We’re at the beginning of the marathon season, and now is the time we need to be vigilant for the symptoms and signs of stress fractures, but also there is much we do to help prevent them.
Let’s talk about some of the myths surrounding stress fractures, and importantly, some of the stress fractures that get ‘missed’. I’m going to give you some tips that might help you spot them earlier, or if you’re a runner, these are things to look out for, so you can then get yourself the right care.
Myths about stress fractures in runners
Only skinny female runners get stress fractures.
Not so. Whilst it is true that more stress fractures occur in women than men, stress fractures are still very common, and so statistically, if you look after male runners, some of them are likely to develop stress fractures. Most of the runners I meet are not underweight, and mostly their issues which generated their stress fractures were training errors, poor biomechanics, and lack of strength training.
You only get a stress fracture if you’re running super big mileages.
Many runners at the beginning of their marathon training schedules, who aren’t even into double figures for mileage, get stress fractures.
The pain isn’t constant, or that bad, so it can’t be a stress fracture.
Stress fractures are sneaky. They often wax and wane in the way that they present, so you may have a runner who describes having dreadful pain after a run, and yet the next day, they have no pain at all during a swift ten miler. Also, they may describe pain that seems to move around. One day, it’s a pain in their groin, the next, it feels like it’s in the buttock. If you have a runner who describes these kind of nebulous or weird symptoms, think stress fracture until proven otherwise.
The patient had a normal x-ray, so it can’t be a stress fracture.
Wrong. You stand a slim chance of picking up a healing stress fracture in a metatarsal bone with an x-ray, but other than that, it’s a completely unhelpful test, because an x-ray can’t rule out a stress fracture. Only an MRI scan can give you the full picture. In addition, an MRI will detect the stage before a stress fracture (a.k.a. a stress response).
The runner didn’t do anything different in their training, so it can’t be stress fracture.
Stress fractures are multifactorial, and I regularly meet runners who trained in exactly the same way that they did the year before, but because their sleep was demolished by a new baby in the household, or crazy travel thrust upon them by work, their recovery was pants. That inevitably led to them getting injured.
What are the symptoms of a stress fracture?
Metatarsal stress fractures:
Some stress fractures are easier to spot than others. If you have a pain in your foot when you’re running, particularly if you find yourself having to adjust how you place your foot when your foot strikes the ground, you might have a stress fracture.
Sometimes you might notice a bit of puffiness in the area of the pain, but from my experience, most stress fractures don’t tend to produce bruising, and I have met some patients whose concerns were dismissed by Doctors because they didn’t have bruising. If you have pain in the foot when you hop, you may well have stress fracture, so stop running and get it checked out.
Tibial and fibular stress fractures:
Most Clinicians are aware that they should be considering a stress fracture when a runner presents with pain in the lower leg, but sometimes the runner’s story misdirects them.
‘I regularly see runners who have carried a stress fracture for a considerable amount of time, but because their symptoms came and went in their shin, everyone thought it was ‘probably just shin splints’ and so the runner continued to run. Until they couldn’t.‘
There are many overlapping symptoms between shin splints (or ‘medial tibial stress’ syndrome – MTSS), stress responses, and stress fractures and it can be hard to differentiate between them without imaging. If your runner has pain on hopping, they may have a tibial stress fracture. Stop them running and get a proper diagnosis.
Stress fractures of the fibula can frequently masquerade as something else. I meet runners who would swear blind that they have a calf tear or pull, but because weeks of stretching and calf strengthening didn’t improve their symptoms, they eventually came to see me. Most of the runners I meet who have acquired a fibular stress fracture, have underlying ankle instability. So, if you have runner with persistent, often vague calf pain, pain on hopping, and an incompetent ATFL, consider the possibility that they might have a fibular stress fracture.
Femoral neck stress fractures:
This is the stress fracture not to miss. Why? Because the outcome can spell disaster for the patient. A missed femoral neck stress fracture that goes on to displace can lead to major surgery, and sadly, for some of patients I’ve seen, a total hip replacement.
How does a femoral neck stress fracture present? Once again, the common symptom is that the runner might have pain in the groin which comes and goes and then travels around. They might feel it laterally in the glutes, they might get thigh pain, and even buttock or knee pain. Bizarrely, in the early stages of the stress fracture, they might feel quite alright when running, but only have pain after running. Later, they might have pain constantly, or an ‘awareness’ of their leg at night.
When we examine these patients, we often find very little in the way of clinical hip signs. So how can you pick it up? Discomfort or pain on hopping means a stress fracture until proven otherwise. The good news is, if there is absolutely no awareness of discomfort on hopping, it’s very unlikely that they have a stress fracture.
If you suspect a femoral stress fracture, get the runner non-weight bearing on two crutches, and get an expert opinion and an MRI scan. These patients will typically need six weeks of total off-loading, followed by lots of rehab. Looked after correctly, most patients will go on to return to running.
Sacral ala stress fractures:
Once you’ve met a patient with one of these, you’ll know what to look out for next time. Whilst they aren’t frequent, they are frequently missed. I saw fifty-one runners in my clinic last year who had sacral ala stress fractures. The majority of them were high level, fast, distance runners, and most were men. These are sneaky stress fractures because most runners will pass it off as being a problem with their sacroiliac joint, or they may give it a label like ‘piriformis syndrome’. Some Clinicians will miss them because they think the patient has a lumbar facetal or disc problem.
Most of the runners I meet with a sacral ala stress fracture can describe a nagging pain or ache in their SIJ area, and many have an underlying ipsilateral hip issue, such as femoral acetabular impingement, which may alter their hip dynamics and thus the biomechanical loading through the sacrum. Once again, the hop test helps flag up these patients.
If you’re a runner with symptoms that sound like a stress fracture, if you’ve concerns about a runner you’re treating, get in touch. I’m at firstname.lastname@example.org