Here is a sample statement that I have heard from many runners over the past few years:
Runner: “Oh, I have never needed physical therapy, my only injuries have been stress fractures.” After this statement, we generally talk for a little bit longer, I ask a few questions, and oftentimes it comes up that the stress fractures have been a reoccurring injury.
People, including runners and physicians alike, think that rest (i.e., omitting running from daily activity) is the treatment for the diagnosis of a stress fracture. And, yes, rest is an important part of the healing process, however, it does not address the CAUSE of the injury in the first place.
Finding the cause of the injury is what makes me and my colleague, Pieter Kroon, tick. If we cannot identify the reason that the specific bone or tissue broke down, then we are doing you and injustice and you are likely to suffer another, similar injury. It is only a matter of miles until the same, unaddressed pattern contributes to another frustrating breakdown.
I cannot tell you the number of athletes that I have encountered that have had multiple stress fractures or stress reactions to the same bones. That should not happen! If you are able to identify and treat the cause of the injury, the injury should not return.
As expected, orthopedic physicians generally approach running injuries with their orthopedic training. If there is no physical trauma sustained, as there is with the majority of basketball, baseball and football injuries, then they get a little baffled. As a collegiate cross country and track athlete, whenever I saw the team physician for a running injury, they always said “you are just running too many miles, your body is breaking down, take a couple of weeks off.” A couple of weeks off!?!? I’m sure that several of you reading this have heard this same frustrating suggestion. Like most of you, my response was always: I am in the middle of my competitive track season, I cannot afford to take a couple of weeks off! It was very hard to hear those words and abide by that advice when something inside of me knew they were missing an important piece of the runner-injury problem. We are runners; we perform a repetitive motion over and over, mile upon mile and day after day. We are not hit or tackled or pushed in the same sense that court-sport athletes are. The cause of our injuries is a little different.
If I am truly running too much, why is it that my left fibula sustained a stress fracture and not the right? I run the same number of miles on both legs, both my left and my right foot hit the ground the same number of times and take the same amount of body weight through them. If it is truly a matter of “over training” then why are both legs not fractured? It bothered me that doctors prescribing rest could never answer that question. However, the occurrence of stress reactions/fractures can be relatively easily explained by looking closely at the biomechanics of walking and running.
In an effort to explain our thought process, I will use the example of the left fibula stress fracture, a common runner injury.
The talocrural joint (ankle joint) needs to extend15-20 degrees in order to for you to propel yourself forward during the running stride. The subtalar joint (the joint between the heel bone and talus bone) needs to invert during push off and evert 10 degrees upon landing. This is very important, as the eversion of the subtalar joint allows the midfoot to unlock during landing so it can function as a shock absorber. Then on push off, the inversion of the subtalar joint locks the midfoot, so the foot can function as a solid lever.
If there is a restriction in either one of these main joints, it throws off the shock absorbing capabilities of the foot and ankle which, in turn, can allow for certain areas to take more shock and forces than they are designed to take. The fibula is only designed to take 20% of our body weight and is frequently described as a “non-weight bearing bone.” How then, does this bone sustain a bone stress injury?? Well, if the mechanics of the foot or ankle are off, say, for example that the talocrural joint dorsiflexion is limited to only 5 degrees, then the patient will evert their foot in order to keep running and these compensatory motions can transfer more stress to the fibula. Mile upon mile, foot strike upon foot strike and the fibula will eventually break down.
When this injury is presented to a physician, they generally tell you to stop running for 6 weeks to allow the bone to heal, or worse, they stick you in a walking boot and then 6 weeks later the athlete expects to just take the boot off and start running again. The bone is healed, this injury is over, time to move on. Unfortunately, this tends to not be the case. Frequently, since the cause of the problem was not addressed (in this case, the restriction in talocrural joint mobility) over time, the stress fracture will return and the runner is now in a horrible cycle of injury, rest, injury and your season is over.
Moral of the story: If you are diagnosed with a stress fracture, see a manual orthopedic physical therapist, have your joint mobility assessed, find out which muscles are strong and which ones are weak. Spend time addressing this root cause of the injury and come back 6 weeks later ready to train and not worrying about sustaining another stress injury.
Stress fractures are initially treated by resting the leg as much as possible. Stopping or modifying activities that increase stress on the legs (eg, running, jumping, or “cutting” in sports) for at least 3 weeks may be recommended to allow the bone to begin the healing process.
Based on your specific injury and condition, your physical therapist can decide whether you should use a compressive brace, crutches, or a walking boot to protect your bone while it is healing.
Initial Treatment
Initial treatment may include muscle-strengthening exercises for the lower extremities and core, stretching exercises, and alternative cardiovascular training, such as swimming or aqua aerobics. Shockwave therapy or the use of a bone stimulator may be warranted if the bone exhibits difficult or delayed healing.
During your rehabilitation, your physical therapist also can design a specific treatment program for you to follow at home to help speed your recovery.
As You Start to Recover
Your physical therapist’s overall goal is to return you to your normal daily tasks at home, at work, and in the community. Without proper rehabilitation, serious problems such as chronic pain, swelling, weakness, and more severe fracture could arise, further limiting your ability to perform your usual activities.
Your physical therapist will design an individualized treatment program for you, based on your unique condition and goals. Your treatment may include:
Range-of-motion exercises. Because you have been less mobile over the past few weeks, your range of motion may have decreased. Your physical therapist will teach you how to perform safe and effective exercises to restore full movement in the joints of your legs.
Muscle-strengthening exercises. Even short-term inactivity weakens the muscles of the legs, increasing the potential for new injuries. Additionally, your stress fracture may have been related to some underlying weakness in the legs. Your physical therapist can determine which strengthening exercises are right for you based on the severity of your injury and where you are in your recovery.
Body awareness and balance training. Specialized training exercises help your muscles “learn” to respond to changes in your environment, such as uneven or unstable surfaces. When you are able to put your full weight on your foot without pain, your physical therapist may prescribe these training exercises to help you return stronger to your normal activities.
Functional training. When you can walk freely without pain, your physical therapist may begin “progressing” your treatment program to include activities that you were doing before your injury. This program will begin with slow, progressive weight-bearing activities, such as hopping and light jogging. Your physical therapist will create your own unique training program, based on your condition, your goals, and your activity levels.
Activity-specific training. Depending on the requirements of your job or the type of sport you play, you might need additional rehabilitation tailored for your job or sport. Your physical therapist can develop a program that takes into account all of these demands as well as your specific injury.
Orthotic therapy. In-shoe orthotics may be beneficial to support your return to activity with no pain as well as possibly prevent future stress fractures, if your foot posture or mechanics were a contributing factor to the development of the original stress fracture.
Education. Proper shoe selection, nutrition, training regimens, and other topics are an essential part of your rehabilitation. Your physical therapist will provide specialized education to aid in your recovery as well as in the prevention of future musculoskeletal issues.
