How to Return to Running After a Stress Fracture
Hello runners!
This is part 2 of my stress fracture article series. In the first part, I shared my stress fracture journey as well as how to recognize a stress fracture and how to get a proper diagnosis.
I recommend reading that article first if you haven’t already.
How I Found Out I Had a Stress Fracture After a Marathon.
This second part will focus on the treatment plan for runners regarding stress fractures as well as how to get back into running.
Treatment Plan for Stress Fractures in Runners
Meeting with general practitioners
Not all treatment plans are created equal. What I mean by this is that a lot of general practitioners have no idea how to manage a stress fracture. This is especially true when it comes to establishing a treatment plan specifically for runners.
After I did my MRI, the general practitioner who had prescribed it to me disappeared into thin air. I had the results, but he wasn’t available for me to book with him to discuss my results and my treatment plan.
I went to a walk-in clinic where I saw another general practitioner and showed them my results. They suggested I stay completely off my foot by using crutches and not work for a month. They also referred me to a sports orthopedist which is a specialized doctor that deals with bones, joints, muscles, tendons, etc.
The referral to the specialist was a good next move. The staying off the leg part, however, I couldn’t get behind. I had already stopped running since my marathon and I was avoiding high-impact activities. I knew I needed a walking boot.
So, as any skeptical physiotherapist would do, I booked yet another appointment with a different general practitioner. This one agreed that I should get a walking boot and that I could walk and work with that while I was waiting to see the specialist. Score!
Meeting with a specialist
When I saw the specialist, they told me I did have a stress fracture and that walking with the boot was all right. This was in no way new information (rolling eye emoji). They said the type of stress fracture I had (Talus) could potentially be a high-risk fracture. Refer to part one of this article for more information on this.
When I asked about a timeline for getting back into running from their opinion, they said they couldn’t tell exactly. “Maybe one year…”. The only thing they knew for sure was that no surgery was required.
I was now 6 weeks in, and I still didn’t have a clear plan as to what to do next. I kept telling myself how stressful this whole process would be if I wasn’t a physiotherapist with knowledge of sports injuries.
As you can see, there were so many sticks in my wheels along the way just to get a diagnosis confirmation and proper advice. This is why it’s important to advocate for yourself and keep looking for the right person who will be able to answer your questions and give you the help you need.
How Long I Kept my Walking Boot
The typical healing time for a low-risk stress fracture is about 6-8 weeks. This can vary depending on each person and it can take much longer for a high-risk stress fracture.
Since I started wearing the walking boot about 1 month after I got injured, I decided to keep it for 8 weeks after that. By the time I got rid of the boot, I was pain-free when I was walking and doing my everyday activities.
Read on in the next section, to see what I worked on while I was still in the boot and healing from the stress fracture.
What I did as a Physiotherapist to Manage my Stress Fracture
Physiotherapists who specialize in musculoskeletal injuries will be your best allies when recovering from this type of injury. If you can find one that specializes in running injuries, that’s even better.
Musculoskeletal injuries are any injuries that relate to bones, joints, muscles, tendons, and ligaments.
So, after I knew that I didn’t need surgery, I started building my rehabilitation plan. This plan included 4 main components:
1) Cardiovascular activity
In my case, I chose to get on the stationary bike. Keeping your cardiovascular fitness is key if you want to get back to running eventually and not have to start from scratch.
Another option could be swimming which is also a low-impact cardiovascular option for exercising.
2) Strength training
I needed to limit the load that was applied to my bone, but it didn’t prevent me from doing strength training and modifying certain positions.
The upper body strength was easy because a lot of exercises could be done either lying down or sitting which has no impact on the foot.
As for the lower body, I did bodyweight exercises and band work in a seated or lying down position. I did this in the initial stages to avoid putting extra load on the healing bone.
When I was pain-free in weight-bearing or walking, I started reintroducing lower-body strength training exercises that put a load on the bone with weights. I’m referring to exercises such as squats, lunges, calf raises, and deadlifts.
3) Rehab exercises
The third component was rehab exercises which included specific exercises to keep my foot and ankle muscles strong since I was wearing an Aircast boot for most of the day.
I worked with the band to strengthen my ankle and worked on range of motion exercises for my foot and ankle to limit lingering stiffness.
4) Recovery Tools
The first recovery tool I focused on was sleep. I made sure I got 7-9 hours of it every night. Sleep is always important, but even more so when you’re trying to recover from an injury. And the best part is that it’s free!
The second tool was to keep up the good habits of eating healthy and staying hydrated. Just because you’re taking a break from running, it doesn’t mean all the good habits need to be thrown out the window. Keep up the good work!
The third tool was stress management and mindfulness. Recovering from a running injury can be stressful, especially when running is an important of your life and part of your identity.
I made sure to keep external stress with work as low as possible. I also did some guided meditations every night to practice being mindful and present. I used a combination of the Headspace, Calm, and Balance apps. Honestly, many other apps offer free options, and you can also find some guided meditations on YouTube. Just find what works for you.
As you can see, there are many things you can focus on even if you can’t run temporarily, so don’t get discouraged!
The specifics of exactly what rehabilitation exercises you should do should be discussed with a qualified healthcare professional such as a physiotherapist to make sure the plan is tailored to your specific needs.
Getting Back into Running after a Stress Fracture
The keyword for getting back into running after having a stress fracture is “gradual”.
Even if you have kept up with your cardiovascular endurance, it’s not advised to go on a 30-minute run the first time getting back into it. You will most likely still need to keep doing your low-impact cardio exercise at first, because you will not be running for long periods.
Most return-to-run programs will include some progressive walk/run intervals. Once again, there is no one-size-fits-all program for everyone. You will need to work with a qualified professional who can guide you along your return to running journey.
Many programs for bone stress injuries are available and have been studied. When working with a professional they will be able to guide you and adapt one of these programs to your needs.
The one that I based myself on was the graduated running program from a study by Warden et al. (2014) published in The Journal of Orthopaedic and Sports Physical Therapy. Below you will find Figure 1 from the article which outlines the return-to-running program for bone stress injuries.
Figure 1
Graduated Running Program to Return a Runner to 30 Minutes of Pain-Free Running
Note. Adapted from "Management and Prevention of Bone Stress Injuries in Long-Distance Runners," by Warden, S. J., Davis, I. S., & Fredericson, M. (2014). Journal of Orthopaedic & Sports Physical Therapy, 44 (10), p. 11.
This program is divided into 5 stages that take you from walking pain-free to running a full 30 minutes.
Here is an overview of the graded bone stress injury program with the different stages:
Stage 0
To move on from this stage, you must be pain-free for 5 days in a row during your usual daily activities.
Stage 1
This stage includes walking and jogging intervals separated by rest days.
Jogging at this stage is defined as running at 50% of your usual pace.
Stage 2
In this stage, the pace progresses until you reach full pace at 30 minutes.
The workouts are still separated by rest days.
Stage 3
This stage has you running 30 minutes for 2 days in a row before having a rest day.
Stage 4
This stage is back to regular and individualized running training according to the runner’s goals.
The most important part at every stage is to monitor the pain. The authors mention that if pain is felt in the area of injury at a certain step, the runner should take a rest day. Their next session should be resumed at the previous step before the step where they had the pain (Warden et al., 2014).
When I was done with stage 3 and running at a regular pace for 30 minutes, I did what any runner would do and signed up for my next race.
I decided to sign up for a half-marathon instead of a full marathon to ease back into it. I followed a half-marathon program without skipping any steps. I kept up with my strength training at least 2 times per week and kept prioritizing my recovery.
The half-marathon went well, I didn’t have any pain, but I took it easy to see how my body would react. This gave me confidence in my abilities and confirmed that my treatment plan had worked!
Lessons Learned from Having a Stress Fracture as a Runner
I can’t stress enough (pun intended) the importance of listening to your body and not ignoring the warning signs. Advocate for yourself and find a healthcare provider that will listen to you and guide you in the right direction.
As we discussed in part 1 of this series, stress fractures can progress into full fractures. The earlier you get a diagnosis and start managing it, the better your recovery will be.
As well, having recovery strategies in place is essential to promote healing and manage stress as you deal with a running injury.
Although they are not fun, injuries are part of the runner’s journey. Sometimes, even if we do everything “right”, injuries still happen.
Just try to remember not to be discouraged if you are injured. There is always something that you can work on while you are healing even if you’re not running temporarily.
This will only make you a better and wiser runner in the future!
Let me know in the comments if you have dealt or a dealing with a stress fracture and how you are coping with it.
Happy Running,
April
References:
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
