Anna Boniface speaks to the ‘Running Physio’ about a runner’s worst nightmare – a stress fracture.
Tom Goom aka the ‘Running Physio’ has been a runner since his teenage cross country days. With a marathon PB of 3.12 his interest in running expanded into his physiotherapy career.
As an expert in running injuries, he has written extensively on the topic, shares his knowledge with healthcare professionals around the world, and also delivers his ‘Running Repairs Course’ internationally and online.
Here Tom gives his insights on the common causes and symptoms of a stress fracture, as well as his recommended treatments to help you return to running.
Anna Boniface: So Tom, what is a stress fracture?
Tom Goom: A stress fracture is an over-use injury. Running is bone loading and overtime it adapts to become stronger. If training is increased too quickly or nutrition and recovery are inadequate, the bone isn’t able to adapt quickly enough. A ‘stress response’ can then occur.
This initial stress response is thought to be inflammation on the bone surface. This can progress within the bone marrow and this can end up as a true stress fracture.
Bone stress injuries vary in severity but they are all on a ‘continuum’. They vary from mild stress reactions through to full stress fractures.
AB: Is shin splints a stress fracture?
TG: ‘Shin splints’ is an umbrella term to describe a number of injuries in the lower leg. ‘Medial Tibial Stress Syndrome’ is thought to be a bone stress reaction along the inside of the tibia (the larger bone in the lower leg).
They vary from mild to moderate stress responses but a stress fracture can also occur in this area.
AB: What are common causes or risk factors for runners getting bony injuries?
TG: Injury can occur when the stress on the bone exceeds its ability to cope. Research suggests that 60-70% of running injuries are caused by training error.
A change in stress that is placed on bone can increase the risk, for example:
– Rapid increase to training volume and frequency
– Change in intensity and type of training
– Running technique e.g. narrow stride width or overstriding.
However, there are factors to consider which impacts the bone’s ability to manage stress. These include:
– Low energy availability and RED-S impacting hormonal health, menstrual status and bone mineral density
– Inadequate recovery and sleep impacting bone adaptation
– Fatigue increasing bone loading
– Muscle weakness for example, gluteal weakness has been a factor contributing to medial tibial stress syndrome in females.
AB: Where are common places to get a stress fracture?
TG: In track and field athletes the tibia is often most common. However, stress fractures in the foot and around the pelvis are common.
AB: What are the key signs and symptoms, how quickly should action be taken?
TG: Bone stress injuries can present differently between individuals. If in doubt, get it checked out.
Key signs and symptoms include:
– Pain with impact that worsens throughout activity
– Difficulty weight-bearing and pain on walking
– Swelling/ bruising
– Night pain
– Bony tenderness
– A history of increasing bone loading, for example, a sudden increase in running mileage.
High-risk stress fractures such as the neck of femur and navicular can progress into true fractures. If suspected, research recommends an urgent X-Ray to exclude a full fracture. They can’t be used to rule out stress fractures, therefore gold standard diagnosis is with an MRI scan, which can also help guide injury management. Low-risk stress fractures can be guided by symptoms rather than an MRI.
AB: How should a stress fracture be treated?
TG: Treatment should always be individualised to the athlete’s goals, type and severity of stress fracture. Offloading through rest from impacting activities is required for the bone to heal. Non-weight bearing cross-training and strength work can continue but needs to be adapted to symptoms and injury location.
When weight bearing pain settles, high impact cross-training can be introduced and loaded strength work can begin. This is a useful time to identify any muscle weakness and strengthen muscles that manage load in the injured area.
Once the day to day activities are pain-free (approximately six weeks) we introduce light impact drills two-three times a day for a total of two-five minutes (see sample programme below). Impact activities are essential to stimulate bone adaptation. In the later stages, we can add higher impact multidirectional plyometric drills.
They can help restore power and bone’s stress tolerance to load in multiple different directions.
Hitting the ‘sweet spot’ requires a careful balance. Too much load can lead to a response but too little can reduce bone density and strength.
At each stage of the rehab programme, the appropriate load needs to be prescribed to optimise bone health.
With high-risk stress fractures, a more conservative approach is needed. These often require a duration of reduced weight-bearing with crutches and/ or a protective boot. Cross-training can continue but under medical guidance and will vary case to case.
Once symptoms improve and there is MRI evidence of healing, a similar rehab programme can begin and weight-bearing can commence.
AB: Is complete rest ever advised?
TG: If training is likely to interfere with healing an initial rest period is recommended. For example, in RED-S cases where energy deficit has impacted bone health, a period of rest whilst addressing the energy availability issue is essential.
Psychological aspects are important to consider. Many athletes feel as if they have lost their coping strategy for stress management. Some may even have a form of exercise addiction which may have contributed to the injury in the first place.
AB: When can an athlete start getting back to running?
TG: An accurate timescale is difficult to predict. A study in 2017 reported: “the expected time to return to full unrestricted athletic participation after diagnosis of a stress fracture is 12 to 13 weeks for all injury sites.” This can give us a rough indication, however, an individualised approach is essential. The athlete must be physically and mentally ready to return to running.
Useful markers we usually recommend:
– Walking pain-free for 30 minutes
– Achieving rehab goals
– Hopping for 30 seconds pain-free
A run/walk approach is used initially, typically starting with a few minutes and distance is increased gradually whilst monitoring symptoms. With time the walk breaks can be reduced and removed. Once distance goals are achieved we look to restore intensity and speed.
AB: Are there risks of getting further fractures?
TG: Unfortunately, you are at higher risk for future stress fractures. This can be reduced by ensuring well-planned training with careful progression that’s supported by optimal recovery, sleep and nutrition.
Incorporating regular strength work can also reduce this risk and improve performance. Train smart. Recovery well. Get strong!