If you have pain when you run, or even when you walk, you could have a stress fracture. Should you stop running with a stress fracture? I address those concerns in my latest Ask Dr. Geier column.

A runner from Seabrook Island asks:

I am a 51-year-old woman who just began training for the Kiawah 1/2 marathon. After 5 weeks of running injury free, I now have a very painful right hip. I have been resting it for the past 5 days and have been taking Aleve but afraid to begin running again as it is still painful when walking. Any suggestions?

This is a terrific question for a runner, or any athlete for that matter, who increases his or her training over a short period of time. The immediate concern to an orthopaedic surgeon or sports medicine physician is the possibility of a stress fracture. If an athlete increases training and places more stress on a particular bone or joint without enough time to appropriately recover from that stress, he or she risks injuring the bone. Initially this can be a stress reaction, but it can progress to a stress fracture.

Also read:
How long does it take a stress fracture to heal?

Stop running with a stress fracture

Signs and symptoms of a stress fracture

Not all bone pain in runners represents a stress fracture. The most obvious example of this concept is shin splints. However, the description of the onset and progression of the pain is fairly consistent in a runner with a potential stress fracture. In my experience, a runner will present describing increasing pain in a particular bone or joint – one of the bones of the foot, the tibia, the hip, the ankle, etc. – that developed over a short period of time. Usually he or she will not remember a specific injury that initiated the pain. Usually the discomfort starts well into a training run but gradually comes on sooner and sooner with increasing training. The pain usually goes away when the runner stops at the end of the training session. As the symptoms progress, it takes longer and longer for the pain to go away. Before long, if the runner keeps training, the pain persists despite rest at the end of a run and even occurs with activities of daily living. While the pain can radiate into nearby areas, it usually is focused in one particular location.

Also read:
Should a runner worry about a stress fracture in the foot?

Risk factors for a stress fracture

As I said, this scenario usually manifests in runners who are training for a race or competition. Most frequently, I see it in runners training for a marathon or half marathon who are increasing the length of their runs over a short period of time. I also unfortunately see it in high school and college athletes in cross country or track seasons. In both cases, these athletes increase their mileage too quickly. In general, sports medicine surgeons recommend that runners increase their mileage no more than 10% per week. For example, if a runner runs 20 miles per week and wants to increase his or her training, then the first week of increased training would involve running no more than 22 miles.

Note the increased uptake in the midshaft of the tibia.

I think that bone pain in the setting of increased training is potentially worrisome. Evaluation for a possible stress fracture is critical. If a runner tries to continue running despite a stress fracture, he or she risks the stress fracture not healing. It could also progress to a complete, displaced fracture. Evaluation by an orthopaedic surgeon with x-rays, at a minimum, is necessary. Often x-rays can be negative within the first 4 to 6 weeks despite a stress fracture being present. Therefore, if I am suspicious that a stress fracture exists despite x-rays that are unremarkable, I often order a bone scan or an MRI.

Also read:
Stress fracture: 5 serious injuries of the foot and ankle

Stop running with a stress fracture

If the workup determines that a stress fracture is present, I think it’s imperative that the runner (or athlete of any sport) avoids any further repetitive impact. In this case, that would mean stopping training. Obviously that’s not the treatment that the runner training for a marathon wants to hear, and I think that is often the reason that runners especially avoid seeing a sports medicine physician initially. Most stress fractures can be treated with simply avoiding running, but some require walking boots or casts. A few potentially involve surgical treatment, such as some tibial shaft stress fractures and certain femoral neck stress fractures in the hip.

Bone and risk of a stress fracture

A final point to emphasize is that it is important to look for underlying risk factors for stress fractures. Osteoporosis, or even osteopenia (a milder degree of bone loss) puts athletes at risk for stress fractures. Obviously women going through menopause are at risk. High school and college-aged female athletes are also at risk for osteoporosis, although this fact is not as widely known. In this group of athletes, the girls often do not get enough caloric and vitamin/mineral intake to meet their metabolic needs. They also often have irregular menstrual cycles due to their high level of training. The irregular or absent menstrual periods can predispose to bone loss and potentially a stress fracture. This pathology (abnormal menstrual periods, disordered eating, and osteoporosis) is commonly referred to as the female athlete triad. I usually talk to any female athlete who suffers a stress fracture about getting a DEXA scan to assess for any bone loss, and if necessary, recommend that she see a sports nutritionist and/or her obstetrician/gynecologist to evaluate the irregular menses.