#428 My doctor said my stress fracture is a delayed union - DOC

#428 My doctor said my stress fracture is a delayed union

My doctor said my stress fracture is a delayed union. What does that mean? Well, that’s what we’re talking about today on the Doc On The Run Podcast.


This is a question sent in by a listener to the Doc On The Run Podcast and this is someone who’s had a stress fracture, and it’s now turned into what the doctor called a delayed union. So she said, “My doctor has told me that my stress fracture is now a delayed union. What does that really mean? What is a non-union? What’s a delayed union?” And all that. And so, this is a great question.

Now, stress fractures are actually graded by one classification scheme and broken down into five different grades, grade 1, 2, 3, 4, and 5.


Grade 1 Stress Fracture

A grade one stress fracture is not really a stress fracture at all. Believe it or not. So even though it could be called a grade one stress fracture. What that means is you actually have an imaging study, like an MRI, and you have something that looks abnormal in the bone, but it’s not pathologic. It just looks abnormal on an MRI because you have an actual healing response taking place.

So let’s say you’re a marathoner, you’re training for a marathon and you train a lot and you go to get an MRI because you think you have a plantar plate sprain because it’s tender where your plantar plate is and all that sort of stuff.

But then, you get the MRI and the MRI comes back. You have inflammation within the medullary canal of your second metatarsal and the radiologist says, “You have a second metatarsal stress fracture it appears, based on your MRI.” And your doctor pushes on it. You push on it. You don’t feel any pain there.

If you have no pain, but you have this imaging study that shows it’s abnormal, well, that’s not pathologic. It’s not actually a problem. It just looks like a problem on your MRI. And in that case, you should not even change your training program according to some of the research that’s been published. So, that’s a grade one stress fracture.


Grade 2 Stress Fracture

A grade two is where you actually have pain. Well, that’s a stress reaction. There’s no crack in the bone, but it looks abnormal on your MRI and you have pain. That’s a stress reaction. That means it’s very angry and it’s about to turn into a real stress fracture.


Grade 3 Stress Fracture

A grade three is a real stress fracture. If it’s in place and it has a little bitty crack, but it’s still aligned properly and it hasn’t moved out of position, that’s what it is.


Grade 4 Stress Fracture

A grade four is where it’s displaced, meaning it’s broken, it’s moved. If you look at the X-ray on your foot, the metatarsal bone is actually bent and out of position. That’s a displaced fracture.


Grade 5 Stress Fracture

Now, a great five is where that fracture has not actually healed. So there’s now a dead space between the ends of the bones where it’s not healing and that’s what a non-union is. It’s where the bone did not unite and it did not come back together and in that classification scheme, a stress fracture that turns into a non-union where it is not healed, is a grade five stress fracture. That’s the worst of the kind of stress fracture you can get, because it’s not healing.


Why does that happen?

Well, several things can cause that to happen. One of them is too much motion and that’s a really common thing. So there’s a slide I have in the talks that I use for physicians when I lecture at medical conferences on stress fractures and runners. And it has a huge bone callus, and this is where it forms a lump of bone around the fracture.

If it develops a lump of bone and a very large callus, that often indicates that your body’s trying real hard to stop all the motion at that fracture site. But because you’re walking on it a lot or you’re running on it a lot, or you’re putting too much stress and strain on that metatarsal, well, it’s not healing and it can’t heal, but it’s trying real hard. So it’s got lots of bone forming around that fracture, but we can still see the fracture line. So even though it’s forming this bone to block that motion, it’s still happening. It’s not healing.

At some point, basically you start to develop scar tissue between the ends of the bone and that actually can block the healing from happening and for it to actually bridge bone across the fracture and completely heal. So, if you’re in this state where your doctor says, “You have a grade five stress fracture or you have a stress fracture that’s turned into a delayed union,” it’s really important to stop and reassess. You have to do something. You need to figure out what happened.

It doesn’t mean that you did something wrong and it doesn’t mean that your doctor did something wrong. It’s just not the outcome that you wanted. It’s just not going the way that it should and you have to do something differently. So more than anything else, you need to recognize it. If you have a delayed union and it seems like it’s not healing, you need to really do a careful and truthful self-analysis. Have you really been following the doctor’s directions?

This is is one of those things where it may be worth talking to your spouse or somebody who really knows you to say, “Does it seem like I’m really doing what I was supposed to do? Or have I’ve been doing something that’s really stressing this thing and moving it too much so that it’s actually having a hard time to heal?”

If it’s not healing, if you’re not moving in the right direction, well, you got to do something. And the first thing to do is figure out whether or not you’ve been contributing to the delayed healing or not. The next thing is to get a second opinion.

You definitely need to get a second opinion from somebody who’s going to look at it with different eyes and think about a new approach because if you keep doing what you’re doing, you’re probably going to keep getting what you’re getting.

If it’s been months and you’re not moving in the right direction, there’s no reason to believe if you keep going down that path, it’s suddenly going to get better. You do not want to think about it that way. You should definitely get a second opinion. So you can come up with some new ideas, some new strategies and a new way to try to get this thing to actually heal so you can get back to running.