Today on the Doc On The Run Podcast, we’re talking about whether or not a runner can have a stress fracture, if there is no crack in the bone on the x-ray.
I was just doing a telemedicine call with a runner, and he had a really interesting question. He said, “Look, I just really want to know if I really have a stress fracture because my doctor took an x-ray and there was no crack. I looked it up and the definition of a fracture is a visible crack.” This is a great question, it brings up a really interesting point. Just last week, I was lecturing at the International Foot and Ankle Foundation Medical Conference, and I was giving lectures specifically on running injuries. One of them was about the difference between a stress response and a stress reaction and stress fractures in athletes.
An unfortunate reality is that when we look at the different grading systems for metatarsal stress fractures, there are a lot of things that cause a lot of confusion. When you look at the system that I like the best and the one that I teach physicians to use, there are five different stages or grades of metatarsal stress fractures. A Grade 1 is where you have nothing on an x-ray, no crack, just like this runner is talking about. You have no pain and it’s not really a problem. What do I mean by that? Well, this is actually what I call a stress response. A stress response is a normal reaction to something you do in training or applied stress. Obviously, when you go out and run, you’re trying to cause tissue damage to make your body build into stronger tissue after the workout.
When you do that to a bone, you get inflammation within the bone. Now, when we say there’s nothing in terms of a crack and there’s no pain, well, this is not something where you would go to the doctor anyway. But where this shows up is there a lot of different studies that look at endurance runners, at professional runners, at ultramarathoners, that show that during different phases of training, likely during build phases, where we’re actually increasing our distance and our speed at the same time, you get increased stress that will show up on an MRI and looks just like the thing that a radiologist would call a stress fracture. But the runner has no pain, so if you don’t have pain, it can’t possibly be a problem.
Now, some of these studies actually say very clearly to the physicians who they know are going to read these studies that if you see this on a runner, you do not need to modify their training program, you do not need to have them stop running. It’s a normal physiologic response, which is why we call it a stress response. Now, a Grade 2 stress fracture, which again isn’t really a fracture, is where you have pain. So if we push on the bone in the spot where we know that you have inflammation and irritation, well, you actually have pain. You have pain when you’re running, you have pain when you’re doing hills, you have pain doing something. Also, when you get an MRI, you see this exact same inflammation that you would see given a stress response.
They look the same on an MRI, the only difference is you have pain in one and not the other. If you have pain and you have inflammation that you can see on an MRI, but you don’t have a crack, well, that’s a Grade 2 stress fracture. I don’t really like to use the term stress fracture for those, that is what I call a stress reaction. Now, if you keep running on a stress reaction, you keep stressing and overstressing the bone that has the stress reaction, it will turn into a stress fracture. That’s a Grade 3. So a Grade 3 stress fracture is the first one where you can actually see a crack. There’s a crack on the bone that you can see either on an MRI, a CT scan, or maybe even an x-ray.
If you get an MRI, you’re going to have lots of inflammation within the bone, and maybe you can even see the crack when you get the MRI. You might be able to see that crack on an x-ray, you would certainly see it on a CT scan. But this is where you actually have more of a serious problem because it’s visible, so it’s obviously there. You’ve actually damaged the bone enough to make a crack in the bone, and you got to take that seriously. But in the Grade 3 stress fracture, it’s a crack, but it’s in the right position. It hasn’t moved out of place, it’s not angulated, it’s not crooked, it’s not bent, or anything like that.
Grade 4 is where you actually have a crack, that is not only visible, it’s out of position. It’s displaced, it’s moved out of position. It’s tilted, it’s crooked, whatever you want to call it, but it’s not even in the right place. Then a Grade 5 stress fracture is actually not really a fracture at all, it’s where the fracture didn’t heal. It’s something we call a non-union. What that means is that it’s not going to heal. The bone did not unite, it didn’t come back together and heal. And because it’s not united, you have a scar tissue that’s between those pieces of bone, and that will block any potential healing unless you do something like surgery to try to get it moving in the right direction.
But all of this to say that when you hear the term stress fracture, you need to pin your doctor down and ask, “What exactly does that mean?” It’s really important you do that. Now, this is a lot of the stuff I talk about in the metatarsal stress fracture course for runners to help you understand, without MRIs or CT scans or x-rays, how it is that you can actually look at your foot, figure out how much it hurts, figure out how to track that pain, figure out how to reduce the stress to that injured area, and then continue to try to train, maintain your fitness, and get back to running faster. That’s really the goal.
You must keep that in mind when you go see your doctor. If they tell you, you have a stress fracture or they tell you have a stress reaction, you need to know what do you mean? Does that mean it’s going to take a short time to heal, a long time to heal, do I really have to wear a fracture walking boot? Can I maybe do some other stuff if I’m not having pain? You got to pin your doctor down on the right answer. That is really important if you want to get back to running as quickly as possible and you have a stress fracture.
In the Metatarsal Stress Fracture Course for Runners I show everything I would do with you, if I was sitting in your living room looking at your foot, trying to help you figure out what to do right now. And in the free Fast-Track Recovery Challenge I show you how you can use the pain and discomfort in you foot as a tool to determine the severity and Fast-Track the recovery.
If you do nothing else today, you should take the first step in tracking your pain. Think about how much it hurts. Right it down. Begin.
Join me in the Fast-Track Recovery Challenge. It’s free. Give me 3 days and I’ll give you a better understanding of your injury and what it is going to take to get back to running faster.
sign up for the Fast Track Recovery Challenge. It’s free.
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Metatarsal Stress Fracture Rapid Recovery For Runners
If you have a stress fracture, you’re probably really freaked out right now and think you’re going to lose all of your fitness while you heal. But it doesn’t have to be that way. I teach doctors how to help runners heal and maintain running fitness.
If your doc said “Stop Running!” You don’t have to stop running. You just have to reduce the stress to the injured bone so it can heal. You just have to be thoughtful about how you maintain your running fitness so you can keep healing.
Run without making it worse. The worst thing you can do is sit still, stop exercising and lose all of your running fitness. It is possible to maintain your running fitness while you heal your metatarsal stress fracture. This course shows how.
Enroll in the Metatarsal Stress Fracture Course now!
If you have a stress fracture
You’re probably really freaked out right now and think you’re going to lose all of your fitness while you heal. But it doesn’t have to be that way. I teach doctors how to help runners heal and maintain running fitness.
If your doc said “Stop Running”
You don’t have to stop running. You just have to reduce the stress to the injured bone so it can heal. You just have to be thoughtful about how you maintain your running fitness so you can keep healing.
Run without making it worse
The worst thing you can do is sit still, stop exercising and lose all of your running fitness. It is possible to maintain your running fitness while you heal your metatarsal stress fracture. This course shows how.
Enroll in the Metatarsal Stress Fracture Course now!
If you have a question that you would like answered as a future edition of the Doc On The Run Podcast, send it to me. And then make sure you join me in the next edition of the Doc On The Run Podcast.
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