#841 Why Stress Fracture Grading is BS for Runners - DOC

#841 Why Stress Fracture Grading is BS for Runners

Today on the Doc On The Run Podcast we’re talking about why stress fracture grading is BS for runners.



I just had an interesting call with an elite runner, who’s a high school cross country runner, and he’s developed a tibial stress fracture or stress reaction. But he thought it was shin splints, and I looked at it with ultrasound, I saw some stuff that made me really worried about it. And I got an MRI to confirm that.

The first question he had was, what’s the grade? And that I think you believe is going to tell you everything that you need to know about your stress fracture, but it doesn’t, and I’m hoping this episode will help explain why.

Grading scales do cause confusion. There are lots of different grading scales when it comes to stress fractures and you have to understand which kind of stress fracture you have, and which grading scale you should even think about in the first place. My favorite one to use and the one that I teach most at medical conferences when I’m lecturing to physicians is called the Kaeding-Miller stress fracture scale. That one has five different rates. Let’s talk about those.

So, you’ve got a  grade one, a grade two, a grade three, a grade four and a grade five stress fracture. Five different ones. Okay, what’s a grade one? Well, a grade one is where you have no pain. So first of all, you have no pain. You wouldn’t be complaining about this in the first place. You have no pain and you do have something on imaging that suggests you’re having a stress fracture developing and also by the way, there is no crack. There is no fracture, there’s no crack. But again, you may see a doctor and they tell you, you have a grade one stress fracture. If it’s this scale, well, there’s no crack, you have no pain,  there’s not a crack in the bone by definition of fracture means you have a crack. There is no pain. It’s not bothering you and you have something that looks funny on the imaging.

If you do a very long run like you did a 50 mile trail race or something and you had no stress fracture, you had no pain in your feet, but you got an MRI, I bet you you’re going to have something that looks like a stress fracture, in which case the radiologist may say that you have a grade one stress fracture, even if you were just doing this MRI out of curiosity, so not helpful at all.

Number two, this is where you also have no crack. You do have pain. Okay, so that’s what the hallmark of the grade two is you do have pain. You’ve got pain that’s related to that area. You push on it, it hurts, you run on it, it hurts something like that. And you also do have something that looks funny on imaging. But again, no crack.

A grade one, this is what I would actually call a stress response. It’s not pathologic. It’s normal and there are studies that show that if you have this you should not, as a coach or physician, you should not mitigate the athlete’s training, you should not reduce the volume, should not do anything. It’s normal. It’s a normal, physiologic response because your body’s getting stronger.

This one, grade two, this is what I call a stress reaction because there is no crack. It can’t be a fracture without a crack. A stress reaction is pathologic. It’s gets getting bad, it’s going to get worse if you ignore it, it’s going to turn into a real trouble and you will get a crack eventually if you ignore it.

A grade three, this is where you do have a crack. You have pain, but it’s in the right position. It is what we call non-displaced. It has not moved. So, if this was the metatarsal bone in a grade three and you have a crack, there’s a crack in here but the bone is perfectly aligned. It’s not out of position. It’s not out of place.

A grade four, that’s where you have a crack, you have pain and it is displaced. “Dis” means not in the right place. It’s moved. It’s out of position. So, in that case,  if this is a metatarsal, it’s moved. So, the bones tilted over, you have a crack and it’s moved. It’s tilted. It’s mal aligned. It’s not in the right place. It’s actually changed its position. That might be a surgical problem so we might have to move it. We might have to actually push it back into position, put a plate and some screws on it to hold it there so it will heal in the right position.

Grade Five, well then what could grade five be if you got this one’s cracked is moved out of position. What can be worse than that? Well worse than that is it never healed. That is actually not a fracture anymore. It’s a thing called a non-union. It didn’t heal. So, a non-union is not a fracture. Non-union is a fracture that was a fracture that stopped healing, got a bunch of scar tissue in between the pieces of bone and it’s not a bone. It’s not a broken bone anymore. It’s a bone that never healed. It’s now two pieces of bone that are separate, and they’re not going to heal unless you do something.

Again, I know this seems complicated. I know that you wish that I could say it’s a grade two and that means you’re going to be off running for two weeks. That’s what most people want me to say or it’s a grade three and you’re going to be off running for three weeks. It does not work that way. You have to understand how to reduce the stress and strain on the piece of bone while you work out, maintain your running fitness, that is the only way to get back to running as quickly as possible.

If you want to understand more about stress fractures, come check out the stress fracture masterclass. It’s where I do a deep dive into all the strategies I use with runners who want to run when they have stress fractures. You’ve got to understand those strategies if you have any hope of maintaining your running fitness and getting back there as quickly as possible. So, come check it out. www.docontherun.com/stressfracturemasterclass and I’ll see you inside.