The Stress Fracture Diary: Part One

Happy Friday!

I've decided to start a new series to talk about running injuries- "The Stress Fracture Diary." Right after my diagnosis, I googled a lot of different terms looking for other runners/bloggers who had gone through what I was about to go through. I found a few runners that blogged about it but much less than I thought I would. During a time when I felt so disconnected from the running community, I really wanted to read other's stories/experiences but I wasn't finding a lot of detail online. So, I'm going to do my best to document the next few weeks/months as best I can so that someday they may help a future injured runner AND help educate any runner about how to avoid this injury. And writing is helping me stay sane as I'm laid up :-)

Today's post will be all the basics: What is a stress fracture? What causes it? What are the symptoms? How is one diagnosed? What is the treatment? How can you prevent a stress fracture? I'll answer these questions with help from the internet and my own experience.

What is a stress fracture?
"Stress fractures are tiny cracks in a bone. Stress fractures are caused by the repetitive application of force, often by overuse- such as repeatedly jumping up and down or running long distances. Stress fractures can also arise from normal use of a bone that's been weakened by a condition such as osteoporosis. Stress fractures are most common in the weight-bearing bones of the lower leg and foot. "- Mayo Clinic

A pain in the ass. - Sarah

What causes a stress fracture?
"Stress fractures often are the result of increasing the amount or intensity of an activity too rapidly. They also can be caused by the impact of an unfamiliar surface (a tennis player who has switched surfaces from a soft clay court to a hard court); improper equipment (a runner using worn or less flexible shoes); and increased physical stress (a basketball player who has had a substantial increase in playing time)."- American Academy of Orthopaedic Surgeons

In my case, my doctor seems to think there are two reasons: bad running form and non-supportive shoes. Yup, that's right, my beloved Hoka One Ones may have caused my stress fracture. There is too much movement in my right foot during a running motion- I need a motion-control shoe to correct this biomechanical issue.
Fun fact- I wore Brooks Adrenalines for three years before making the switch to Hokas. It seems plausible that since I had no issue with the Brooks that switching shoes could have been the trigger to causing a stress fracture.

As for the "too much running" theory, I was only running 10- 15 miles a week when I was experiencing symptoms. I think it was just the total accumulation of miles in the Hokas that led to the fracture.

What are the symptoms?

"The symptoms of stress fractures can vary widely. However, the most common complaint is pain. The pain may develop gradually and often is relieved by rest. Pain usually becomes more intense with physical activity and can be associated with swelling. Swelling and tenderness may be present in the area of pain. It is rare to see bruising or discoloration."- American Orthopaedic Foot and Ankle Society

One of the biggest reason it took so long to diagnose my stress fracture is that my symptoms were very atypical. I did not have a lot of pain. I would say I had some discomfort, but not true, real pain. I also had discomfort all over my foot- not just in one area. Most stress fractures have acute pain in a specific area- they site of the fracture. Most stress fractures can't pass the "single leg test"- hopping on the affected leg without pain. I had a little pain on the top of my foot, in my toes, my ankle, etc. Also, my pain did not become worse with activity- it got better! Which is what lead to the first diagnosis- tendinitis. With bone issues, the pain usually gets more intense the more you run- mine was the opposite which mimics a tendon/soft tissue issue. 

What concerned me the most- and what sent me to see the doctor the first time- was the swelling. My foot first started swelling in June. It cleared up through most of July and August but by late August, it was swelling after every run. That's what sent me back to the doctor in September. Below is a picture before diagnosis, after a week of diagnosis/treatment and today. You can really see how swollen it was before we knew it was a fracture. 

How is a stress fracture diagnosed?
"While doctors can sometimes diagnose a stress fracture from the medical history and physical exam alone, imaging tests are often needed to confirm the diagnosis.

• X-rays. In many cases, stress fractures aren't apparent on regular X-rays taken shortly after the time your signs and symptoms begin. It often takes several weeks — and sometimes longer than a month — for evidence of stress fractures to show up on X-rays.
• Bone scan. A few hours before a bone scan, you'll receive a small dose of radioactive material through an intravenous line. The radioactive substance accumulates most in areas where bones are being repaired — showing up on the scan image as a bright white spot. However, many types of bone problems look alike on bone scans, so the test isn't very specific for stress fractures.
• Magnetic resonance imaging (MRI). MRI uses radio waves and a strong magnetic field to produce detailed images of your internal structures. MRI usually can visualize stress fractures within the first week of injury, and this type of test is better able to distinguish between stress fractures and soft tissue injuries."- Mayo Clinic

I first went to the orthopaedic doctor in June due to swelling. He took x-rays, manipulated my foot, and concluded that there was no way I had a stress fracture because I'd be in a lot of pain from where he was pressing and pushing on my foot. He told me to come back if the pain increased or the swelling continued.

In late August, I made another appointment (for September) because the swelling was back and the discomfort was slightly worse and was happening when I wasn't running. At this appointment, he manipulated my foot, watched me hop on it (thus passing the "single leg test" which most stress fractures can't), and again assured me I did not have a stress fracture. He scheduled an MRI for 9/17/ 2014 and  sent me on my way. He also told me to keep training- there was no reason for me to stop running. I ran the Divas Half Marathon that weekend.

The day after my MRI, a nurse called me to tell me that my foot was indeed fractured in the second metatarsal and that I needed to get off of it immediately. She also told me I'd be non-weight bearing for six weeks. The next time I visited the doctor, he showed me the MRI and explained that what they look for is inconsistency in the bone coloring on the MRI (i.e., cloudy white where it should be dark, dark spots where it should be light). And sure enough, you can see the fracture. The white dot you see on the outside of my foot is something the MRI people taped to my foot before the exam- they asked me where I felt the most pain- and damn if it doesn't line up perfectly with the stress fracture.

Cloudy white where it should be dark.

Dark where the bone should be white.

What is the treatment?
"Treatment will vary depending on the location of your stress fracture and its severity. The goal of any treatment is to help you return to all the activities you enjoy. Following your doctor's treatment plan will restore your abilities faster, and help you prevent further problems in the future.

• Rest. Take a break from the activity that caused the stress fracture. It typically takes 6 to 8 weeks for a stress fracture to heal. During that time, switch to aerobic activities that place less stress on your foot and leg. Swimming and cycling are good alternative activities. Remember, however, that you should not do any physical activity on the involved foot or ankle until you consult a doctor.
• Protective footwear. To reduce stress on your foot and leg, your doctor may recommend wearing protective footwear. This may be a stiff-soled shoe, a wooden-soled sandal, or a removable short-leg fracture brace shoe.
• Casts. Stress fractures in the fifth metatarsal bone (on the outer side of the foot) or in the navicular or talus bones take longer to heal. Your doctor may apply a cast to your foot to keep your bones in a fixed position and to remove the stress on your involved leg. Casts are a type of external fixation. To keep weight off your foot and leg, your doctor may recommend that you use crutches until the bone heals.

Surgical Treatment- Some stress fractures require surgery to heal properly. In most cases, this involves supporting the bones by inserting a type of fastener. This is called internal fixation. Pins, screws, and/or plates are most often used to hold the small bones of the foot and ankle together during the healing process."- American Academy of Orthopaedic Surgeons

In my case, my treatment is six weeks of non-weight bearing activity. This means no walking, standing, swimming, biking, etc. Basically a lot of sitting. Unfortunately, due to the placement of my fracture, my doctor is going with a very conservative treatment plan to avoid the bone completely breaking. If this bone were to break, there is no guarentee that I would ever be able to run again. Scary. 

I have an appointment with the ortho on October 22. If there are signs of healing, I may be able to bike or swim. But still no walking or running. Instead of crutches, I am using a knee scooter to get around. It is extremely inconvenient to not be able to move around or walk the way I want to but it beats the alternative- surgery or permanent mobility issues.

Once I'm off the scooter and out of the boot. I can slowly start walking again. It will probably be about 4 weeks post-boot that I will be able to start incorporating running back into my walking. I should be back at pre-injury level (distance, pace, etc) by January. 

Scooter Queen.

How can you prevent a stress fracture?

"These guidelines can help you prevent stress fractures.

• Maintain a healthful diet. Eat calcium and Vitamin D-rich foods to help build bone strength.
• Use proper sports equipment. Don't wear old or worn running shoes.
• Alternate your activities. For example, you can alternate jogging with swimming or cycling.
• Start any new sports activity slowly. Gradually increase time, speed, and distance; a 10% increase per week is fine.
• Strength training can help prevent early muscle fatigue and prevent the loss of bone density that comes with aging.
• If pain or swelling returns, stop the activity. Rest for a few days. If pain continues, see your doctor." - American Academy of Orthopaedic Surgeons

If you're still reading, you get a gold star because this was a loooong post! But, I hope it helped shed light on the mysterious and challenging stress fracture! It's not really mysterious. But it is challenging- more on that in the next post :-)