blog post to figure out the difference between the two of these.)
The only TRUE way to know whether you have a stress fracture: is by getting an MRI.
Then why did my physician order an xray and then send me on my merry way?
Xrays are commonly and frequently the first type of imaging performed because of how easy it is to get one, and...frankly, they're way cheaper. While xrays are still good imaging tools, stress fractures are sneaky. It's not uncommon for an xray to come back "clean", meanwhile, you actually do have a stress fracture. (I know, I know. Not the nice black and white answer we're all looking for. But now you know.)
What do you do next if you think you *might* have a stress injury? Can you still run on it?
Time to take some action.
You ran through the checklist.
You answered the questions.
And you're finding you fit the description.
You do the tests, and they're NEGATIVE.
Be honest with yourself.
If the pain is NOT going away like we described above but you're thinking "oh it's not that bad"…
Maybe you've been training through it for a while now and just ignoring it as it's gotten "only a little bit worse"…
Could it be shin splints? Yea, maybe.
Could it be the start of a bone stress injury? Maybe.
I know, I know. Again, some real strong grey answers here.
Your best bet: take a look at your training log. Can you see if you've been missing your strength workouts, skipping mobility, increasing speed training too fast, too soon? Or had a recent mileage increase?
These are all factors that any health care provider will take into consideration when looking at your case. No reason you can't learn from your own body too, right? ;)
If things just aren't adding up though, then take this as your sign. Take 1 week off. Do some more gentle, less heavy impact training. Kick that strength work into high gear. And if after 1 week it's still a problem, consider scheduling an appointment with your doctor.
ON THE FLIP SIDE…
You run through the checklist.
And it was like looking in a mirror.
You did the tests,...
And they're POSITIVE.
You know what to do. Put your training on hold. Go see your doctor. Stat. (now you even know what imaging to ask for; look at you, action taker!)
Believe me, no one wants to put a temporary hold on their training.
But a temporary hold is WAY better than 2-4month hold.
Because that leads us to…
How long will it take to recover from a bone stress injury or stress fracture?
Everyone's favorite non-answer: it depends.
Hey, I'm just telling the truth.
Because the more YOU know and understand, the better questions you can ask your doctor, podiatrist, physical therapist, sports chiro, etc.
For any bone injury including fractures, standard healing time bone tissue takes 6-8 weeks.
But that doesn't mean you're back to full running.
Depending on the level of bone injury (meaning how intense it is), it may take longer.
It may take shorter.
It all depends at which stage you caught it at.
Can you see where this is going?
If you take the time to catch it at the bone reaction stage, you may be able to take 2 weeks off from running, and with the help of a physical therapist, make your gradual return to running in a controlled, and pain-free manner.
If you end up on the stress fracture end of the spectrum….it could potentially be 2-4 months.
Can you start to see how an pinch of precaution can be a pound of prevention?
(I'm not sure that's actually how that cliché goes, but we're sticking with it now. You get it. )
The point is: the more you learn and the more you Dare to Train Differently, the better you get at understanding what your own body is telling you.
But onto probably the most important part of this blog post:
Hold Up! Are my "shin splints" actually stress fractures?? How do I know the difference?
Let off the panic button.
Let's take a look down logic alley:
Yes, shin splints (MTSS) and BSI's are BOTH:
Hurt with running
Tend to go away after your workout is over
Can happen in that same general shin area
Feel achey, sore, and deep
And might test positive with all of the tests above
But there is a difference!
Shin Splints (Medial Tibial Stress Syndrome) Symptoms:
Are usually spread over a larger and more "vague" area, for example:
"the whole front of my shin"
"it sometimes wraps around to the inside of my leg"
"it's only the lower vs upper half of my shin"
"sometimes the pain moves around"
Symptoms are also typically more tolerable (read: you're more likely to just "push through it" and keep going…for months.)
Can actually go away after your warm up (when you pay attention, you might notice a decrease in intensity of symptoms; this is definitely a sign it's NOT a stress fracture)
Stress Fracture symptoms:
That your symptoms progressively get worse the more you run
You're able to point to a very SPECIFIC spot where it hurts
That specific spot still lingers…after you run.
Can you feel the panic deflate now?
Let's give you some action steps...
If you want to learn more about shin splints, check out this blog HERE.
If you're looking for a way to nip some potential, low-grade shin splints in the bud, you're going to benefit from the exercise I have in this blog HERE.
And if you want to PREVENT stress fractures and shin splints, use my tried and true exercises I use every day in the clinic, click HERE for my Stronger Feet Workshop.
But after reading this blog post, you've come to the conclusion you're probably struggling with a potential stress fracture,...
Go take care of yourself.
Make that doctor appointment.
Go see a PT.
You're worth it.
You deserve medical care.
You deserve to run pain free.
If you need a little extra motivation or an online-running buddy to hold your hand, I'm always here cheering you on.
Until next time…
Dare to Train Differently,
Marie Whitt, PT, DPT //@dr.whitt.fit
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