#412 Runner with a stress fracture that was never broken - DOC

#412 Runner with a stress fracture that was never broken

Today, on the Doc On The Run podcast, we’re talking about a runner with a stress fracture that was never broken.


All right, when you hear this title you’re probably thinking, how is it that a runner can actually have a stress fracture that was never even broken in the first place? Well, this is a real-world situation that I had with a runner who called me for a second opinion. It was someone with a stress fracture that was actually told they have a stress fracture, had an MRI that showed a stress fracture. The doctor said it was a stress fracture. But it wasn’t actually a stress fracture at all.

So what happened in this situation was there’s a patient who had chronic plantar fasciitis. Now that’s just irritation of a ligament on the bottom of your foot. She’d been running. It had been bothering her. She wanted to know if she had a partial rupture or something else worse going on, and she got an MRI. Turns out she’d been running a lot, in spite of this pain in her arch and heel, and she got an MRI and it showed some inflammation in her fourth metatarsal bone.

Well, the signal change that the radiologist notices on an MRI that suggests that you have increased inflammation within the bone, on the MRI, is then read as a stress fracture. Specifically, a Grade I stress fracture on this scale called the Kaeding-Miller Classification Scale.

And in that scenario, according to this classification scheme, a Grade I stress fracture is where you have no pain, you have some imaging abnormality like signal change or edema within the bone on an MRI, but there is no crack anywhere visible on medical imaging. Not on x-rays, not on an MRI, not on an ultrasound, not on a CT scan. Nowhere, no crack identifiable anywhere. So there’s actually no crack. If there is no crack, it is not technically speaking a fracture. It’s not actually broken.

So what that means is that this runner who had inflammation within the bone actually had this thing that we call a stress response. It’s not a stress fracture. It’s different. A response is a normal physiologic thing that happens in tissue in response to forces that have been applied to it, to stimulate stress and growth within the bone.

Just like when you stress your biceps by lifting up weights and doing curls over and over and over in the gym, while that stresses the muscles, they become sore, you get a little inflammation within the muscle. That is part of the repair process. The muscle gets repaired, it gets stronger and then you can do more curls later with heavier weights.

The same thing happens in your feet. It happens in the metatarsal bones. It happens in the tibia. It happens in lots of places where you can get increased signal or increase uptake within this bone that looks like damage to the bone.

But if you have no pain, it is not a stress fracture. It is a stress response. It is a normal thing and you don’t have to mitigate your training if that is your case. So, that’s what I was able to figure out during this telemedicine visit with this runner and of course she was very relieved to know that it wasn’t really a problem.

Now, of course I gave her some stuff to do in addition to that, to make sure that it didn’t become painful, because if you have a stress response and you really beat it up enough, it can then turn into a stress reaction, which can then turn into a stress fracture, which actually is a problem.

So don’t take this as advice to tell you can just run if a doctor told you have a stress fracture. You need to go back to the doctor or go get a second opinion from someone that actually understands the difference between those things, or you need to figure out the difference between those things yourselves, so that you can make the right decision for you. And so you can get back to running as quickly as possible.