Dr. Christian Bigosinski (Guest): I’ll make the analogy of a paper clip getting bent back and forth, and that’s what out bone does when we run. We bend those bones back and forth. If you bend that paper clip back and forth long enough, the middle of that paper clip starts getting hot and then eventually it can break and our bones can do the same thing and that’s what happens in a stress fracture.
Melanie: How does that happen with runners? You’re out there running on the streets. Is it something that’s acute, chronic, does it happen all of a sudden?
Dr. Bigosinski: Build up to it is usually chronic. When we go back and talk to these folks about the history, they say, “Yeah, sort of sore in that area for a few weeks and then one day, I was running and then I felt a really intense, more acute pain.” That soreness that they have early on is more of what we call a stress reaction where that bone is getting irritated or inflamed and then that really acute, sharp pain is when that bone actually fails or breaks.
Melanie: Wow. If you’re running and you start to feel this pain, what do you suggest and where are they going to feel this pain in the stress fracture? Is it more in the heel? Is it in the back, in the gastrocs? Do they feel it more like a shin splint?
Dr. Bigosinski: The most common areas for stress fractures in runners are definitely the shins or the big shin bone, the tibia in the lower leg, as well as some of the small bones in the foot. Some people might start getting pain on the outside part of the foot; that’s a very common area for stress fractures in runners. Rarely folks can get them higher up in the pelvis area, either the femur which is the large upper thigh bone or in some of the bones of the pelvis itself. Most commonly, folks are going to feel this down in the shin or in the foot.
Melanie: If someone suspects that they might have a stress fracture, they come to see you and what can they expect? Do you generally do X-rays and what are some of the treatments?
Dr. Bigosinski: Oftentimes, we will get some imaging such as an X-ray just to make sure that there isn’t anything else going on. If the X-ray looks normal, occasionally we’ll get another test like an MRI or a bone scan to confirm the diagnosis. The treatment of these depends a little bit on how chronic or how acute they are, and oftentimes the mainstay of treatment for this is what we would call relative rest, so staying away from activities that cause recurrent pain in the area. If it’s in a high-risk area, sometimes we do put folks on crutches or put them in something like a CAM walking boot, which is like a removable cast that they can wear.
Melanie: Taking a runner off the street is no mean feat. They do not like to have to stop. Do you advise during that time so that they feel like they’re still doing something that they cross-train, maybe swim or bike? Or is it no go for really any kind of exercise?
Dr. Bigosinski: Absolutely. That’s one of the challenges in treating active people is that you want them to stay active and maintain some level of activity, so doing things that are less weight-bearing like riding a bicycle either outside or riding an exercise bike might be tolerable and might not cause pain for folks and that’s certainly okay. Or getting them in a pool and having them do some water jogging or swimming is also another choice. Then there is more elaborate equipment such as harness or pneumatic running systems that folks can use to maintain some level of running but helps take some percentage of their body weight off. There’s a lot of options that we have in treating these and allowing runners to stay active while they’re healing.
Melanie: Is there any sort of risk factors that would contribute if they have poor arches or poor running shoes or they don’t have an orthotic and they’re pronating? Do any of those kinds of things and the constant pounding contribute to it or not so much?
Dr. Bigosinski: There are certain anatomic features that might make somebody more prone to this, but the things that we see the most often are some combination of over training and possibly an associated nutritional deficit. In other words, folks aren’t getting enough calories or building blocks back in their body to allow their bones to heal normally. I would say those two causes, either too high a volume of running or not enough caloric intake are the predisposing factors that we see the most often in our office.
Melanie: If you’re giving them some nutritional fact or advice, do you recommend certain things, chocolate milk afterwards, things to keep their caloric content up so they don’t suffer a nutritional deficit?
Dr. Bigosinski: Absolutely. Chocolate milk is a great recovery drink in getting something on your stomach within 30 minutes of finishing an exercise can be really important for recovery. Then there is different ways that we can quantify their caloric intake and how many calories they are burning and that gives us a little bit more specific information of how close they are to their caloric needs. On occasion, I’ll also refer them to a sports dietitian or a sports nutritionist to help with that process, and I think that folks get a lot out of those meetings.
Melanie: Dr. Bigosinski, is there a way to avoid stress fractures completely? Like if you’re going to really examine their training, their running mechanics, their general nutrition as you said, is there something you can tell them about whether it’s cross-training or decreasing mileage or changing it up a little to help them avoid that?
Dr. Bigosinski: Absolutely. I usually recommend a slow increase especially at the beginning of the running season of about 10 percent per week in either the volume that they’re running or the intensity that they’re running at. With that slow increase of about 10 percent per week, that gives the bone time to rest, heal, and remodel so it can take the kind of pounding that you would go through in the course of a busy running season.
Melanie: If they’re starting to feel pain, general soreness, or they think they might be getting close to over-training, do you recommend wrapping, icing, putting the leg up? What do you recommend as sort of some additional ways that they can help themselves?
Dr. Bigosinski: That certainly depends on the specific problem, and with the stress factor, we really recommend rest as the main mode of treating this. A lot of folks tend to run through certain kinds of pain and the red flag for me would be that if their pain is getting more intense earlier and earlier in their run, then that would be a reason for them to come in and see a sports medicine physician to get an accurate diagnosis and figure out what treatment plan would be best.
Melanie: Dr. B, you must see as I do that these runners are a dedicated bunch. If they’re running the speed at which they’re training is something to take into consideration, and so impact and active forces connected to the stress fracture, are you able to convince them to maybe slow it down a little bit, to alternate what they’re doing on any given days so that maybe they’re not as prone to these things?
Dr. Bigosinski: I think the trick there is to get the message across that a little bit of treatment now or an ounce of prevention is worth a pound of cure down the road. If you can halt the process of the stress reaction turning into a stress fracture, and then having much longer recovery time if that bone does fracture, then most runners are able to see the logic behind that. They’re able to take the foot off the pedal a little bit or maybe complement their running regimen with less weight-bearing exercises, again, either in the pool and exercise bike or maybe some weightlifting or cross-training activities.
Melanie: What about the nutritional deficiencies? We don’t have a lot of time, but calcium, vitamin D supplementation, do you advise that for hard core runners?
Dr. Bigosinski: Off the bat, usually not. Calcium and vitamin D are certainly important for bone health, but we haven’t had a lot of evidence to show directly that calcium and vitamin D deficiencies increase your risk for having stress fractures or stress reactions. At the same time, it’s always really important to make sure they are getting the appropriate levels and there are significant vitamin D deficiencies that some folks do have. Again, that’s another reason to see a physician in regard to us so that we can obtain the proper lab work to work that up.
Melanie: Do you see any difference in soft surfaces versus… because I’ve heard some theories that when they run on soft surfaces, they feel like it’s kinder to their body, but yet I’ve also heard that it can actually increase the loading on bones. Does surface matter?
Dr. Bigosinski: It’s interesting. The research on that is all over the place. There doesn’t seem to be a big difference between running on hard concrete versus running on really soft wooded paths. Just like there’s no direct evidence to show that one type of shoe makes you either more prone or less prone to getting stress fractures. That’s something that we still need to continue researching and get a little better handle on going forward.
Melanie: In just the last minute, give us your best advice for runners out there to avoid stress fractures and why they should come to Maine Medical Center for their care.
Dr. Bigosinski: I think to avoid stress fractures, the main thing is really paying close attention to your body and slowly ramping up your training in the beginning of the season. At Maine Medical, we have a group of doctors that has decades of experience in dealing with this types of injuries, and getting an accurate diagnosis is really the most important thing going forward to help prevent this from becoming worse and to get a good plan together to allow folks to continue running through the whole running season.
Melanie: Thank you so much, doctor. That’s great information. You are listening to MMC Radio. For more information, you can go to mainemedicalcenter.org. That’s mainemedicalcenter.org, mmc.org. This is Melanie Cole. Thanks so much for listening.