#861 Chronic stress reaction versus acute on chronic stress reaction in a runner - DOC

#861 Chronic stress reaction versus acute on chronic stress reaction in a runner

What is the difference between a chronic stress reaction, or an acute on chronic stress reaction in a runner? Well, that’s what we’re talking about today on the Doc On The Run Podcast.



I just had a consultation with a runner, this was the story, she actually had pain that she thought might be a stress fracture that had been coming and going for about a month or so when she’d been increasing her training volume doing training, doing certain exercises that are supposed to build her running fitness, and it seemed to be volume related. Thus, meaning that the more training she did, the more she would notice this discomfort.

But it wasn’t killing her. She wouldn’t have pain walking around. She wasn’t having pain when she got out of bed in the morning. But she was concerned about it. So, we got some x-rays and when we got the x-rays of her foot to look at it, the radiologist mentioned a number of different things that might suggest that this could be an acute on chronic stress reaction. But what does that mean?

Well, chronic means it goes on a long time. It means that you either had a stress fracture or stress reaction that you kept just basically training on and let not letting it completely recover. And so, it stayed more inflamed for longer, or you got one, you let it recover, but then you got one again, by doing the exact same thing the same way, loading the foot the same way and you’ve done that repeatedly over months or years.

Acute on chronic means that maybe you’ve had an excess stress applied to one metatarsal that predisposes you to a stress reaction. It gets inflamed, the metatarsal gets thicker, and then you really flare it up. It’s really like kind of a new injury to that bone when the bone looks like on the x-ray that it’s happened a number of times over the years.

What do you do when you get this episode? What does it mean? I think it may be helpful to actually read to you what was specifically on the x-ray report from the radiologist. So, let me tell you. The first thing was no evidence of acute fracture or dislocation, that means that they don’t see a fresh break in the bone. They don’t see a joint that’s dislocated meaning out of place, and it says joint spaces are preserved.

In addition to that, what they had was mature osseous remodeling sclerosis, cortical thickening and osseous fusion of fourth metatarsal shaft most likely represents a healing chronic stress fracture. And in addition to that, they said cortical thickening of the third metatarsal shaft, so that’s two different bones, third metatarsal, fourth metatarsal and in the third metatarsal shaft, it was most likely representing a chronic stress reaction. Then the recommendation from the radiologist was consider further evaluation with a right foot MRI to assess for acute on chronic stress related changes.

Let’s talk about what these things mean. First of all, the last thing, the recommendation from the radiologist is what? Order a more expensive test from us and let us do that more expensive test so that we can make more money and MRI is not the best way to do this. What the MRI will show you is let’s say you have, let’s talk about the third metatarsal. This is the one that’s the simplest.

The third metatarsal here has this noted thickening of the cortex of the wall of the bone. So, the sides of the bone have actually gotten thicker and as a consequence of the chronic stress, the bone becomes stronger as a consequence of this thing called Wolf’s law, which means that bone will become stronger, get thicker, and become more durable in response to stresses applied to it. That’s why we need to do weight training, when you work out you’ll actually get thicker, more dense bones.

If you do zero activity like you’re in outer space, and you don’t have any resistance training while you’re in outer space, the absence of gravity will let you get osteoporosis. So, your bones get weaker when you remove all stress. So, if you had a third metatarsal that has this increased thickness in the sides of the bone that make it look like it’s been chronically stressed over and over and you’re wondering whether or not that’s the issue right now, an MRI that has no inflammation within the bone inside the bone it looks normal, tells you this is not happening right now. This is definitely old.

The confusion comes in when you have one that is acute on chronic meaning that you it looks like it’s thicker, it looks like it’s old and you have inflammation in the bone that lights up. Well, maybe it’s a new injury, but it doesn’t really tell you if it’s been continual, or if it’s been intermittent. One thing you could do is you’ve got really three different options here.

First thing you could do is yes, you could get an MRI, but that’s the problem that I was just telling you is that it doesn’t really differentiate everything and it doesn’t tell you anything about what you should do as time goes on, because you’ll have remodeling in the bone inflammation that sort of facilitates that remodeling in the bone that looks like it’s something’s wrong with the bone for months. Even when you’re in a normal healing process.

Second option is to get an ultrasound where you actually look at it with ultrasound instead. I know you’re going to say, “Oh, but I heard ultrasound doesn’t work because it doesn’t go through your bones.” It’s not going through the bones, you’re going to the surface of the bone. I actually take an ultrasound unit with me when I see people in person and what I do is I actually looked at this specific one to see, do you have any fluid right over the bone that we can monitor and see change, because if that inflammation goes away, the fluid right over the bone near the covering of the bone called the periosteum, if it all gets resorbed, and it goes away, we know that that’s calmed down, and this thing is over with.

The other thing you can do without any imaging at all is figure out the severity and you track the severity, the same way that I would teach you in the course on how to run with a metatarsal stress fracture. This is the same strategy I teach to you in the stress fracture masterclass. So, you don’t necessarily need an MRI. You don’t necessarily need x-rays or an ultrasound or any of that kind of stuff. You just have to understand how to determine the severity of the injury, how to make sure that you get it to calm down, how to make sure that you start ramping up your activity without making it worse. That’s the big key.

If you want to learn those strategies, come join me in the stress fracture masterclass, I do it live, which you can join me there at www.docontherun.com/stressfracturemasterclass. So, come check it out, and I’ll see you in the training.