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, coach, and/or nutritionist.

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. I found a great article in Running Times that addresses this issue. In the article ("Is it a Stress Fracture?") Tim Noakes, MD listed four symptoms of a stress fracture:
"1) it comes on without warning; 2) there is no other obvious explanation; 3) 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'; and 4) it fails the 'hop' test, which means it hurts if you hop on the injured leg (don't try this if you suspect a hip stress fracture)."

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 found 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!

For 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 and I would not have been able to afford it if the insurance company had not paid for it. Luckily, 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 right leg with my hands to put it in the car. By the time I arrived home, I could not walk. I had to call my husband home from work to help me out of my car and carry me inside. 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 right pubic symphysis (a pelvic bone)
* 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). 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 stress fractures. 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.

An interesting side note on pubic ramus 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 pubic rami 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. Actually, when you look at the diagram above, that makes sense. Look at all the muscles/ligaments/tendons attached at or near the pubic ramus. Many of them go down and attach at various points along the thigh and at the knee on the other end. So 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 at the pubic arch seemed to be good indicators of the pelvic stress fracture in my case.

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. So I'm still not healed and am wondering why it's taking so long. A well-known doctor told another runner (pelvicstressfractures.blogspot.com) with the pubic ramus 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. However, there was one success story where a runner was able to start running again at 14 weeks.

Because the 2nd doctor and the associated physical therapy were not in my network, there were quite a bit of out of pocket expenses. In order to save money I put off getting the recommended blood tests done. However, at 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. I am very curious what the Vitamin D test will show, since I have been supplementing for almost 4 months now.

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, I could be prolonging healing by continuing my cross-training activities. I just don't know. Since my doctors can't agree on this, I'm assuming they don't know either. I'll know the answer when I can run again. In the meantime, I'm letting pain be my guide. I don't take any medication, so I know right away if something hurts.

In the words of runner Ben Cheever "I'm an American and know that every crisis requires a purchase." He said this in regards to a long term injury that would not heal. Like most of us, he went out searching for answers by purchasing various miracle products (e.g. the Sacro Wedgy, MBT shoes, foam roller) and by trying several different doctors with different therapies. His article appeared in the recent issue of Runner's World and it was both entertaining and eye-opening.

Like Mr. Cheever, I also felt that my stress fracture crisis required that I "do something" to be proactive. Since I wasn't allowed to run, I purchased the following items that I hoped would aid my recovery. The jury is still out on whether anything helped or whether it just made me feel better to do something proactive:

• The Bone-Building Solution: A book by Sam Graci, Dr. Carolyn DeMarco and Dr. Leticia Rao. The premise is that a processed food (acidic) diet causes your body to break down the minerals in your bones to act as a buffer: "When we consume processed, fast, convenient foods and forgo our traditional salads, vegetables, fruits, berries, whole grains, and the recent addition of 'green drinks', our bodies' biochemical processes becomes exposed; they are under siege by dangerous acidification. To counter the potential, modern-day physical destruction caused by repeatedly consuming caustic, acid-forming foods, your bones break down and dissolve, releasing calcium, potassium, and sodium from the bone matrix to form chemical buffers or anti-acids called bicarbonates to soak up and neutralize the acids. The result: weak bones, poor tooth enamel quality, brittle nails, kidney stones, cardiovascular disease, heart disease, and a dissolving backbone." Of course, they are promoting a product (Greens+ supplements), but they do provide references and studies for their statements and assumptions. In any case, most of the nutritional literature I have read recommends a more natural (unprocessed) diet with fruits and vegetables.
• Greens Plus® With Wild Berry, 9.4 oz powder: A line of supplements by the author of the above-mentioned book. I use their Wild Berry Burst Powder which mixes with 8 ounces of water to provide a total of 165 mg of the highest ORAC-rated* Antioxidant Fruit Extracts per serving. "One daily serving of GREENS Plus® Wild Berry Burst delivers the nutritional equivalent of more than five full servings of fresh fruit and vegetables...[and] provides food source vitamins and minerals, in their biologically complex form, as nature intends them to be."^*2
• Rainbow Light Food-Based Calcium Tablets: A food-based natural calcium supplement (no artifical color, flavors, sweeteners, or preservatives) that "delivers 500 mg calcium and 250 mg magnesium in just one tablet, with Vitamin D and glutamic acid HCL, natural cofactors to ensure assimilation, plus botanicals with a natural concentration of minerals, such as horsetail, nettles, and organic spirulina."^*3 Based upon my doctor's recommendations for my age/health, I take two of these a day in order to result in maximum absorption. "The percentage of calcium absorbed depends on the total amount of elemental calcium consumed at one time; as the amount increases, the percentage absorption decreases. Absorption is highest in doses <= 500 mg."^*4
• Vitamin D: The article in the July/August 2009 Running Times indicated that if your Vitamin D is too low, your body can't assimilate calcium properly. This is why a bone in Deena Kastor's foot snapped like a twig during the Beijing Olympics. "Although her calcium levels were normal, her body was unable to assimilate the bone-building mineral because she was too low in Vitamin D."
• Whole Foods Unsalted, Dry Roasted Almonds: Because of the possible link between a low fat diet and stress fractures, I added in this healthy "fat".
• Tomato Sauce (Lycopene): Lycopene, the antioxidant that gives tomatoes their red color, may benefit bone health in men and women. A recent study found that taking more than 10mg of lycopene per day helps maintain bone density, compare to taking only 3 mg per day.
  

In addition to the above products, I have reviewed the running form information in both 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 gentle stretching 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 cycling and deep water running are helping to keep up my cardiovascular fitness as well as providing increased blood flow/oxygen to the soft tissues and bone. However, I haven't found anything that keeps my cardiovascular fitness at the same level that running did. It could be due to the fact that I'm not an experienced cyclist. Possibly once I am able to keep a faster pace for longer distances and up hills, I may be able to attain close to the same fitness I had with running.