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Cross Country season is over and one of our biggest battles is preventing stress fractures in the fall!

We see a great deal of endurance athletes at Dr Mark Kemenosh and Associates, which range from runners to cyclists, to swimmers, as well as putting them all together in the form of triathlons.  We have truly started to pride ourselves in being the doctor’s office that most endurance athletes in the area turn to for treatment and advice.  With cross country season being in full swing now this far into the fall, we are starting to see an uptick in stress fracture related cases.

The Mayo Clinic’s online definition of stress fractures is stated as:

Stress fractures are tiny cracks in a bone. Stress fractures are caused by the repetitive application of force, often by overuse — such as repeatedly jumping up and down or running long distances. Stress fractures can also arise from normal use of a bone that’s been weakened by a condition such as osteoporosis.

Stress fractures are most common in the weight-bearing bones of the lower leg and foot. Track and field athletes are particularly susceptible to stress fractures, but anyone can experience a stress fracture. If you’re starting a new exercise program, for example, you may be at risk if you do too much too soon.


While starting to research this blog post, I couldn’t help but notice a great article written by Thomas C. Michaud, D.C. and published in Competitor Magazine on February 11th, 2014.  Dr. Michaud stated (with references) that in the United States, one in five runners will sustain a stress fracture which means the US running population creates around 2 million stress fractures per year.  Dr. Michaud references a very good study done by Matheson which evaluated 320 athletes with stress fractures.  69% of the population in that study identified themselves as runners, while only 4% were from basketball, 5% from tennis, and 8% related to aerobics class, as the initial cause of injury.  Does this mean that running is bad for you?  No, but you may want to look at my earlier blog posts about running too far, too fast, and the relationships between injury in runners who ramp up their training too quickly.


What was extremely AWESOME about DR. Michaud’s article is that he pointed out that while stress fractures are indeed related to impact forces, that rarely we consider muscle strength as a very important prevention factor when discussing stress fractures.  Dr. Michaud’s thoughts were that:

In many cases, stress fractures are not the result of weak bones cracking when exposed to excessive stress, they are the result of various biomechanical factors in which healthy bones break down when exposed to otherwise manageable impact forces. Though rarely considered, muscle strength plays an important role in the prevention of stress fractures. In an interesting study of muscle volume and the development of stress fractures, researchers from Australia (3) determined that a 10-millimeter reduction in calf circumference was associated with a fourfold increase in the incidence of tibial stress fracture.


So if you are feeling recurrent pain in your legs, and you think a stress fracture could be in play, when should you see a doctor? 

You should contact a doctor if the pain becomes severe or persists even at rest.  Stress fractures are most often caused by the repetitive application of a greater amount of force than the bones of your feet and lower legs normally bear.  Bones are alive, we rarely think of them of being alive, but they are constantly growing and resorbing.  Bone growth and resorption is a constant process which goes on night and day, never stops.  When we exercise and put weight through our skeletal system, it gets denser, meaning the bones actually get stronger.  A stress fracture is most often caused by forces increasing into the bones without the ability of the bones getting denser.  In a nut shell, repetitive force into the bones causes turnover of bone cells, but you actually do this while your rest.  So recovery times are key during any time that a stress fracture is present.

Before coming to see a doctor, the following things are great to be ready to tell us.

What activity makes your symptoms better worse?  What other types of medical problems do you have?  If you are female, are you having regular menstrual periods?  What types of medicines and supplements do you take regularly?  What type of sports are you involved in?  Are you still able to practice or compete in those sports?  Who else have you seen for this injury, if anyone?  Have you had any imaging recently for this complaint?

Commonly, depending on your symptoms, the doctor may treat you right away or have you sent for diagnostic imaging.

In most cases, x-rays will be ordered when looking for stress fractures.  With that said, it is important to understand that often times stress fractures are not apparent on x-rays.  It may take a few weeks for stress fractures to show up clearly on x-ray.

MRI is the best tool that we have for detecting stress fractures as MRI can detect areas of inflammation noted as an early stress response.  MRI has the best ability to detect a stress fracture within the first week of injury.  So, in cases with severe unrelenting pain, the MRI allows the doctor to be able to see changes in both bone and soft tissue.

Treatments are variable when it comes to stress fractures depending on the severity and pain response, but here are a few treatments available.

Rest:  Decreasing the bones weight bearing load until healing occurs is often the most important first step to keep a stress fracture from being let go until a full blown fracture starts to form.  Some patients will need to be taken off weight bearing activities while others may be still permitted to walk around lightly.  Another important factor is SLEEP!  For your bones to properly heal, you actually need to get some sleep at night!

Ice:  Ice may or may be prescribed and is dependent on the amount of time since you feel the stress fracture occurred.  Ice can often reduce swelling and relieve pain, however after the initial acute symptoms, ice can often be contraindicated as it can slow healing factors.

Resume Activity:  Once your doctor allows you to resume activities, it may seem like common sense, but you will need to return to activities slowly to stop the possibility of a recurrence.  Activities like running need to be rolled back into SLOWLY, as even after the bone heals, it will still need to adapt to the loads present.  Running on softer surfaces and possible changes in footwear are a great idea to be evaluated.

What can I do to prevent a stress fracture?

In a previous blog post, we discussed a research paper that loosely proved that novice runners who increase their weekly marathon distances by less than 20% each week were very much LESS LIKELY to have an injury versus those who increased their weekly distance by 30% or more.  This study somewhat proves the old adage that “slow and steady wins the race”.  So the take home message here is make changes slowly to any new exercise program.  Set manageable goals and work your way up slowly and move progress along gradually.

Footwear can be huge in preventing stress fractures in the lower body.  Often it seems like common sense, but we forgot that most running shoe companies test their shoes to be effective at shock absorbing for a certain amount of miles.  Shoe fit is also very important.  Some runners can run in anything and not get injured, while others may need a custom fit orthotic.  Runners with high arches will most likely need to select a running shoe built to support height of the arch.  Dr. Kemenosh and our friends at the Running Co. of Haddonfield and Moorestown are both sneaker fanatics who can greatly aid you in a search for the right shoe.

Often times, endurance athletes who get higher into the mileage find that cross training is needed to keep up a high level of exercise that their overall output demands.  You can add lower impact activities to your work outs like swimming, biking, and weight training.  Weight training is often passed over by running athletes and as stated above, an Australian study has loosely proven that muscular strength helps to lower the possibility of stress fractures.

Nutrition, wow, we could actually write another blog post on nutrition alone and to stop from going into all sorts of nutrition information we will simply say that you need to eat well to keep your body healthy.  Often times around our office we like to say, “you don’t put cheap gas in a race car”.

If you or anyone you know is suffering from a common running problem like stress fractures, feel free to reach out to Dr. Kemenosh, Dr. Gross, Dr. Evans, or Dr. Legath at 856-228-3100.  Please note that the information above is strictly information and should be treated as such.  Dr Mark Kemenosh and Associates cannot and will not be held accountable for the information above being misused.  If you come to our office, we always do an examination so we get to the bottom of your specific problem.