Breaking Point: Navigating Stress Fractures in Athletes🏃‍♀️🦴

Dr. Jennifer Greene, PT, DPT, CFMT

Are you a Runner? A Lifter? Have you had any changes to your fitness routine that have significantly changed your activity levels? Well, if you are any of these, and you tend to exercise without a lot of rest.....this article is for you.

As an active person myself....I enjoy running, lifting, being productive and getting things done! So, even on days when I enjoy running about 6 miles, I love getting in an extra walk and also cleaning the house. I might even throw in a workout! And that isn't necessarily abnormal for me.....

I go from heavy lifting to running long runs the next day, and I do throw in some lighter workouts in between.....but what I don't do a lot of is...rest...

Recently, my body began to experience some things I never really experience: Pain and discomfort with running and walking....a Day of soreness that I could hardly move....and it didn't really go away. The soreness did, the discomfort in my bones did not. This was something that I have never really had to deal with?! Me??? These things don't happen to me....

Well....just like everybody else in the world, I am no exception to life and it's surprises. Although I would like to think I am...these experiences humble me back to reality.

In the last month, I have gone through this similar experience three times. Twice due to my running. Limping around for a day at work...hardly able to move from a long and hard workout. And the pain not going away. I had an idea of what it might be, but I didn't really want to accept it. I still don't. I actually have still not gotten an X-ray. Not yet....I think I know what it is. I know what they will tell me...Give me a boot and tell me not to walk for 6 weeks. OR don't give me anything and tell me that I can walk, but only minimally....it depends on the doctor...but I'm pretty sure I have a stress fracture, or the part that happens just before that. So I thought I would use this experience to help you.

What is a stress fracture??

A stress fracture is a tiny crack in a bone, often caused by repetitive force or overuse. These fractures typically occur in weight-bearing bones, such as the lower leg and foot. The pain associated with a stress fracture tends to worsen with continued use until it begins to affect your walking and ADLs, and you will notice pain and tenderness that is localized around a specific spot. Some common areas are: Your Foot, Your Tibia, Your Fibula and Your metatarsals. It can also occur in your femur.

It may be also associated with Shin Splints or Medial Tibial Stress Syndrome

Factors that increase the risk of stress fractures include engaging in high-impact sports, sudden increases in activity, certain foot conditions, and repetitive heavy lifting/lifting.

You see, the main issue is the repetitiveness of the activity, or not allowing your body to appropriately adjust to the activity. You may be wondering...why? Why is this so important??

Well with exercise and activity, your bones become denser by responding to the forces placed upon it and remodeling.

As Yu Yuan, Xi Chen, et. al wrote in ' The roles of exercise in bone remodeling...': "Exercise increases bone mineral density, bone mass, bone strength, and bone mechanical properties. It seems to directly or indirectly act on almost all the bone cell types and affect many aspects of bone remodeling. Cumulative evidence suggests that exercise promotes bone formation by stimulating MSC osteogenic differentiation and the activities of osteoblasts and osteocytes, where exercise-elicited mechanical loading and the Wnt-Catenin and BMP pathways seem to play an important role.''

If exercise is good for bone formation, how does overuse and over-exercising cause damage?

One of the ways your bones and muscles get stronger with exercise is that they break down a little bit during the activity. They break down and then they build themselves back up on their rest days your rest days and build back up to their normal strength, and get stronger over time. This is normal.

When you are over-exercising, you are 1. not giving the bone enough time to rebuild and get stronger and 2. Your muscles may also be becoming so fatigued that they are unable to really assist the bone in absorbing the shock of the forces added during activity, causing more stress that is added to the bone, which then may lead to a tiny crack called a stress fracture.

Other Risk Factors include (per OrthoInfo.aaos.org)

Non-modifiable risk factors include:

• Biological sex: Females are at higher risk than males, but bone stress injury is common in both.

• Race: White people have lower bone density and weaker bone structure than other races.

• Age: Bone stress injury risk increases with age.

• Genetics: You may have a higher risk of a bone stress injury depending on how your genes are expressed to control bone health.

• Alignment: Different degrees of foot arch height, foot length, leg length, and knee alignment can increase risk.

• Prior injury: An injury significantly increases your chances of having another injury in the future.

• Female athletes in cross country, gymnastics, and outdoor track; these athletes have the highest rates of stress fractures.

Modifiable risk factors:

• Strength: Weak muscle cannot absorb as much force, so the force is then put through the bone.

• Fatigue: Tired muscles and a tired body are not able to absorb forces which are then transferred to bones.

• Flexibility: Tight muscles and stiff joints will not absorb as much force, sending the force through the bone.

• Biomechanics: The way you run and jump can change the force transmitted from the ground through the body.

• Low energy intake (relative energy deficiency in sport, known as REDS): Not taking in enough fuel for your level of exercise will increase the risk of developing a bone injury. Learn more: Sports Nutrition

• Recovery: Those who get less than 7 hours of sleep each night and do not take rest days (days where you do not exercise) are at higher risk for stress injury.

• Nutrition: Low levels of Vitamin D may lead to poor bone healing.

• Footwear: Worn-out, poorly cushioned shoes may increase risk.

• Training surface: Hard surfaces without spring (like concrete) will increase force through the body

• Volume and intensity of training (this is known as training load): Starting new running or jumping activities that your body is not used to will increase risk.

• Osteoporosis or similar conditions that cause a decrease in bone strength https://orthoinfo.aaos.org/en/diseases--conditions/stress-fractures/#:~:text=A%20stress%20fracture%20is%20an,developing%20a%20bone%20stress%20injury.

So, how do you know you have a stress fracture??

Common symptoms involve the following:

1. Pain/Discomfort in a localized spot on your leg, foot or other bone.

2. This pain goes away with rest at first, however in time, it does not go away with rest.

a. You begin to experience these symptoms at rest, with walking, and even with sleeping

b. You may notice swelling and bruising

c. Sudden difficulty walking on hard surfaces and bearing full weight on that extremity.

d. No significant changes with massage or soft tissue work.

How do you confirm a fracture?

It is recommended you see your doctor to confirm. The MD will take imaging, likely an X-ray or even an MRI to confirm the fracture. Sometimes, these fractures are very hard to detect due to their small, hairline nature.

How do we treat a stress fracture?

Treatment varies depending on the location and severity of the stress fracture.

Ideally, since the injury is caused by overloaded stress, treatment is focused on unloading the bone and allowing the bone to heal and remodel.

• Rest from the activities that are causing the fracture. That means NO running.....limit walking and try to unload the leg with walking.

• If the bone does not heal, then surgery may be an option, but this would be a last resort. I would suggest you just take the time to heal right and avoid the activities.
  

How long will it take?

Bone stress injuries usually can take anywhere from 3 weeks up to 3 months or so to heal.

Those fractures that have been more chronic (present for long periods of time) will likely take longer to heal.

"Although it can be hard to rest, resuming activities too early can make the injury worse and delay healing.Pain is used as a guide to determine how your injury is healing. If you have a fracture, your doctor may order repeat X-rays or a CT scan to assess healing." (per orthoinfo.aaos.com)

"When a doctor has cleared you to return to sports activities,  your return must be slow and gradual so your bone can adjust to the increase in load. It may take many weeks to slowly increase the frequency, duration, and intensity of exercise to get back to your full activity level."(per orthoinfo.aaos.com)

So how do we AVOID a stress fracture? How are we able to be proactive and prevent this?

GIVE YOUR SELF RECOVERY DAYS!!!

Let's read that again....this may be for me more than you...

GIVE YOUR SELF RECOVERY DAYS!!!

One more time...

GIVE YOUR SELF RECOVERY DAYS!!!

• Allow yourself rest. Allow yourself to recover. If you don't want to allow yourself to recover, at least let your bones recover! Do it for your bones!
  

• Allow yourself time to adjust to a new schedule and to your new routine. Give yourself a number of weeks to months to allow your body to adjust to the force of the new exercise and activity. Better yet, cross train! Give yourself days where you do cycling instead of running. Or swimming!
  

• Eat enough food and nutrients and calories, Optimize Vitamin D, Calcium, Vitamin C for healing.
  

As for me, I am trying to accept decreasing my activity level....It is hard. It is very hard. So, if you want to joint me on social media, I am going to be sharing a few parts of my little journey to see what I can do to keep living my life and doing things that I love while also allowing my body to heal.

Until next time!

Sincerely,

Dr. Jennifer Greene, PT, DPT, CFMT