Why is Physical Therapy Important After Being Diagnosed with a Stress Fracture?

Here is a sample statement that I have heard from many runners over the past few years:

Runner: “Oh, I have never needed physical therapy, my only injuries have been stress fractures.” After this statement, we generally talk for a little bit longer, I ask a few questions, and oftentimes it comes up that the stress fractures have been a re-occurring injury.

People, including runners and physicians alike, think that rest (i.e., omitting running from daily activity) is the treatment for the diagnosis of a stress fracture. And, yes, rest is an important part of the healing process, however, it does not address the CAUSE of the injury in the first place.

Finding the cause of the injury is what makes me and my colleague, Pieter Kroon, tick. If we cannot identify the reason that the specific bone or tissue broke down, then we are doing you and injustice and you are likely to suffer another, similar injury. It is only a matter of miles until the same, unaddressed pattern contributes to another frustrating breakdown.

I cannot tell you the number of athletes that I have encountered that have had multiple stress fractures or stress reactions to the same bones. That should not happen! If you are able to identify and treat the cause of the injury, the injury should not return.

As expected, orthopedic physicians generally approach running injuries with their orthopedic training. If there is no physical trauma sustained, as there is with the majority of basketball, baseball and football injuries, then they get a little baffled. As a collegiate cross country and track athlete, whenever I saw the team physician for a running injury, they always said “you are just running too many miles, your body is breaking down, take a couple of weeks off.” A couple of weeks off!?!? I’m sure that several of you reading this have heard this same frustrating suggestion. Like most of you, my response was always: I am in the middle of my competitive track season, I cannot afford to take a couple of weeks off! It was very hard to hear those words and abide by that advice when something inside of me knew they were missing an important piece of the runner-injury problem. We are runners; we perform a repetitive motion over and over, mile upon mile and day after day. We are not hit or tackled or pushed in the same sense that court-sport athletes are. The cause of our injuries is a little different.

If I am truly running too much, why is it that my left fibula sustained a stress fracture and not the right? I run the same number of miles on both legs, both my left and my right foot hit the ground the same number of times and take the same amount of body weight through them. If it is truly a matter of “over training” then why are both legs not fractured? It bothered me that doctors prescribing rest could never answer that question. However, the occurrence of stress reactions/fractures can be relatively easily explained by looking closely at the biomechanics of walking and running.

In an effort to explain our thought process, I will use the example of the left fibula stress fracture, a common runner injury.

The talocrural joint (ankle joint) needs to extend15-20 degrees in order to for you to propel yourself forward during the running stride. The subtalar joint (the joint between the heel bone and talus bone) needs to invert during push off and evert 10 degrees upon landing. This is very important, as the eversion of the subtalar joint allows the midfoot to unlock during landing so it can function as a shock absorber. Then on push off, the inversion of the subtalar joint locks the midfoot, so the foot can function as a solid lever.

If there is a restriction in either one of these main joints, it throws off the shock absorbing capabilities of the foot and ankle which, in turn, can allow for certain areas to take more shock and forces than they are designed to take. The fibula is only designed to take 20% of our body weight and is frequently described as a “non-weight bearing bone.” How then, does this bone sustain a bone stress injury?? Well, if the mechanics of the foot or ankle are off, say, for example that the talocrural joint dorsiflexion is limited to only 5 degrees, then the patient will evert their foot in order to keep running and these compensatory motions can transfer more stress to the fibula. Mile upon mile, foot strike upon foot strike and the fibula will eventually break down.

When this injury is presented to a physician, they generally tell you to stop running for 6 weeks to allow the bone to heal, or worse, they stick you in a walking boot and then 6 weeks later the athlete expects to just take the boot off and start running again. The bone is healed, this injury is over, time to move on. Unfortunately, this tends to not be the case. Frequently, since the cause of the problem was not addressed (in this case, the restriction in talocrural joint mobility) over time, the stress fracture will return and the runner is now in a horrible cycle of injury, rest, injury and your season is over.

Moral of the story: If you are diagnosed with a stress fracture, see a manual orthopedic physical therapist, have your joint mobility assessed, find out which muscles are strong and which ones are weak. Spend time addressing this root cause of the injury and come back 6 weeks later ready to train and not worrying about sustaining another stress injury.