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Surviving Stress Fractures
Q: I think I may have some stress fractures in my feet; how can you tell for sure, and what should I do in the meantime to continue with my exercising?
A: Simply put, stress fractures result from a series of tiny fractures that are unable to heal properly. This could be due to a number of factors, though more commonly from adding higher intensity or greater frequency exercise without adequate rest or recovery time. A similar occurrence, which remains a problem in military populations, is sometimes referred to as "march fractures." Determining the origin of athletic stress fractures referred to above requires that you assess the health of your athlete as a whole. Factors that may contribute to stress fractures include: 1) bone health; 2) menstrual status; 3) biomechanics; 4) physical and emotional stress; 5) running or training surface; and 6) the athlete's training program, stage and intensity (3).
The most common site for stress fractures in the feet is the bone just behind the fourth toe. People with rigid ankles and high-arched feet may be particularly susceptible to this injury. Stress fractures seem to be more prevalent among women than men, and represent up to 10% of all sports injuries (3). They occur more frequently in female athletes who aren't menstruating regularly--the decreased estrogen levels may cause bone thinning, making the weaker bones more susceptible to stress fractures.(2)
Some features that are common to stress fractures include: 1) repetitive exercise; 2) localized pain that becomes worse with ultrasound; 3) recent change to your training regimen (this could be from the introduction of high-impact exercise such as running or aerobics; backpacking with heavier weight over longer-than-usual distances; increased intensity of exercise, whether from adding jumping, speed, or distance without being properly prepared); 4) no notable traumatic event; 5) pain with weight bearing that diminishes with rest. If you feel point tenderness above and below the area in question, but there doesn't appear to be definitive swelling, you may still be suffering from a stress fracture. X rays usually are not sensitive enough to detect the fine cracks until about 6 weeks later when your body has had time to begin callus formation (fine bony repair material) that can then be seen on an X ray (3).
Delayed diagnosis generally means prolonged rehabilitation and significant time away from activity, so if you fear you may have a stress fracture, it is probably a good idea to see your doctor. If you catch them early enough and change your training habits, they can heal by themselves in as little as 6 weeks; otherwise it may take 6-12 months with substantial loss of conditioning and sanity!
ALTERNATIVE TRAINING DURING RECOVERY
1) Switch to a non-weight bearing exercise such as biking or swimming. You might also find that something like rowing is tolerable, even though there is some pressure on the feet as you push off the foot stretchers.
2) Did you recently try a new shoe design? Check the wear pattern and padding of your shoes. If it's been a while since you've replaced your running shoes, you may be surprised to find worn spots on the bottom of the shoes or in the cushions. Replace your shoes after 200 miles of running, as the midsole cushion will no longer be effective. Try to get a professional to help you select appropriate footwear for your chosen activity.
3) You may find some relief by replacing (or getting) orthotics (especially if you have high arches) or inserts such as Superfeet.Make sure you have good foot support, and consider athletic taping if you must be on your feet for extended periods of time while the foot heals.
4) Experiment with snug, stiff-soled boots to see if they help temporarily relieve the pain. These would be okay for a few hours at a time; however, a cast would not be appropriate in most cases, as complete immobilization provided by a cast would cause your muscles to atrophy.
5) Along with the above, use ice and massage and consider an anti-inflammatory medication.
1) Adding a well-planned and well-rounded strength program to your regimen can help prevent the occurrence of stress fractures in the bones of your feet and legs, particularly in women who are at risk for bone injuries or osteoporosis. Be especially careful to gradually increase the intensity of your training program if you've had a history of stress fractures.
2) As another preventative measure, if you already know that you have high arches and rigid ankles, consider starting a program to increase ankle flexibility. Such a program might include bodyweight stretches such as a calf stretch on a step, stretches using exercise bands (such as those available through Jump Stretch Inc.) or manual resistance.
3) When you do return to your higher impact activities, do so slowly and gradually. Select shock-absorbing shoes. Avoid running on asphalt or concrete -- instead, grass, bark, dirt/trails, or sand are much more forgiving.
4) Make certain you have addressed any nutritional deficiencies -- get adequate calcium (1000-1500 mg/day) and protein (.8g/kg bodyweight minimum), and consider estrogen replacement if you are post-menopausal.
1) Athletic Training and Sports Medicine (American Academy of Orthopedic Surgeons) 1997.
2) Micheli, Lyle J. M.D., Sports Medicine Bible, 1995.
3) Otis, Carol M.D. in Medical and Orthopedic Issues of Active and Athletic Women, Ed. Agostini, Rosemary, MD. Ch. 42: "Stress Fractures in Athletes," 1994.
4) Shangold, Mona, and Mirkin, Gabe, M.D. Complete Sports Medicine Book for Women, 1992.