Last updated: 31-Oct-18
By Karina Teahan, Chartered Physiotherapist
If you have read my article, How to diagnose a stress fracture, and have digested the bad news that you have, indeed, got a Bone Stress Injury (BSI), do not get too depressed. I have lots of advice for how to get you back to running. You ARE going to have to be patient, though. Do not rush at this. Slowly, slowly wins the race in this case.
“Incrementing a running programme too rapidly or frequently relative to a runner’s usual activities is thought to be central to a stress fracture” 1
Phase 1 – Initial Management
You must stop running even with low risk BSIs to permit tissue healing. Minimise walking as much as you can as well. If you do feel pain, then it is likely you are still loading too much around the fracture site at this stage of healing. Night pain is another warning sign.
Useful hints for comfort are to wear cushioned shoes and/or insoles if you have a rearfoot or leg BSI.
Conversely, stiff-soled shoes may be more appropriate if you have a forefoot or mid-foot BSI.
If you are not pain-free during and after usual daily activities, you need to think about weight bearing.
You may need to go partial weight bearing with 1-2 crutches, wear a pneumatic brace (tibia or fibula) or go completely non weight bearing with a walking boot.
This is also a time to reflect and address your own individual risk factors and look back on your training diary to identify a change in training that may have led to this injury (see previous article).
Don’t despair, you can do some cross training 1 2 3 : cycling (dependent on BSI site), swimming, deep water running (DWR), and anti-gravity treadmill training (ATT) 4.
IF you are pain-free when walking. DWR is actually cardiovascularly close to real running at low to moderate intensities, not so much at high intensities. In order of increased load on the bone while running it is as follows from low to high:
DWR→ATT→Treadmill running→Overground running.
Alter-G Treadmill Trainer 4. Photo credit: Pasadenapt.com
Phase 2 – Return to Running
This is for the low risk group.
Running technique: increase your stride rate/cadence above your usual rate. Try using a metronome set at 10% above your normal rate to help get you used to this new tempo. Run “softer”. You can also work on strength. For example you should try to increase the strength of your calf muscles for tibia injuries, and foot for metatarsal BSIs.
High risk groups are more complex in that they may have delayed healing time, and the risk of bad or non-union of the bones. They may also require a much longer period of non-weight bearing. In certain cases, you may need surgery. I strongly advise you to see a sports physician and physiotherapist to help you manage your risk injury.
Return to running in the Low Risk Group involves a gradual and controlled increase in jogging, then running. You can start this once you have been pain-free for 5 consecutive days during normal activities. You must add loading to heal the bone but it needs to be optimal loading. You must balance healing and the consequences of not training.
The table below is a suggested return to running plan up to 30 minutes1. If at any stage you feel your symptoms returning, take a rest day and drop back to the previous pain-free level.
Keep a running diary so you can monitor changes. Allow periodisation so perhaps after each 3-week running block you have a week with less loading and try some deep water running.
Anti-gravity treadmill training is great but will not be accessible for everyone and can be quite costly. Try alternate loading through a variety of sports and activities.
Think about your bone health. It has been shown that repeated, short duration, high impact (once your bone is healed) even for a few minutes may help your skeleton to adapt to tolerate a greater load, more so than just distance running 5 6.
BE AWARE! A premature return to full running risks re-injury.
Return to Running plan
Each letter signifies a session so A is day 1, B is day 2, etc.
| Stage/ level | Description |
| 0 |
Pre-entry to graduated running program Pain during walking in normal daily life |
| Stage/ level | Description |
| 1 |
Initial loading & jogging |
| A | Walk 30 minutes |
| B | Rest |
| C | Walk 9 minutes and jog 1 minute (3 repetitions) |
| D | Rest |
| E | Walk 8 min and jog 2 min (3 reps) |
| F | Rest |
| G | Walk 7 min and jog 3 min (3 reps) |
| H | Rest |
| I | Walk 6 min and jog 4 min (3 reps) |
| J | Rest |
| K | Walk 4 minutes and jog 6 minutes (3 reps) |
| L | Rest |
| M | Walk 2 minutes and jog 8 minutes (3 reps) |
| N | Rest |
| Stage/ level | Description |
| 2 | Running with increasing intensity |
| A | Jog 30 minutes |
| B | Rest |
| C | Run 30 minutes at 60% normal pace |
| D | Rest |
| E | Run 30 minutes at 60% normal pace |
| F | Rest |
| G | Run 30 minutes at 70% normal pace |
| H | Rest |
| I | Run 30 minutes at 80% normal pace |
| J | Rest |
| K | Run 30 minutes at 90% normal pace |
| L | Rest |
| M | Run 30 minutes at normal pace |
| N | Rest |
| Stage/ level | Description |
| 3 | Running on consecutive days |
| A | Run 30 minutes at full pace |
| B | Run 30 minutes at full pace |
| C | Rest |
| D | Run 30 minutes at full pace |
| E | Run 30 minutes at full pace |
| F | Rest |
| G | Run 30 minutes at full pace |
| 4 | RETURN TO RUNNING |
Conclusion
Stress fractures are something that most runners face during their running lives. They have to be treated with respect. The main thing is to get a good diagnosis and then to stick with the programme.
IF you start running hard and fast too early, you will damage yourself. Return to running gradually, use the ideas above as a guide, work with a physio and you will reap the rewards.
About the author: Karina Teahan (BSc, MMT, MISCP) is a chartered Physiotherapist and elite runner who graduated from University College Dublin in 2002. She did a Masters at the University of Western Australia and worked in Dublin, Manchester and New Zealand. Karina is now based in a Primary Care Centre in Cork, Ireland.
Notes
EXOGEN: low-intensity pulsed ultrasound is used by some for the treatment of fractures & mal-unions and non-unions. More details at www.exogen.com
References:
- Warden SJ, Davis IS, Fredericson M. Management and Prevention of Bone Stress Injuries in Long Distance Runners. JOSPT. 2014;44(10):749-765
- Behrens SB, Deren ME, Matson A, Fadale P, Monchik KO. Stress Fractures of the Pelvis and legs in Athletes: A Review. Primary Care. Sports Health March April 2013. 5(2): 165-174. DOI:10.1177/1941738112467423
- Managing Stress Fractures in Athletes: Rheumatology Network. December 2010
- www.alterg.com
- Rubin and Lanyon. J Bone Joint Sugy 1984;65:466-71
- Umemura et al. J Bone Miner Res 1997;1480-5
