Always check with your doctor prior to starting/modifying any exercise/nutrition program. The information presented on this site constitutes my opinions/viewpoints and should not be used as medical, personal, training, or professional advice.
"It's like driving a car at night. You never see further than your headlights, but you can make the whole journey that way." --E.L. Doctorow
Boston Marathon 2010
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stress fractures in the runner
Stress Fractures...At A Glance

Symptoms

* From Tim Noakes, MD in the article "Is it a Stress Fracture" in Running Times: "you can sometimes find a spot on the bone so tender that pressing on it will produce a pain he describes as exquisite or nauseating".
* Per elite runner Dathan Ritzenhein: "If it doesn't feel better as a run progresses, it's probably a bone."
Diagnosis

* X-Ray (may or may not show stress fracture)
* MRI (usually best at stress fracture detection and most expensive)
* Bone Scintigram with injectable tracer (good option, but for stress fractures it doesn't provide the level of detail/healing status as the MRI)
Other Tests

* Bone Density Scan to rule out osteopenia/osteoporesis
*
Blood tests to measure Vitamin D, calcium, hormones, thyroid, and kidney function.
Anatomical Distribution of Stress Fractures in Runners*6

1 Tibia (55%)
2 Metatarsals (23%)
3 Fibula (14%)
4 Femoral Neck (4%)
5 Pubic Arch (2%)
6 Femoral Shaft (2%)
 
Causes

* "Bones are constantly attempting to remodel and repair themselves, especially during a sport where extraordinary stress is applied to the bone. Over time, if enough stress is placed on the bone that it exhausts the capacity of the bone to remodel, a weakened site -- a stress fracture -- on the bone may appear." *1
* Bones and the tendons and ligaments that attach to them that haven't been given enough time to adapt to increased mileage, increased intensity, and/or hard running surfaces can lead to stress fractures. Tendons attach muscles to bones and ligaments attach bones to bones. If you injure one of these soft tissues or don't allow them time to adapt, they can exert too much or improper force on the bone(s) and possibly result in a stress fracture.
* Poor/Improper Footwear
* Improper Running Form
* Weak and/or Fatigued Muscles: "Strong muscles are better shock absorbers and don't tire as easily. That's important because, as podiatrist Stephen Pribut notes on his website, tired muscles transmit more stress to the bones."
* Decreased Fat Intake in Female Runners
* Inadequate Calcium/Vitamin D Intake
* Inadequate Nutrition/Overly Acidic Diet
* Low Bone Density and Menstrual Irregularities
* Cambered Running Surfaces: Most roads are cambered to allow drainage, which puts additional stress on the soft tissues as one leg is landing higher than the other. Asphalt roads are thought to be 40% to 60% softer than concrete, but some experts think it's better to run on level concrete than a cambered asphalt road.
* Hard Running Surfaces: Too many miles on hard running surfaces without giving the body time to adapt has been linked to stress fractures. Additional information on running surfaces can be found at: Concrete vs. Asphalt, Part I and Part II.

Running surfaces listed in order from softer to harder:
* Sand
* Grass
* Packed Dirt
* Rubber Track
* Crushed Gravel or Limestone
* Blacktop/Asphalt (many roads) - Camber may be a factor in pelvic injuries.
* Concrete (many sidewalks)
How Long will it Take to Heal my Stress Fracture?*7

* Fractures of the foot bones usually heal within 6 weeks, with an increased healing time as one moves up the bones of the leg.
* The tibia and femur may require 8 to 12 weeks.
*
The pelvis may require 3 to 4 months, if not longer.
* Other factors (e.g. continuing to put weight on the bone, nutritional, hormonal or metabolic deficiencies) can increase the healing time.
Possible Stress Fracture Treatments

* Rest from weight-bearing activity for a "period of 4 to 8 weeks, although periods of rest of 12 to 16 weeks is not uncommon for more severe stress fractures." *1 "If a stress fracture occurs in a weight-bearing bone, healing will be delayed or prevented by continuing to put weight on that limb." *1 Note: On a personal note, my pelvic stress fractures took over 12 months to heal.
* Providing support to the limb with an AirCast may help take some of the stress off the fracture. The AirCast has pre-inflated cells that put light pressure on the bone, which reduces edema and promotes healing by increasing blood flow to the area.
* For more severe stress fractures (e.g. femoral neck stress fractures), especially those that may result in a complete fracture, crutches may be prescribed.
* An ultrasound bone stimulator may be prescribed to aid in healing the stress fracture.
Possible Cross Training Options

Usually you're told to avoid weight bearing exercise. If your doctor says it's okay, I've found deep water running and the exercise bike allow me to maintain fitness and emulate running without bearing weight. Check with your physician, but other non-weight bearing exercises (e.g. rowing) may also be allowed.
* Deep Water Running
* 9 Week Water Running Plan

Returning to Running

This is the hard part. Previous stress fractures have been cited as a risk factor in new stress fractures. When the runner is allowed to run again, the return should be gradual in order to allow the bones and soft tissues time to adapt. "Moderate stress applied to the bone in a controlled manner can strengthen the bone and make it less susceptible to a stress fracture." *1
* Returning to Running After a Stress Fracture or Other Major Injury
* Return to Running Program
* Stress Fractures in Female Runners: Returning to Running
* Strength Training may help since fatigued muscles transmit additional stress to your bones.
* If there doesn't appear to be an obvious cause for the previous stress fracture (e.g. sudden mileage increases, running surfaces, inadequate footwear, inadequate nutrition), some experts recommend having a gait analysis done to determine if a runner's biomechanics may be a contributing factor to injury.

Since I have had one fibular stress fracture and two pelvic stress fractures, this is a topic of great interest to me. But let me preface this article by saying that I am not a doctor, nurse, or medical professional, and I have no medical training.

I am just a runner who unfortunately ended up with 3 stress fractures in 3 months, which led me on a quest to obtain as much information about this type of injury as possible. This article shares the information I have found but it in no way should be used in place of the care/recommendations of your health care provider.

Before I was officially diagnosed via x-ray and MRI with a stress fracture, I wondered how to tell the difference between a soft tissue injury, bone bruise, and a true stress fracture. An article in Running Times titled "Is it a Stress Fracture?" addresses this issue. However, the "hop test" isn't recommended if you suspect a hip stress fracture or think it might further aggravate the injury. Check with your physician if you're unsure.

Elite runner Dathan Ritzenhein has an even simpler test: "If it doesn't feel better as a run progresses, it's probably a bone." I've actually AirCastfound this to be the case with all 3 of my stress fractures. My soft tissue injuries would feel better as the run progressed with increased blood flow to the area of injury. My bone injuries became much worse as the runs progressed. I don't know how scientific this all is, but it certainly applied in my case. With the pubic ramus stress fracture, the first sign I had that something was amiss was when I could not stand on the leg on the affected side to put on shorts/pants. I had to sit down to get dressed!

Exogen Bone StimulatorFor the fibular stress fracture, I was given an aircast to wear (photo above) and an Exogen Ultrasound Bone Healing System (photo right) to help the bone heal. Something worked (either time, the bone stimulator, or aircast) because my fibula had healed within 4 weeks. The aircast has duplex aircells that provide graduated pneumatic compression and the pressure pulsates when walking.  It encourages recovery by enhancing hydraulic support and reducing swelling and edema. At least that's what the literature says. The Bone Healing System was really expensive, but luckily my insurance covered it. It can continue to be used on other stress fractures, although I had hoped I would not need it again.

On April 14th of 2009, I was still planning on running the Boston Marathon in less than a week, but my last several runs had produced a lot of pain. I realize now that I was in denial. My 2 week taper with shorter runs allowed me to think that I could still run Boston. However, during my last run the pain was so bad at mile 5 that I stopped and could barely get back to the car (less than a 1/4 mile away). I had to lift my leg with my hands to put it in the car. I used crutches for the rest of the day and broke my policy of avoiding medications (over the counter or prescription) by taking the anti-inflammatory Aleve. By the next day, I was able to walk, but with a limp.

The following day was my recheck appointment on my fibula. As I limped into the exam room, I mentioned the hip and groin pain. The first x-ray indicated that the fibula had healed. The second x-ray revealed one and possibly two stress fractures in the pelvis. An MRI the following day revealed:

* Fracture of the pubic symphysis (a joint that connects the two halves of your pelvis)
* Fracture of the right inferior pubic ramus (a pelvic bone where the hip adductor attaches).
* Partially torn right hip adductor tendon
* Injury or subtle avulsion (tearing away) of the left hamstring tendon at the ischial tuberosity (where the tendon connects to the pelvis)

The doctor told me "no running for 8 weeks". He also said to increase my calcium and Vitamin D intake. In addition, I found a link between a low fat intake and injury in female runners. Consequently, I started adding in the "good fats", such as almonds, in my diet. They did a bone density test at the hospital and that turned out normal. So I honestly think my problems were due to nutrition (too little calcium, vitamin D, and good fat), mileage (not enough base building), and running surfaces (too many miles on cambered roads and hard surfaces). According to the sidebar at the right (anatomical distribution of stress fractures), my stress fractures were in 3 of the less common areas for runners. That makes me think that inadequate nutrition was as much of a factor as repetitive strain in my fractures.

The doctor said I could do non-weight bearing cross-training such as deep water running and the recumbent exercise bike but to avoid the elliptical and weight bearing activities. It was a long 8 weeks! However, I found a great article on deep water running and how it could be used to maintain cardiovascular fitness for up to 8 weeks. The article even gives a 9 week water running plan with intervals and "water tempo runs".

I tried running again at 8 weeks and found that I was still not healed. Further research revealed that pelvic stress fractures take much longer than other (non-core) stress fractures to heal. I sought a second opinion at another doctor who told me that pelvic stress fractures may take 12 to 16 weeks to heal if there aren't other factors involved (e.g. nutritional deficiencies, metabolic disorders, hormone imbalances, pelvic tilt/gait imbalance). It actually took over a year for my pelvic stress fractures to heal. From reading the experiences of other runners with pelvic stress fractures on the Runner's World forum, this length of time is not uncommon.

The second doctor did not want me doing any activity for several weeks (even non-weight bearing). He recommended physical therapy for my pelvic tilt which is what he believed was one of the causative factors in my stressfractures. He also recommended that I get hormone, metabolic, and Vitamin D tests done to make sure all of those values are in the proper range to allow bone remodeling.

ChiRunning Intermediate MarathonAn interesting side note on pelvic stress fractures is that the referred pain from the fracture actually resulted in groin, knee, and thigh pain for me. I thought I had additional stress fractures in the knee or thigh, but the bone scintigram ruled that out. From reading the experiences of other runners with pelvic stress fractures, the groin, thigh, and/or knee pain are not that unusual. Every attempt at running before the fracture healed resulted in the return on my groin, thigh, and knee pain, as well as the inability to bear all my weight on the leg on the affected side. There are several tendons (and their associated muscles) with attachment points on the pelvis. Many of the tendons attach at various points along the thigh and at the knee on the other end. Tendons attach muscle to bone; ligaments attach bones to bones.

It makes sense that the knee might not track properly if the muscles/tendons are overcompensating due to a stress fracture at the pelvic connection point. Of course, there could be several other causes for knee, thigh, and groin pain, but those in combination with the bone pain in the pelvis seemed to be good indicators of the pelvic stress fracture in my case. For an understanding of referred pain, think about where it hurts if you pull on your hair at the tip. It doesn't hurt where you're pulling the hair. It hurts at the attachment point (the scalp).

After 13 weeks, I tried a two mile run. I completed the run but it set back my recovery. I limped for a week and could not put all my weight on the affected side. I still wasn't healed and couldn't understand why the healing process was taking so long. A well-known doctor told another runner with the same stress fracture that it could take 6 to 11 months to heal and to avoid activity. Many of the runners on this pelvic stress fractures blog have been out several months. The pelvic stress fractures forum on RunnersWorld.com has been a great source of comfort and information to me.

ChiRunning Intermediate Half MarathonAt 15 weeks I was still not healed. I had just read the article in the July/August 2009 issue of Running Times about Vitamin D and stress fractures. That made me decide to get the blood tests done. I went to my "in network" doctor and requested several lab tests, including the 25-hydroxyvitamin D test. My vitamin D levels were low, which the doctor thought may have been preventing me from absorbing the calcium that my body needed.

Since I've received different advice from two different doctors, I wasn't sure whether to do non-weight bearing activities. I finally decided to let my body be the guide. Of course, my cross-training activities may have prolonged the healing process. I just don't know. Since my doctors can't agree on this, I'm assuming they didn't know either. I decided that I would know the answer when I could run pain-free again.

My time off from running allowed meto really study running surfaces and running form and revamp how I run, I have reviewed the running form information in the Pose Method of Running, Run for Life, and ChiRunning so that I can continue working on maintaining the lower-impact, injury reducing, efficient running form described in these books. Apparently, the way you run can reduce shock to your knee by as much as 50%!

I am also doing strength training and dynamic flexibility exercises in the hope that my muscles, ligaments, and tendons will provide my bones with the kind of support they need. "Strong muscles are better shock absorbers and don't tire as easily."*9

The pelvic stress fracture is somewhat like a cut on your hand between your thumb and index finger. Every time you use your fingers, it pulls apart the cut and opens up the skin trying to heal. I think that's a similar analogy to a bone with a crack in it. When you look at the diagrams above, there are many tendons attached to the pelvis. As you use the tendons, muscles, ligaments, they pull on the bone where it's trying to heal. I think that's why they tell us to avoid activity to let the bone heal. Of course, the down side of complete rest is that you have to return to walking and then running very gradually once you heal. The bones have to get used to weight bearing activity all over again or you risk another stress fracture. It's a long process to recover from a pelvic stress fracture, but looking at it from the other side, I believe I'm a better (and wiser) runner because of the experience.

 



*1 Wikipedia, Stress Fracture
*2Greens Plus® Web Site Literature
*3Rainbow Light®Web Site Literature
*4NIH Ofice of Dietary Supplements: Calcium Fact Sheet
*5 Running Times, July/August 2009: The Vitamin D Dilemma
*6 Adapted from Orava et al. 1978, p22), ©Elsevier Science
*7 Lore of Running by Tim Noakes, MD
*8 Run for Life by Roy M. Wallack
*9 Stephen Pribut, MD
*10 Pelvic Myoneuropathy