This Sunday the Grizzly, a multi-terrain 20mile race (and 9 mile Cub race) is for the 29th year taking place on the East Devon coast. It is organised by the Axe Valley Runners and is a well known off road long distance race enjoyed by many the avid runner across the country. More than 2000 runners will have been preparing for this event over the last few months, training through the cold wet days of the winter. We have a number of First Physio patients taking part again this year as with the nature of the training for such an event even the most balanced and gradual training plans can lead to injury or niggles. Fortunately this year all that have come for advice and treatment are doing well and will be running on Sunday. However, last year this wasn’t the case with a rare (thankfully) but very limiting injury presenting itself 6 weeks before the event.
The scenery of the Grizzly is spectacular but to have such views you have to climb hills... and lots of them on uneven surfaces. The 20 miles course covers an ascent of 3500 feet! There are steep cliff paths, bogs and two sections of pebbly beach. Hence any good training program for such an event should include good mileage but also completing some of these miles on uneven surfaces. This is exactly what one of my patients last year was doing. He was a Grizzly veteran having done a number before and was following a similar pattern of training, the only difference being he had started slightly later with his training.
He presented with what he thought was an annoying niggle that wasn’t going away on the outside of his foot that he thought was a muscle pull but his frustration being he couldn’t ‘run through it, it makes me stop and walk a bit’. It became clear quickly that it wasn’t a pulled muscle or a shoe issue as he had hoped but a stress fracture of this 5th metatarsal (outside edge of foot).
There was no way with this diagnosis that I could advise he keep running, he needed to stop and get it imaged which would prove either way if my diagnosis was right. Breaking bad news to patients is never easy but ultimately he wasn’t going to be doing the Grizzly and he wouldn’t be running for 6 weeks minimum. Trying to understand why he had developed a stress fracture was something both the patient and I wanted to try and work out as a lot of the risk factors weren’t present in his case. The only links that could be made were the increase in training more quickly than previously attempted and increased body weight.
Back in July 2015 Jonathon Brownlee (Olympic triathlete) updated the world media via his twitter page that he had been diagnosed with a femoral stress fracture (thigh bone). Even an elite athlete with all the highly developed sports science and training given to him, he developed a stress fracture. Ultimately, why such an injury occurred I am sure will have been scrutinised. Achieving the ultimate training goals and high performance runs a fine line next to injury and even with the best athletes sometimes it is crossed (as Jonathon Brownlee's example shows), but this is part of being an athlete whether elite or recreational and its how the person responds to such a situation which will be key to his future success and recovery.
My patient will be running on Sunday with a smile upon his face...some of the way at least. His training this year having been increased more gradually with a good amount of time having been spent in the gym developing his global strength as well as the mileage on the ground. I look forward as I always do to the texts and emails on Sunday and Monday to tell me the successes, times and funny events that have happened.
Good luck to every one competing on Sunday – have fun on the Grizzly!
Below I have provided a brief explanation of what a stress fracture is and how it may be managed. Please do remember it is a rare injury!
What is a stress fracture?
Stress fractures are overuse injuries of bone, and may be defined as partial or complete fracture that results from repetitive application of stress of less strength than that required to fracture bone in a single load. There results in an imbalance between bone formation and resorption as a result of an excessive repetitive load.
Excessive force or too repetitive a force, beyond what the bone can withstand can lead to bony damage occurring. This initially results in a bony stress reaction; however, with continued use damage may progress to a stress fracture.
There are two main groups in the general population that are very susceptible stress fractures: athletes and military recruits (although they tend to fracture in different parts of the bone and areas which relates to the different loading patterns of an athlete compared to a military recruit). As a result, much of the research based on stress fractures tends to come from the military population as a result of the frequency of this type of injury, including our local Marine recruits in Lympstone.
Prevalence of stress fractures
It’s important to remember stress fractures account for between 1% and 20% of all athletic injuries, with 80% of stress fractures in the lower extremity (Kahanov et al, 2015). They are rare!
What are the symtoms?
Recognition of the symptoms is often difficult and often ignored by an athlete initially and difficult to detect as a physio. The clinical picture or story is the key in my opinion and understanding the patient’s journey to the point of attending physiotherapy over the previous few months is so important.
The list is not exhaustive: Vague pain that is not related to a specific structure, diffuse tenderness around the area, no known trauma to that area, increased pain with weight bearing, pain at night, pain at rest (constant low grade dull ache).
What could be the cause?
Change in training load / overtraining / training with no plan or rest days, change in footwear or surface running / weight bearing on, metabolic issues effecting bone density...again it’s not exhaustive and in fact much more complex than this.
If you suspect a problem or stress fracture
Getting the correct diagnosis is so important; do not bury your head in the sand!
Most stress fractures are managed with clinical findings and diagnosis alone and recovery fully as a result. However, you need to get the correct advice early, it is not something you can train through and is unlikely to just ‘go away’ unless you have an rest from weight bearing for another reason for a number of months and then it could still come back without a graduated return to loading / rehab plan.
Elite athletes will be given immediate imaging of the bone (bone scan, CT Scan and/or MRI ) to establish if the clinical diagnosis matches the imaging. On x-ray, unless the stress fracture is so advanced an actual fracture has occurred will not show any bone reaction that may be present so may actually be normal despite there being a problem with the bone.
Seek professional advice and assessment if you are in doubt.
Chartered Physiotherapist MSc, BSc (Hons), MCSP, MHCPC
Owner First Physio
Disclaimer: The opinions expressed are those of First Physio only and do not constitute medical advice.
- Stress fractures of the femoral shaft in athletes: a new treatment algorithm. A Ivkovic, I Bojanic, and M Pecina, Br J Sports Med. 2006 Jun; 40(6): 518–520.
- Stress fractures of the femur in athletes. DeFranco MJ1, Recht M, Schils J, Parker RD. Clin Sports Med. 2006 Jan;25(1):89-103
- Diagnosis, treatment, and rehabilitation of stress fractures in the lower extremity in runners.Kahanov L1, Eberman LE2, Games KE2, Wasik M2. Open Access J Sports Med.2015 Mar 27;6:87-95
- Femoral shaft stress fractures in athletes. Hershman EB1, Lombardo J, Bergfeld JA. Clin Sports Med.1990 Jan;9(1):111-9.