What is the worst way to tell a stress reaction from a stress fracture? Well, that’s what we’re talking about today on the Doc On The Run podcast.
I lecture at medical conferences about stress fractures, trying to teach physicians the difference between a stress response, which is totally normal and not even a problem, a stress reaction, which is basically an irritated and inflamed metatarsal bone, and a stress fracture where there’s actually a crack that can cause real trouble.
Well, one of the questions doctors ask me is what’s the best way and the worst way to tell a stress reaction from a stress fracture, because it does make a difference. A stress fracture takes a lot longer to actually heal than a stress reaction. So, the very worst way to tell a stress reaction from a stress fracture, unfortunately is actually the normal way and that is waiting until your initial x-rays change and rule the stress fracture in or rule the stress fracture out.
What does that mean? Well, what that means is when you go to the doctor and you have pain, you tell him you’ve been running, tell him you’ve been ramping up, tell him that you’ve been training for a marathon or an Ironman or an ultramarathon, and that your level of activity has been continually increasing, and you started to get this aching pain in your foot, which seems like a stress fracture. Well, they take some x-rays, and if they take x-rays when that process first started, if you have a stress reaction, it won’t show up because there’s no crack. If you have a stress fracture and it’s a very, very small crack, it won’t show up either on those initial x-rays when you go to the doctor.
So, what the doctor does is they say, “Okay, well, based on your story, based on your exam, it seems like you probably have a stress fracture. What we’re going to do is we’re going to put you in a fracture walking boot. We’re going to have you wear that for a month or six weeks. And then when you come back, we’ll take another set of x-rays of your foot. And if at that time we see a change in the metatarsal where it’s trying to heal the stress fracture, then we’ll actually know that it’s a stress fracture and not a stress reaction.”
Well, here’s the two reasons why that’s the worst plan. The first thing is that if you just have a stress reaction, you do not need to be in a fracture walking boot for six weeks. If you wait for six weeks, you are going to unnecessarily lose almost all of your running fitness, and you’re going to get weaker and stiffer and develop all of this loss of neuromuscular connections that keep you coordinated, and all that puts you at higher risk of re-injury later.
The second reason is that it could take up to six weeks or even longer to see a change in the bone that finally makes the diagnosis of a stress fracture. Meanwhile, you’re just sitting around doing nothing, wondering what’s actually wrong.
So, getting the x-rays at the first session with the doctor and then getting them later, either 4 weeks, 6 weeks, 8 weeks, 12 weeks, some other interval is what’s normal, but that is not the best way to do it. That for sure is the worst way to tell a stress reaction from a stress fracture if you’re a runner.