9 Stress fracture diagnostic mistakes to avoid.

Its marathon season again, and already my clinic is littered with stress fractured runners. I have written about stress fractures before, and I make no apologies for banging on about them again because they can be serious, and cause heartbreak and a shed load of ‘life inconvenience’.

Sometimes patients present late – often weeks after the onset of their symptoms. So, I am on a mission to improve our awareness as to how they really ship up in clinic, so that we can act earlier, rather than later.


I think the reason for these late presentations is that there are a lot of myths around stress fractures, that prevent the clinician from taking action.

Let’s debunk a few of these…

1. Stress fractures only happen to marathon obsessed, skinny Paula Radcliffe types.

Nope. Guys get stress fractures, just like the ladies and many carry a little bit of ‘timber’. Dodgy biomechanics combined with poor running technique, topped with a ridiculously ambitious training schedule, is guaranteed a recipe for a stress fracture.


 2. The patient isn’t doing enough mileage to generate a stress fracture.

It’s perfectly possible to give yourself a nicely wounded tibia on a couple of “Les Mills body attack“ classes a week, let alone a full on “Marathon des Sables” training schedule.


3.  The pain comes and goes and moves around, so it can’t be a stress fracture.

This is one of the key symptoms which should actually make you prick your ears up and think that a stress fracture is a possibility. Stress fractures behave mysteriously; one day you can run comfortably, the next day you’ve got terrible groin pain and are limping, and the day after that you might feel like it’s in your glutes.
These kinds of waxing-and-waning symptoms are very common, especially with femoral neck stress fractures. Remember, not everybody presents with a pain they can point to.


4.  There was very little to find on examination, so I’m not worried.

Whilst tibial metatarsal stress fracture patients may have localised symptoms and tenderness, most patients with stress fractures at other sites, such as the hip, sacral ala or pubic ramus, might not have much to find when you flip them around in a consulting room. I think the single most useful clinical sign (based on a gazillion wounded bodies coming to visit me) is to ask the patient to hop. If they can “feel it” in one leg, and not the other, it’s a stress fracture to be proven otherwise.


5.  The patient didn’t do anything different in their training program, so a stress fracture is unlikely.

Not so. Stress fractures are multifactorial in nature. Your patient may be sticking to the same marathon training regime they have been using year upon year, but if suddenly a new baby or an increase in working hours means significantly fewer sleeping hours, then it’s a slippery slope of poor recovery and decompensation.


6.  The patient has buttock pain, so it must be the sacroiliac joint that’s the problem.

Beware the serious runner in this scenario.

Big mileage, speedy, experienced male runners, frequently present with sacral ala stress fracture symptoms which mimic SIJ type pain, so if in doubt, stick them in the scanner.


7.  It settles when they stop running, so it can’t be that serious.

Firstly, bones need offloading to properly in order to mend. The rapid onset of symptom relief that the patient experiences when they stop running is not a sign that all is well, done and dusted.

In other words, when you’re unsure, using symptoms to test return to impact is not a great strategy, because it puts the patient into a limbo situation of never quite properly recovering. A proper diagnosis, followed by a correct period of offloading is what’s needed, or the patient will go around in circles when they re-load. This gets very boring after a few weeks, and ironically, often prolongs their return to running, and that debut marathon.


8.  Think stress fractures can’t be serious?  Think again….

This patient was advised to try and weight bear on his leg and “get off his crutches”. He went on to have surgery when his stress fracture became displaced and he snapped his femoral neck. Thus endeth his running future.




9.  X-rays will pick up a stress fracture – eventually.

X-rays are totally and utterly useless when it comes confidently ruling out a stress fracture. Forget them! Go straight to MRI, and whilst you’re at it, forget that myth of seeing changes on an X-ray at around six weeks which confirm a healing fracture. This only happens if you snap your leg.

Burn any outdated textbooks that you originally read this advice in.
Next, stamp on the ashes, put them in an urn, and scatter them at sea. You get the point. And a trip to the seaside.

Can’t Access an MRI? Well, if it’s a lower limb problem, offload the patient – non-weight bearing onto crutches – until you can get a proper diagnosis. Most patients who are passionate about their running will be willing to consider self-funding of an MRI, which can often be for £250 or less.

Scanning enables you to give them an accurate diagnosis and, and with luck, peace of mind. Remember to give the opportunity to make that decision about funding.

It’s their call /marathon/honeymoon /ski trip/ stag-do.

The best way to spot a stress fracture is to think of the patient who presents with odd symptoms that move around, and pain that comes and goes.

Get them to hop – if it feels difficult or uncomfortable compared to the other side, it’s a stress fracture until proven otherwise.

Also, patients will often have an “awareness” of their symptoms at night time, so ask them if they can “feel” their leg at night, rather than asking them if they have “pain”. They may deny the latter.


If you are in doubt about a patient in your care, who may have a stress fracture, then get in touch with me, I’m more than happy to give some guidance. Email me at css@sportdoclondon.co.uk

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