#498 Best way to tell a stress fracture from a stress reaction - DOC

#498 Best way to tell a stress fracture from a stress reaction

Today on the Doc On The Run Podcast we’re talking about the difference between stress fracture and stress reaction.


Metatarsal stress fractures are one of the most common overtraining injuries afflicting runners. Much of the time the stress fracture is preceded by what we as doctors call a “stress reaction.” If you ignore the warning signs of a stress reaction and keep on running in the same way, applying the same stress, the stress reaction will advance to a full on stress fracture that can keep you out of training for months.

Most people think an X-ray of the foot is the best way to tell the difference between the stress fracture and a stress reaction. But that assumption is false.

If you’re trying to figure out whether or not you’re in the early phases of the stress fracture injury process you have to take action to figure out what is going on immediately. This episode will explain that process.

Every single day I think about running injuries, talk about running injuries and talk to injured runners who were trying to continue to run and heal, while they heal their running injuries.

In my experience most injured runners misunderstand this process. In fact, many doctors misunderstand this process as well. We all want something simple like an x-ray of the foot or an MRI to give us a clear picture and a concrete answer immediately. If your doctor is unsure whether or not you have a problem with the metatarsal bone, one of the extensor tendons, or one of the neighboring joints, then an x-ray or an MRI might be useful.

But if your doctor, or if you as the injured runner are already convinced you have a stress related problem like a metatarsal stress fracture or metatarsal stress reaction, then there is often a serious problem with ordering both of these studies.

An x-ray of the foot will only show 2 things:

1) a severe stress fracture that has a significant crack in the metatarsal bone.

2) a stress fracture that has been present for a long time and already started to heal.

An MRI of the foot will only show 2 things:

1) a severe stress fracture that has a significant crack in the metatarsal bone.

2) inflammation within the metatarsal bones that may be over read by the radiologist and actually called a stress fracture when it’s really only a stress reaction.

Let’s imagine you are worried you had a stress fracture. You decide to call me for a second opinion WebCam visit so we could discuss it and decide how bad it is.

You might think the first thing I would do is order an x-ray or an MRI. But you would be wrong.

Here’s what I would ask you to do.

  1. Get your base numbers on how much pain you have. Rate everything on a scale of 1 to 10. How much pain do you have sitting in the chair, right now? If the number is zero write it down. If it’s a 2 out of 10 write that down. How much pain do you have walking around your home with shoes on? How much pain you have walking around barefoot? How much pain you have walking up or down the stairs? How much pain you have on carpet vs. hardwood floors vs. tile? Write all of your base pain numbers down so you can compare those numbers to what you’re about to do next.
  2. Try to remove some stress off of the metatarsal using any of the different methods I illustrate and describe in the Metatarsal Stress Fracture Course for Runners. Let’s say you add some padding. Walk around and get your numbers again. Write down all of those numbers as well after you try it out and see how much better it feels.
  3. Figure out how much the pain is caused by inflammation, and how much pain is attributable to just the bone injury, whether it’s a stress fracture or stress reaction. There are several different ways to do this which I describe all of them in detail in the Metatarsal Stress Fracture Course for Runners. Many runners want to take ibuprofen. But taking anti-inflammatory medications at this stage of your evaluation process is a bad idea. Ibuprofen can simply decrease your ability to feel the discomfort and that is completely counter to the process at hand. Most people want to apply and ice pack to the top of the foot. This can reduce some inflammation but it’s not the best method because it doesn’t decrease the temperature deep within the foot. You can completely submerge your foot in ice water. That is certainly more effective. But an even better method of removing the inflammation in and around the injured metatarsal bone is to do the contrast bath routine. There is a whole lesson that explains exactly how to do that in the Metatarsal Stress Fracture Course for Runners.
  4. So to recap, when doing your web cam second opinion call, I would ask you to get all of these base numbers first. Then you get a second set of numbers by removing some of the stress and strain to the injured metatarsal bone. Of course, we would discuss the particular method that would be best for you based on your circumstances. After that we would discuss the best message of reducing the inflammation in the injured metatarsal bone.

The assessment process from there is actually very simple. If you have a stress reaction you should expect a huge improvement in the amount of discomfort or pain, you have once you’ve removed inflammation.

If you have a severe stress fracture with an actual crack in the bone, you won’t see much improvement at all.

When you reduce all of the stress and strain applied to the specific injury metatarsal bone a mild stress reaction will improve greatly.

Let’s give an example.

You have no pain when you’re sitting on the couch, which you would rate as a zero.

You have a pain level of 2/10 while walking barefoot on carpet.

You have a pain level of 1/10 while walking around the house wearing running shoes.

Then you modify the insert in your running shoes and your pain goes to zero.

A freshly cracked or fractured metatarsal bone will never be a zero when you’re walking around, even if you do make some modifications in the insert in the shoe.

But what all this tells you most importantly is how much activity you can actually do. An MRI or an x-ray would never give you that answer.

The most important goal when you have any over training injury like a metatarsal stress fracture is to figure out how to maintain your running fitness by reducing the stress and strain to the injured metatarsal bone…so you can keep working out!

You can only do that if you have a clear picture of the severity of the injury, which you can only get by testing different methods of removing the stress and strain to the metatarsal bone while you are simultaneously reducing the inflammation contributing to the pain level.

And just as a side note, although the fracture walking boot is the most common treatment prescribed for injured runners with these kinds of injuries, it is something I rarely use for any significant period of time with injured runners. Although the fracture walking boot will protect the metatarsal bone it will also decimate your fitness.

If you’re not sure exactly where you are in the continuum of injury from stress response to stress reaction to stress fracture, make sure you either go through the Metatarsal Stress Fracture Course for Runners or get a second opinion immediately with someone who understands running injuries. That will help you get back to running as quickly as possible.