#252 How long to heal stress reaction vs stress fracture in a runner? - DOC

#252 How long to heal stress reaction vs stress fracture in a runner?

I was just at a medical conference in Hawaii, at the International Foot and Ankle Foundation meeting. This is a large group of podiatrists, sports medicine doctors, foot and ankle surgeons, and they’re all there to learn new techniques and rejuvenate their medical education at this conference.

The lecture I was giving when I came upon with this topic, it’s called “Stress Response, Stress Reaction and Stress Fracture in Athletes.” What I was doing in that talk was basically going through and explaining the differences between a stress reaction, a stress fracture, a stress response, all of that, and of course, what it really means to them as a physician who’s going to see somebody like you and try to help you heal the thing and get back to running.

Now in that talk, there was one thing that was really interesting. It’s an interesting piece of published data that was published in a medical journal article, in a peer-reviewed article. And what it showed was that when you look at a certain grade of stress fracture on this one classification scheme, the difference is in these two is that the patient has pain. They have something on their images. They have something on an MRI that shows up, but in one case there is no crack in the bone visible on x-ray. And in the other case, there is a crack visible on x-ray.

The question I asked the doctors in the audience was…

“What do you think? Would it take less time to heal if you have no crack visible on an x-ray than if you do actually have a crack visible on an x-ray? 

And the simple answer is that there should be a difference in the amount of time that it actually takes to heal, because obviously if you can see a crack visibly on an x-ray, there has to be more damage. You can see a crack on the x-ray. I think of that as a true stress fracture. When you can see a crack on the x-ray, when it’s inflamed on an MRI, when it hurts when you push on it, it hurts when you run on it, that’s a true stress fracture.

When you think about a stress reaction, well that’s where you have what most doctors call a stress fracture, but you don’t see a crack on the x-ray.

Yes, the bone would be inflamed on an MRI. You have pain when you run, you have pain when you push on the bone.

But you can’t see any visible crack on an x-ray or a CT scan or sany imaging study. In that case, it’s just inflamed and irritated. It’s a stress reaction.

Now you would think that a stress reaction would heal faster than a stress fracture, and I believe that it’s true, that it would heal faster. But what’s interesting is that this one study, the statistic is that it takes 12.9 weeks to heal and get back to running if there is no crack on the x-ray or if there is a crack on the x-ray. 

Part of the discussion in that conference session was really important and I think key for physicians to help them understand that there really is a difference between these two conditions. 

And yes, in spite of the published research, if you have a diagnosis of a stress reaction in a runner, you’re running, you start to get pain, there’s no crack on the x-ray but you treat it early, then I believe that you will get back to running a whole lot faster.

But I think that in this particular study, what happened is that most of the athletes continued to train on it, continued to run on it. They tried to ignore it, they stuck their head in the sand, and then after they finally went to see a doctor, they had really beaten it up quite a bit more. And so it took longer for them to get back to running. 

One other explanation of why it is that it might’ve taken them just as long to get back to running if they did not have a crack on the x-ray versus when somebody does have a crack on the x-ray is that the doctor might be overly conservative.

The doctor might treat you the same way as you have a foot with somebody that does have a crack on the x-ray, in which case then you would wind up, of course, with the same amount of “healing time” and you would still take just as long to get back to running because many doctors will use standardized protocols in an effort to speed things up in clinic and simplify their treatment decisions as they go through a busy day in the office seeing patients.

You want to make sure that you get individualized treatment. You also want to make sure that you get treatment as early as possible when you have any aching pain in your foot or leg that you think might be a stress fracture. 

If you really want to get back to running as quickly as possible, you cannot ignore it. 

You cannot delay the diagnosis and you certainly cannot delay the appropriate treatment. 

And if you just think you have this weird aching pain, you have throbbing pain, you have something that could be suggestive of a stress fracture, you need to get it checked out, get it under control, get it healing, so that you really can get back to running as quickly as possible.



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