Managing stress fractures is difficult. Anyone who tells you different is lying or does not fully understand the many variables that go into their development or rehab. Personally, I feel like they are the hardest running related injury to treat.
Endurance sports tend to self select a lot of very self motivated people. It takes disciple and drive to be able to dedicate a large portion of your week to running, cycling or swimming. Anytime you see an athlete setting a PR or standing on a podium, you need to understand the massive amount of time and dedication that got them into that position.
When things go sideways and a stress fracture develops, it can be hard to adjust the approach that often allowed them to get to that point in their training. Once a stress fracture is diagnosed, running is often taken off the table for a period of time to allow the fracture to begin healing. The tendency for many endurance athletes is to immediately shift their time spent running into another training modality.
I can understand this mindset and this is my personal default in training too. Maintaining some level of fitness is good mentally for a lot of endurance athletes, but it also runs the risk of making them underprepared for when they are able to run. I’m not saying don’t ride a bike, swim, etc during the recovery process. What I am saying is that our goal doing rehab is to put your skeletal system in the best possible position to deal with the muscular contractions and shock attenuation that are present when we run.
One of the most frustrating parts about stress fractures is that they are often painless once we remove the aggravating activity. Stop running, and your shin stops hurting. For many endurance athletes, this is false hope. A couple weeks off, plug into the bike, pool or anti gravity treadmill, and then they go back to their previous training. Lather, rinse and repeat.
I appreciate the dedication from the runner that bikes for two hours or runs 90 minutes in the deep end of a pool. While these training modalities may feel good physically and mentally, they do not put the body in a position to deal with the demands of running. They may be good for maintaining a certain level of cardiovascular fitness, but limited cardiovascular endurance is rarely the cause of a bone stress injury.
Bone is never metabolically stable. It is always changing and adapting to the different forces we place on it. Playing basketball, going on bed rest or putting in a four week block of running fundamentally changes our bones makeup for better or worse. This is important to remember because when we are non weight bearing, or even just not running, our bones are not in as good of a position to handle the loading of running. We might not have pain, but our bones are not better able to deal with the demands of running that led to the stress fracture to begin with.
There are a massive amount of variables that go into bone health and the potential factors going into a stress fracture, but a stress fracture is a sign that something needs to change. In my opinion, it is inappropriate management to simply say rest for X number of weeks and then ease back into training. We need to actually change a variable or we will be in the same situation again.
It can be a hard pill to swallow that a mistake was made and change is necessary. This could include a consultation with a dietician, a change in training approach or maybe a more comprehensive lifting routine. For many athletes it highlights the importance of training stimuli and nutritional strategies to prepare the skeletal system for the demands being placed upon it.
Load the Affected Area
The main goal of the rehab process for a BSI should be a continual progression of loading through the affected area. If you have a femoral neck stress fracture, your rehab should progressively load the hip. If it’s a metatarsal stress fracture you need to progressively load your foot. This same strategy should apply to whatever bone the problem occurred in. Often this idea is lost in the rehab cycle. Maybe some low-level exercises are prescribed, but rehab is largely defined by the time from injury instead of a progressive loading strategy through the area. The forces your body deals with in running are MUCH higher than basic weight bearing or band resisted exercises.When recovering from a BSI your end-stage rehab should look much more like a quality strength program than a set of exercises on a table.
When I’m working with a patient you have to prove to me that you can run. Although we can often give you a time table into when returning to running may occur, simply being off of running for a while is not the solution to their current situation. You have to prove your tissues are ready to run. When we look over the course of a plan of care we should see a gradual progression of loading THROUGH the affected area.
In my next post, I’ll cover how I determine if a runner is ready to run depending on their stress fracture location. Thanks for reading!
Nathan Carlson PT