I had done everything “right’’ during my fall 2022 marathon training. I was getting at least 8 hours of sleep every night, I was fueling my body properly, staying on top of my strength training, and following my running program to a tee.

Yet, the week before my marathon, the thing I dreaded the most as a runner happened: a stress fracture. Only at the time, I didn’t know I had a stress fracture.

This blog post is part 1 of 2 on my stress fracture adventures. This first part will focus mostly on the signs of a stress fracture and finally obtaining a diagnosis in the hopes of helping other runners who are going through this.

What is a Stress Fractures?

Let’s start with the basics. The first thing to note is that stress fractures don’t just happen overnight. It is an overuse and overload injury.

Stress fractures happen when the load that is applied to the bone is greater than what the bone can adapt to (Warden et al., 2021). 

Load to the bone > bone adaptation capacity = stress fracture

The second important aspect of stress fractures is that they are on a continuum and included under the umbrella of bone stress injuries.  

When the load is applied in excess to the bone, it first starts with a stress reaction progressing into a stress fracture, and finally a full fracture (Fredericson et al., 2006; Warden et al., 2014).

 Continuum of bone stress injuries

 Stress reaction → Stress fracture → Full fracture

The earlier we can be aware of the bone stress injury on this continuum, the better as the recovery will tend to be quicker.

What Are the Risks of Getting a Stress Fracture?

Stress fractures in runners are common as it is a sport that demands repetitive loading on bones. In the Journal of Sports Medicine, Kahanov et al. (2015) report that up to 16% of injuries in runners will be stress fractures.

Multiple factors can lead to stress fractures, and in my experience, it is usually a combination of factors.

The risk factors can be divided into intrinsic factors which are specific to the athlete and extrinsic factors which have to do with the external conditions in which the athlete trains (Robinson et al., 2019).

Here is a table that summarizes some of the risk factors of bone stress injuries:

In my case, I had the female part in my corner, but that’s not necessarily enough to cause a stress fracture on its own. I also think the environmental factors broke the camel’s back. Let me explain.

The Week Leading Up to the Marathon

A week before my marathon race, I was tapering down. If you’re unfamiliar with it, tapering is when you reduce your training volume and intensity to reduce fatigue while still allowing you to maintain your fitness level.

I had a 17 km run, which was my last “long run” before the marathon. When I looked outside that morning, it was pouring buckets. I didn’t feel like running for 17 km in the rain, so I called my mom and said I would go over to her house to run on her treadmill.

Everything was going well, the run felt like a breeze, and I had put on a movie on the big screen (Ocean’s Twelve, one of my favorites). At the 11 km mark, I felt a sharp pain in my left ankle, out of nowhere! At first, I thought it might be a muscle spasm or maybe, a tendon irritation, so I kept pushing through.

I finished my 17 km, but the pain never went away, and it increased as I kept going. When I finally got off the treadmill, I was limping. When I took my shoes off, the painful area was now also swollen. It was BAD. How was I going to run a marathon in a week?

As I limped upstairs, my mom asked: “What happened to you?”. Her guess was as good as mine. I was blindsided.

Being the physio that I am, I was trying to self-assess my left ankle…maybe it was a tendon irritation or a nerve. It made sense with the area that was hurting. I didn’t even want to consider it could be a stress fracture at the time.

If you ask any physio, we’re great at telling people what the right thing for them to do would be, but we’re terrible at taking our advice. So, I decided to take it super easy for the rest of the week. I took some anti-inflammatories every day and taped my ankle. I also did a few easy runs with more supportive running shoes which I thought helped. The day before my marathon, I felt much better and I had no more pain when I jumped. Score!

On race day, I was feeling pumped and ready. The race was difficult as there was a slow, but deadly incline for the first half of the marathon. But, I was pain-free! I finished the race feeling tired, and it wasn’t my best time, but I was still proud of myself for having completed yet another marathon.

And then, I paid for it. When the adrenaline started wearing off after a couple of hours, the pain in my left ankle set in. I was sore everywhere, as you usually are after a marathon, but I was also limping heavily because of my left ankle. What had I done?

When I got home, I saw the top of my left foot near my ankle was swollen and red. I had a full range of motion in my ankle, but it was painful when I moved it. Over the next few days, it didn’t get better. I knew I had to do something about it.

How to Diagnose a Stress Fracture

The diagnosis of a stress fracture will be made by a doctor. There are several aspects that they will need to look at.

In the British Journal of General Practice, Robinson et al. (2019) outline the characteristics to look for when diagnosing a stress fracture:

-Taking history into account (how it happened, what your training looks like)

-Looking at your risk factors (we talked about intrinsic and extrinsic factors above)

-Pain: usually localized during or after the activity

-Swelling, redness, and tenderness in the affected area

-Hop test: hopping on one leg will reproduce the pain

Once you are asked about your history and that the physical assessment has been done, some imaging will typically be prescribed.

They usually start with standard X-rays, because it is the most accessible and the cheapest to get done. However, we know that most stress fractures will be missed with standard X-rays. 70% of stress fractures don’t appear on X-rays in the early stages (Robinson et al., 2019).

Current research still states that the gold standard for diagnosing a stress fracture is Magnetic Resonance Imaging (MRI). Not only will these be able to detect stress fractures, but also stress reactions (Robinson et al., 2019).

As mentioned earlier in this article, catching bone stress injuries earlier in the continuum is ideal as the sooner you get a diagnosis, the sooner you can start managing it properly and keep it from getting worse.

What Are the Types of Stress Fractures?

Let’s start by looking at what bones are most affected by stress fractures.

In their article in Joint Bone Spine, Saunier & Chaperlat (2018) mention that the most affected areas for stress fractures in athletes are as follows: 

• Tibia (33%)

• Tarsal bones (20%)

• Metatarsal bones (20%)

• Femur (11%)

• Fibula (7%)

• Pelvis (7%)

 I have some images a bit lower in this article so you can visualize these bones on the body (see Figures 1, 2, and 3).

The next thing to be aware of is that stress fractures can be divided into low-risk and high-risk. As you probably guessed it, low risk is better because it has a better outcome and typically heals quicker.

Low-risk fractures usually respond quite well to conservative treatment whereas high-risk fractures don’t heal as well and could potentially lead to surgery or even a full fracture. That’s why it’s important to diagnose these early so we can appropriately manage them and avoid future damage.

Here is a table to sum up what low and high-risk fractures entail and what bones fall into which category:

(say that it’s adapted from Kahanov and Warden)

To help you visualize all of this, here are some figures that I put together illustrating the low and high-risk stress fractures as well as a closer look at the foot.

Can you guess which one I had if you look at the image of me pointing at my foot?

It was the Talus bone! However, mine was the anterior and dorsal part of the talus and not the lateral aspect. It was kind of a grey area as to whether it was low or high risk. This brings me to my next point on how I got my diagnosis.

My Stress Fracture Diagnosis

After a week of being in pain, I called up one of my physio friends to assess me. I was becoming increasingly convinced that my pain was bone-related and I needed an outsider’s opinion.

After assessing me, my friend also concluded that it was probably a stress fracture. My foot was a bit swollen and red. I had a full range of motion, but it was painful. My strength had not been affected. I could walk, but it was painful, and when I would rest the pain would decrease, even disappear. I was female and had just done extensive training for a marathon and completed one. I had also changed my running surface a week before the marathon.

My physio friend suggested I start by doing an X-ray because, in Canada, most doctors won’t prescribe an MRI either way before having an X-ray.

As predicted, the X-ray came back negative. I went back to the doctor’s office and explained my story. He was reluctant to prescribe an MRI, but I made my case and pushed for it.

I’m glad I did because it came back positive for a stress fracture in my left talus bone. This is a reminder to always advocate for yourself in the health care system. If a doctor or any other health care professional is being dismissive, find another one that can help. Get a second opinion. You know your body more than anyone else!

To Summarize Diagnosing a Stress Fracture

We know that bone stress injuries will have a better chance of healing if they are diagnosed early on. We especially don’t want to miss and ignore the high-risk stress fractures that could eventually lead to a complete fracture and keep you away from running even longer.

Pay attention to the signs your body is giving you and don’t hesitate to consult a professional to seek help. If you see a physiotherapist, they should be able to redirect you toward a doctor for imaging. Working with a physiotherapist that specializes in treating runners is even better! The doctor can then assess you and prescribe the right imaging to confirm the diagnosis. If you get dismissed or feel you have not been given the right information, ask for a second opinion.

In part 2 of this stress fracture series, I will go over what happened after I got the stress fracture diagnosis, how I managed it, and how I went back to running. Stay tuned!

Happy Running,

April

References:

Kahanov, L., Eberman, L. E., Games, K. E., & Wasik, M. (2015). Diagnosis, treatment, and rehabilitation of stress fractures in the lower extremity in runners. Open access journal of sports medicine, 6, 87–95. https://doi.org/10.2147/OAJSM.S39512

Fredericson, M., Jennings, F., Beaulieu, C., & Matheson, G. O. (2006). Stress fractures in athletes. Topics in magnetic resonance imaging : TMRI, 17(5), 309–325. https://doi.org/10.1097/RMR.0b013e3180421c8c

Robinson, P. G., Campbell, V. B., Murray, A. D., Nicol, A., & Robson, J. (2019). Stress fractures: diagnosis and management in the primary care setting. The British journal of general practice : the journal of the Royal College of General Practitioners, 69(681), 209–300. https://doi.org/10.3399/bjgp19X702137

Saunier, J., & Chapurlat, R. (2018). Stress fracture in athletes. Joint bone spine, 85(3), 307–310. https://doi.org/10.1016/j.jbspin.2017.04.013

Warden, S. J., Davis, I. S., & Fredericson, M. (2014). Management and prevention of bone stress injuries in long-distance runners. The Journal of orthopaedic and sports physical therapy, 44(10), 749–765. https://doi.org/10.2519/jospt.2014.5334

Warden, S. J., Edwards, W. B., & Willy, R. W. (2021). Preventing Bone Stress Injuries in Runners with Optimal Workload. Current osteoporosis reports, 19(3), 298–307. https://doi.org/10.1007/s11914-021-00666-y