Lindon Beh, Physiotherapist
understanding and Treating Foot Stress FRACTUREs
The first few weeks coming out of lockdown unfortunately saw an unpleasant trend. Physios were seeing an increase of people with foot pain, that when further investigated turned out to be stress fractures.
Stress fractures are one of the most feared running injuries to get because unlike other running injuries (tendon pain or PFJ pain etc.), you cannot run comfortably without pain and you will likely need a good period of full rest.
What is a Stress Fracture? What is a stress response?
A stress fracture is a small break in a weight-bearing bone that is caused by repetitive impact loading. Unlike an impact fracture, that may be caused by trauma or a fall, stress fractures have a gradual onset.
A stress response is when the bone is overloaded but has not fractured. This is the early stage of a stress fracture. If the same level of activity continues the stress response will eventually break down and become a stress fracture. Stress responses are effectively bony oedema without a fracture line.
The most common bones of the foot to have a bone stress injury are the metatarsals (especially the 2nd and 3rd), the navicular and the calcaneus.
How Do Stress Fractures Occur?
Bone stress injuries will occur when there has been an increase in impact loading - running, walking, jumping, that the bones cannot tolerate. Bones will have a capacity for load. When there is a significant imbalance between the bones’ capacity and the impact loads, that has been ongoing for a substantial time, a bone stress injury will occur. An imbalance can sometimes be hard to pick up by yourself because bone stress injury pain will often only come at the later stage of the injury when things are too late.
In short there is too much impact loading in too short an amount of time and an imbalance between rest and recovery.
Military recruits are notorious for developing bone stress injuries early on in their training. They may be lacking a strong base level of conditioning, then are required to march and run huge amounts several times a day, every day!
During lockdown there were two trends we were seeing.
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People began to walk and run more (because there were no other sports to do!). They often had a substantial increase to their usual amount. Eg. if you work in an office and walk 5,000 steps a day, then immediately begin walking 15,000 steps a day. That is a threefold increase the bones have to get used to!
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Previously active people did not do much during lockdown. When lockdown ended they returned to their previous level of sport. During the lockdown their body would have deconditioned and returning to their previous sporting level immediately would have been too much for their bones to handle.
What are the Symptoms of a Stress Fracture?
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Foot pain during a run or walk that gets worse as you continue
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A small area of pain on the foot that is tender to touch
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Swelling on top of the foot
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Foot pain at rest
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Inability or pain hopping
How Do I Tell If I have a Stress Fracture?
If you have foot pain and develop some of the symptoms above, a medical practitioner will be suspicous of a bone stress injury. A MRI, CT or bone scan will be administered to determine if a bone stress injury exists, and the extent of the injury. X-rays are not as useful because bone stress fracture lines will be small and may not come up clearly. Furthermore x-rays cannot pick up stress responses.
How Do I Treat a Bone Stress Fracture?
Unfortunately there is no magic bullet for a bone stress injury except a deload and rest. Tape, massage, dry needling etc do not accelerate bone healing time frames.
Depending on the site and severity of the stress injury, you will likely need at least 6 weeks offloaded from impact loading. You may be required to use a moonboot or crutches if there is a stress fracture.
You may be sent to a GP or Sports Doctor to have your bone mineral density, bloods, vitamin D, menstruation and hormones investigated in case there is another contributing factor to your bone injury.
How Do I Safely Return to Running?
When you have been given the all clear to return back to impact loading and you are pain free in walking and hopping, it is vital you follow the below principles so there is no recurrence!
1. Gradual Loading
a. It’s tempting to return back to your previous level of activity or to increase your activity after every successful run. However you must remember why the injury developed in the first place - there was an imbalance between impact loading and recovery
b. When you return back to running interval training is recommended. Intervals give your bones a chance to rest and your muscles to not fatigue. The intervals will break up the constant impact loading (see table below).
c. Avoid running on consecutive days initially will allow your bones to recover and remodel.
d. When you are ready to increase your running volume slow and steady increases are key. It is recommended that you increase your running volume by small amounts every 3-4 weeks.
e. Avoid double run trainings on the same day. Running on the same day means the bone does not get a full 24+ hours to recover. It is often a recipe for disaster in developing a bone stress injury. I would argue that only elite and professional level runners should be running twice on the same day. You would be better off running once but for longer if you have had a bone injury in the past.
f. Avoid ‘recovery runs’ - a run the next day after a hard or long run - they are overrated. If you have run so hard that you need a deload day the next day, your body is fatigued. You will not be getting much training benefit running in a fatigued state, you would be better off doing cross training or strength training instead. Many coaches refer to this as ‘junk miles’ (mileage that adds not training benefit).
2. Strength Work
a. Bone injuries tend to occur when muscles fatigue. The muscles are unable to produce and absorb as much force, so the bones get impacted harder.
b. Heavy strength training, particularly to the calf and foot, will ensure your muscles can absorb more load. Heavy strength training (I’m talking with heavy weights in rep ranges of 4-8, not body weight endurance exercises that are 15+ reps) has been shown to improve running economy as well - it will make you faster!
c. Olympic weightlifters and powerlifters have the highest bone density of all athletes. This is because they do heavy strength training that remodels their bones to be stronger.
3. Rest Weeks
a. In periods of heavier training, ensure you are taking a rest or deload week every 4 weeks. This allows your bones to have a break from the constant pounding of impact loading, and for your muscles to recover so they become less fatiguable.
4. Nutrition and Supplements TO HELP STRESS FRACTURES
a. Ensure you are getting adequate Vitamin D and Calcium in your diet. An appointment with a sports doc, GP, dietitian or nutritionist may be beneficial to make sure your diet and vitamins are adequate. Also ensure you are getting enough sunshine (Vitamin D)!
5. Sleep and Monitoring Fatigue FOR STRESS FRACTURES
a. Ensure you are getting adequate sleep. Sleep is when your body and bones recover. In a military study, researches were able to substantially reduce the amount of bone stress injuries in recruits by changing two things: the amount of marching and ensuring recruits received 6 hours of sleep per night!
An Example of a Return to Running Program After Bone Stress Injury
Warden, Stuart & Davis, Irene & Fredericson, Michael. (2014). Management and Prevention of Bone Stress Injuries in Long-Distance Runners. The Journal of orthopaedic and sports physical therapy. 44. 1-50. 10.2519/jospt.2014.5334.
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