The Biggest Mistakes Runners Make Returning from Stress Fractures
Bone stress injuries (BSI’s) refers to overuse injuries to bone (such as stress fractures and stress reactions). Running is one of the most common sports that we see BSI’s in because of the repetitive nature of the sport. Research has shown that 4-5% adolescent cross country male and female athletes experience a BSI annually. In elite athletes, 20% sustain a BSI annually. While the terminology can be confusing, there is a differentiation between stress reactions and stress fractures. A stress reaction refers to a bone injury that presents with localized edema on MRI, but without evidence of hairline fracture. A stress reaction can progress to a stress fracture where we see a visible hairline fracture on MRI. Treatment usually involves 8-12 weeks of non-weightbearing (depending on location and degree of injury). Think about that for a minute… 8-12 weeks of non-weightbearing and zero impact for a runner is a long time. A BSI is your body telling you that the stress of training you’ve put on it for several weeks have caused the bone to inadequately remodel and repair itself. There is a shift in activity between the osteoclasts that breakdown bone and the osteoblasts that rebuild it. This is a naturally reoccurring process in the body. If the recovery in training doesn’t match the intensity, the osteoblasts can’t rebuild quickly enough. If you have had ONE bone stress injury, your risk of having another increases 6x.
The bright side of all of this is bone heals really well with time and rest. If you’re off crutches and out of your walking boot, here are some things to keep in mind when returning to activity.
Here are the common mistakes runners make when coming back from a stress fracture:
Going back too fast too soon: You should be walk/jogging for 4-8 weeks after a stress fracture (depending on location and severity of course) and your physio can help guide you through the specifics. So NO, you are not resuming your regular 7 mile run with your group just yet.
Doing your walk/jogs too fast: This is not meant to be an interval workout. I’ve seen runners do their first 10 x 1' min jog, 1’ min walk with jogs at 6:45 per mile pace. This defeats our purpose. Go into your walk/jogs with the intention that this will be more of a walk with small bursts of jogging. The jogging portion should be much slower than your normal easy pace and can gradually let that increase as the weeks go on.This is not meant to get your heart rate up. In the mean time, if you’re worried about fitness, go unleash the beast on the bike or pool.
Not incorporating bone loading specific exercises: These are small plyometric jumps that I prescribe to all of my patients returning from a BSI to strengthen and accelerate the healing of bone. Yes, we need to rest it early on… but we need to load it when it’s appropriate. Plyometrics that focus on small quick jumps, and reducing ground contact time is a good stimulus to increase bone density. Your physio can help you determine when incorporating this is appropriate.
Pain: Look, bone stress injuries are a different category and it is not normal to have mild pain. The < 3/10 pain level rule does NOT apply here. Everything needs to be pain free before you return to running. There are certain situations where patients experience phantom pain in the foot where the fracture was or have muscular pain around the injury site. If you are not sure, consult your doctor or physio.