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Do I have a stress fracture?

This is one of the most common questions an endurance athlete will ask themselves when dealing with any kind of pain or discomfort. The term stress fracture fits in the broader category of bone stress injuries. A bone stress injury is when the micro damage that occurs when we're running and doing other activities is greater than our body's ability to remove that damage, and that can be things from a stress reaction, all the way to a full fracture. This is highlighted really well in this article by Warden and colleagues in 2012, this small graphic highlights exactly what that progression can look like when we're dealing with bone stress injuries.

Bone stress injuries can occur in any bone in the body. When we're looking specifically at runners, we tend to see these happen the most in their legs because those are the bones and the areas of the body that are having to deal with the biggest increase in stress when we go from walking around our daily lives to being able to run. And when we talk about bone stress injuries, we really have to go back to basic biology and understand how bone behaves and how that impacts both the development of these injuries, as well as how we treat them, and we reduce the risk of them occurring.

One key principle to remember is that our bones are always changing. From the moment that you wake up in the morning to the last minute before you go to bed at night, your bones are constantly getting stronger or weaker based off of the decisions that we make during the day, what we do, what we eat when we rest, all of these things change how our skeleton is adapting to our day to day lives.

We see changes happen on a minute to minute basis, but we also see drastic changes in people's skeleton when we look at weeks months, and even years of time. When we look specifically at running, our bones have to deal with two different stresses. The first thing that we have to deal with is the actual impact between our foot and the ground. This is called a ground reaction force. The second stress that we have to deal with is the contraction of our muscles.

So every time our foot hits the ground, the muscles of our lower leg have to tighten to make sure that we can absorb that impact and not fall on our face and continue to progress forward. So when that happens, our muscles, they attach to tendons and those tendons attach to bone. Every time a muscle contracts that tendon creates a little bit of a tugging sensation on its attachment site, to whatever bone that it's attaching to, and that creates a little bit of stress.

Now, in good circumstances when we're healthy and training well, that can actually prove to make those bones a little bit stronger, but when we're running into an injury, that can be a little bit of a problem. When we're dealing with runners we have to remember that idea that our bones are dealing with those two separate forces, the impact between our foot and the ground and the muscle contractions that happen throughout our body.

So how do we figure out if we're dealing with one of these one? Well unfortunately, a lot of the tests that people do to try to either rule in or rule out a stress fracture are not very good. Back in physical therapy school, we learn things like putting a tuning fork over an area, palpating or pressing on the affected bone, running ultrasound over the area. We learned that these tests might help us figure out if someone is dealing with a bone stress injury and unfortunately, when we look at the research on them, they're just not very good at ruling in a ruling out a stress fracture. So we can have lots of runners that either have pain when we press on someone's bone and they don't have a stress fracture, and we also have a lot of people that have a stress fracture and when you press on the effected bone, they don't have pain. So these aren't great tests.

The other thing that people will often do is get an Xray or a radiograph. Radiographs are easy to get. They're cheaper than a lot of other imaging and so normally they're a first line thing that people will go through. While they can help in diagnosing bone stress injuries at some points in time, they're about 10% accurate. So we can't put too much stock in someone saying I got an Xray of the area and it didn't come back that I had a stress fracture. In order to figure that out, we really have to have an MRI or a CT scan.