Today on the Doc On The Run podcast we’re talking about whether or not you should run when you have a stress fracture in the heel bone.
In this session I’m going to explain to you about whether or not it’s a good idea and how you might be able to run with a stress fracture in the heel bone.
The first thing to think about is like what is a stress fracture in the heel bone. The heel bone is an irregular bone. It’s an odd shape. It’s not tubular. It’s not square. It’s very thin on the outside and it’s sort of squishy on the inside. It’s kind of like a sponge. It’s really kind of like a hard boiled egg. A hard boiled has a hard shell on the outside and if you drop it cracks but it does not really deform and that’s usually what happens with heel bone when it actually fractures. If you drop it hard enough it will completely explode and the shell bursts outward in a bunch of little pieces and then we have to go and try to put it back together.
What we do is we actually put a plate and a whole bunch of screws to suck all those pieces together but it is never perfect. It is never the same again like a real fracture in the heel bone like that where it exploded is no good.
My grandfather actually had one of those when my little brother got a rocket that you pump up and shoot up in the air. You fill up with water, pump it up and shoots up in the air. Of course we went over to my grandparents’ house to show it to them and it landed on the roof. My grandfather climbed up on the roof and when he was getting down stepping off the ladder, the ladder came out from under him and I remember seeing him and can still visualize him actually moaning in pain there on the walkway where he landed.
I thought he broke his leg. A few weeks later he actually took me and my little brother to the circus and interestingly I remember him being on crutches and he had a cast and I actually thought he broke his leg. Many years later I was actually in practice, I had done surgery on someone to fix a fracture of the heel bone on this guy who fell out of a tree while he cutting down a limb and I was explaining to her what I did and she said “Oh that’s what happened to you grandpa.” Well the interesting thing was that she said actually after that happened to him she said he never again took another step without pain.
So two things are interesting about that. One was that I still find it fascinating that I never knew that. That he never one time complained about that pain. I mean he was a tough guy. He was very strong-willed and he didn’t let that bother him. He didn’t let it slow him down. He walks five miles a day well into his eighties. He was very active and it didn’t stop him from doing what he wanted to do. But as my grandmother said it always bothered him.
The first thing is that you don’t want to wind up in that scenario. You don’t want to run on a stress fracture until it explodes and then have pain the rest of the time that you’re trying to run. You don’t want to do that for the rest your life so you have to take it seriously.
Most metatarsal stress fractures by comparison, are structurally more stable than the heel bone. The heel bone when it breaks apart, it’s catastrophic. It’s very difficult to fix. A metatarsal stress fracture, if you break it and you cracked the bone and bones twist and moves out of place, we can still actually put the bone back. We can move it back into position, put a plate and screws on it and it will heal in a way that you should be able to continue to run without any long-term problems. That’s not really true in the heel bone.
With the heel bone if it explodes, it can disrupt the subtalar joint that’s underneath your ankle joint, that’s where all the pronation, supination happens. You can really cause a lot of damage if you blow your heel bone apart. So you have to take it seriously.
Now because this is a serious thing, many people want to get evaluated with an MRI or CT scan or something like that and that is much better than X-ray. On X-ray not a lot shows up. Sometimes you can see a little crack but that’s highly unlikely. What most people think they’re going to see is this huge crack that’s sort of curving around the heel bone that they’ll see that on an X-ray but that’s not what usually shows up, it’s very subtle. It’s a lot easier to see on an MRI.
One time I actually was seeing a runner. She was actually a doctor. She knew the severity of this. She knew how risky it was. I looked at her and she thought she had chronic plantar fasciitis. She didn’t have chronic plantar fasciitis. So after evaluating her and checking her. Just doing the simple test that we do to tell whether or not you do or do not have a stress fracture in the heel bone, I was like look I really think you have a stress fracture in heel bone and she said “Are you sure? I mean I think it’s just plantar fasciitis.” I said “Look I think it’s really a stress fracture in the heel bone and since you don’t believe me why don’t we get an MRI so that you can confirm that you really do have this much more significant, much riskier problem.” She said okay so she gets a schedule for the MRI and then I was going to go see her, she got the MRI, we’re meeting that day in the late afternoon and when I saw I said “How are you feeling?” and she said “I’m pretty sore today” and I sad “Why?” and she said “Well I ran sixteen miles earlier today.” I said “What? You ran sixty miles today. Why did you do that?” She said “Well I knew that you’re going to tell me to not to run so I wanted to fit in one more long run.” Fortunately for her it didn’t blow apart and it didn’t really cause any permanent damage. So she got away with that one.
The first thing is like if you say “Can you run with a stress fracture in the heel bone?” the short answer is probably you could. But it’s very very risky. She did it and got away with it. You do not want to run until you blow it apart. So you have to think about how important is it to run and how damaged is it. Where is it along that continuum like is it just inflaming kind of swollen within the heel bone? Is it really damaged? Is it really tender? Is it really swollen? Is it bruised? You have to figure out how far along your injury is to determine whether or not it’s worth it to run. Once you think about those things, the key here is how important is it to you to run.
If you’ve been training for year and you finally got into Ironman Hawaii, well truthfully for me personally I would do it. It took me ten years to get in the Ironman Hawaii so I would still do the race. Most doctors would say that’s crazy. I know the risk but I really wanted to do Ironman Hawaii for a very very long time. If you decided okay you really want to do a marathon. You only want to do one and you’ve been training really hard and you’ve been training for many many months and the stress fracture is not really that severe. You might want to do some stuff the back off and let it heal a little bit and then still do the race and still be okay. You could do that.
One of the main advantages of a stress fracture in the heel bone, is the heel bone has a great blood supply. It heals faster than any other bone in your body. So when you do get a heel bone stress fracture, you can feel confident that you have to be off of it a lot less time that it would take even for a metatarsal stress fracture to heal. Because of the good blood supply, because of its healing potential if you’re diligent about taking the pressure and removing the stress away from that heel bone, it can improve really quickly. So that’s a huge advantage you can get it to heal quickly.
There are also some other tricks you can do to get it to heal faster too while you’re trying to make the decision about when you should run. But the key here is that it’s not going to take too much for the thing to heal, it’ll heal quickly. Now, if you have a subtle stress fracture it may just take a week or two to get it to heal to the point that you can continue training and running. And then during that period where you’re decreasing your run, you can do other stuff to maintain your core fitness. Do all these other things to try to supplement your running fitness so that you can better protect and better stabilize your foot when you run so you do apply less stress to the heel bone when you run.
There are lots of strategies to try to mitigate the forces to the heel bone and the main thing of course is to try to maintain running fitness and try to stop running for the lowest amount of time, if you stop running at all. You have to take it seriously. You have to really think about what the problem is. You have thing about how bad it is. You have think about what your goal is and then you have to go to your doctor and explain all that.
Here are a couple scenarios. Let’s say you got a stress fracture in your heel bone and you’re a year out from your key race. Okay, if you just qualified for Ironman Hawaii, your foot hurts. You thought it was plantar fasciitis. You go get an MRI or you check it the way that I showed you in the Runner’s Heel Pain course and you decide “Okay, I definitely have a stress fracture in the heel bone. This is definitely not plantar fasciitis.” Well then you know, you have a whole year so you do not want to wind up cracking your heel bone and winding up with problems that sidelined your training for months over the course of that you’re leading up to your key race.
In that scenario I would say, I think you should be very aggressive by getting this to heal. I think you should do everything to make it heal in terms of nutritional supplements, really monitoring your nutrition, really making sure you’re sleeping and hydrating. Doing everything you can to support the healing process and just basically take the time off for the short-term whether that’s crutches or fracture walking boot to maximally speed the healing initially to get it jump-started so that you can ramp up the healing process and then still have ten or eleven months to really train hard for your key race. When you have a year and you get a stress fracture in the heel bone, I think that makes the most sense because you don’t want to monkey with it a few months later. You want to get that over with right now.
The next scenario would be if you have let’s say four months before your key race. You have been training a lot, you still have some key build phases in there but you get a stress fracture. Okay, well in that case then you have to decide. There’s basically two ways to go with this. One of them is to really treat it aggressively. Take a little bit of time off in terms of either not running or immobilizing it, offloading it using crutches or something for a very short period of time to really jump start the healing and then resume your training or you could try to see if you can get away with a lot more activity and then see how you’re doing for your race.
That second idea is riskier. You’ve got to talk about that very closely with your doctor. That’s mainly what I do when I talk to runners. They have these problems in virtual doctor visit. We try to figure out, okay is it worth the risk or not? Is it better for you to do some stuff to maintain a lot of running fitness at the risk of not having it completely healed before your race or is it better to take a little bit of time and get it to really heal quickly and then resume your training but then actually figure out some strategies to try to supplement all that running fitness. So you don’t really lose your running fitness while you’re not “running on it” during that initial period of just a couple of weeks or something. You have to really be thoughtful about that particularly when you’re about four months out from the race.
The last scenario that we are going to talk about is if you’re four weeks out from your race. This is worse. This is what happens to most runners. It’s like they think they have plantar fasciitis and they’re ignoring it. It doesn’t really hurt that bad. It kind of hurts when they’re running. It kind of bugs them. They don’t really notice any bruising. They don’t really think it’s swollen. They just know it’s a little bit bothersome and they think its plantar fasciitis. So you keep training, you keep running, it’s getting a little worse over time but you don’t really notice is get that much worse and suddenly it’s really kind of achy when you’re running.
Now you’re about four weeks out. You’re really right at the end of your training. You have a few more long runs, a few more speed session but truthfully you’re like almost at maximum race fitness. This is really scary to runners because you’re like okay great you go see a doctor, they say “Well you have a stress fracture in the heel bone. You can’t run for six weeks. You can’t do anything. You need to use crutches or something for a month or six weeks.” That’s devastating because this is right when you’re like really really you put in so much effort, so much time and you want to know is this really necessary or not.
Well it’s not always necessary. Again, you’ve got a lot of fitness at this point. You’re not going to lose all of them for four weeks particularly if you’re strategic about what exercises you do, how do you do them and do them in a way that doesn’t put any more stress on the heel bone. Then you can probably maintain all that running fitness, heal the stress fracture enough that you can get through your race without having it blow apart. You just have to talk to a doctor who’s actually going to sit down with you and consider those variables and understand that this race is really important that you really want to do this race. You have to tell them “Look I’m going to do this race”, “Okay I want to do this race. Your job is not to tell me to not run. Your job is to help me figure out what can I do to heal this thing is fast as possible. What can I do to reduce the stress so that it will heal while I do these other things to maintain my fitness and what are the other things I can do to maintain my fitness so that I can actually show up in the race in four weeks with the thing healed enough that it’s not going to blow apart and stable enough that I can do the race without so much pain that it distracts me and hopefully still achieve my goal time.”
If you do all those things, then yes you can run with a stress fracture in the heel bone. You just have to decide is it worth the risk or not. You can do anything you want. You just have to be prepared to pay the consequences. That’s true of all these scenarios. If you’re going to sit on crutches for six weeks and wear a cast for six weeks, you’re going to have to pay the consequences. You’re going to have permanent stiffness and weakness and osteopenia where the other bones are actually more at risk of developing stress fractures later and you’re going to have a whole sort of increased risk of all these other overused injuries later just from the treatment that was prescribed for your heel bone.
Nothing is free in medicine. For everything that you do, there’s a risk and a benefit. But there’s no benefit without risk unfortunately with most of the stuff doctors tell you to do. So you have to decide. Are you willing to pay the consequences? Are you willing to miss your race? Are you willing to use crutches for six weeks? Are you willing to have a little bit of risk while you try to maintain your fitness and then monitor it very closely and provide more feedback going back and forth with your doctor and your coach to see if that’s going to work or not?
You just have to decide what’s right for you. The whole key when you have a stress fracture whether it’s a metatarsal stress fracture or a heel bone stress fracture is to really communicate carefully and be thoughtful about what your most important goal is and then figure out the fastest way to get it to heal and the best way to maintain your running fitness while it heals. If you do that, you can still stay on track with all your running goals.
If you have a question that you would like answered as a future addition of the Doc On The Run Podcast, send it to me PodcastQuestion@docontherun.com. And then make sure you join me for the next edition of the Doc On The Run Podcast!
Dr. Christopher Segler is a podiatrist and ankle surgeon who has won an award for his research on diagnosing subtle fractures involving the ankle that are often initially thought to be only ankle sprains. He believes that it is important to see the very best ankle sprain doctor in San Francisco that you can find. Fortunately, San Francisco has many of the best ankle sprain specialists in the United States practicing right here in the Bay Area. He offers house calls for those with ankle injuries who have a tough time getting to a podiatry office. You can reach him directly at (415) 308-0833.
But if you are still confused and think you need the help of an expert, a “Virtual Doctor Visit” is the solution. He has been “meeting” with runners all over the world and providing just that sort of clarity through online consultations for years. He can discuss your injury, get the answers you need and explain what you REALLY need to do to keep running and heal as fast as possible.
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