Stress Fracture Recovery Fundamentals

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Bone stress injuries (BSIs) are complex. I’ve highlighted this idea in many posts and videos over the last few years. Today, I wanted to shift the focus from that idea to concrete ways we can confidently say a runner recovering from a BSI can begin running. With any running injury, the first question often asked is “When can I run?”. I wanted to cover a few benchmarks I feel are necessary for runners that sustain a BSI to master before we can begin running again.

The overall idea is that you have to PROVE that your body is ready for the demands of running. There are general time frames for when specific injuries can begin running, but that time frame is not a guaranteed start date. The human body is pretty good at figuring out ways to get something done. We can shift loads to different areas, alter the way we are moving and avoid doing things that hurt. This is a positive attribute to have, but can be negative during the rehab process. Here are three concepts I think are vital for effective BSI rehab.

Progressive Drills Loading the Affected Area

If we break down bone stress injuries to the simplest cause, we stressed the body more than it could handle. This is a fundamental concept we should remember as we progress a runner through rehab. We have to make sure that area can tolerate stress, in positions similar to running BEFORE running may resume. The most common error I see in BSI rehab is that the affected area is not forced to deal with enough stress during the recovery process. 

If a runner is coming back from a BSI they HAVE to challenge the specific tissue during the rehab process.

If your BSI is in your metatarsals, you have to progress through drills that substantially load the metatarsals. If your BSI is in your hip, you have to progress through drills that substantially load the hip. We want to stress the affected tissue so it is forced to adapt and become more resilient to the demands of running. If the athlete feels apprehensive about that, they are NOT ready to run.

Here is a sample loading progression for someone recovering from a tibial stress fracture. I would expect a patient to be able to display precision with all these drills PRIOR to beginning a running progression. With this specific BSI, we want to make sure the runner can show competency with single leg tasks and activities that put their foot and ankle in various positions.

Seated Plantar flexion with Band

Soleus Press Progression

Double Leg Heel Raise

Single Leg Heel Raise

Soleus Walk with Weight

Squat Clocks

Progressive Walking OVER other Cross Training

Many runners become anxious with the idea of not training for weeks or months following an injury. Many BSIs are not painful with activities like cycling or swimming, so athletes will often move their endurance training to these environments assuming they will “lose less fitness” when they are allowed to run again. They often try to replace the time they would be spending running with some other form of cardiovascular training.

Being active is important during the “non-running” phases of recovery, but cycling, elliptical and swimming do not require the same loading parameters as running. When we run, our bones have to deal with the impact of landing on one foot as well as the muscular contractions that allow us to land and propel our body forward. Swimming and cycling may keep our heart and lungs in a little better shape, but they do not impart the same demands as running.

This is not to say do not swim or run, but there are better fitness activities to prioritize during the initial phases of injury. Progressive walking is my preferred method of cross training because it loads the body in a similar way to running even though the walking gait is not nearly as stressful as the running gait. This does not mean going for a leisurely stroll, but a brisk-paced walk that gets your heart rate up for 30-40 minutes.

In general, I want my BSI patients to be able to walk 45 minutes to an hour prior to running.

Quality Strength and Conditioning BEFORE we Return to Running

Depending on the type and severity of BSI, runners are typically prescribed a period of non-weight bearing, partial weight bearing or avoidance of impact related activities. When we run on a consistent basis, our body adapts to that consistent stress. When we stop running, everything gets weaker. Muscles, tendons and bones all lose some of their abilities because the stress of training has been removed. Because of this, my expectation is that a runner begins quality strength work prior to running. This allows these structures to maintain a percentage of their capacity during the non-running phase.

While stress fracture location, patient anatomy/preference, and many other factors affect strength prescription, I would expect most patients to be able to tolerate this regimen before we run. 

Goblet Squat

Kettlebell Deadlift

Step Ups

Lateral Toe Taps + Band

Bridge + SLR

Suspension Trainer Row

Pushup Isometric

I need runners to prove to me they can handle these three areas before we can start the process of plyometrics and running. By checking off these three areas, we know that runner is ready for the next step of the rehab process.

Thanks for reading!

Nathan Carlson PT, DPT, USATF