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Ask Dr. Rick – June 2010

June 10, 2010

Dealing with Stress Fractures

As warm weather approaches and athletes start to prepare for their summer training, it is imperative to be very careful of overuse injuries of the lower extremities. The most common is the dreaded stress fracture. A stress fracture is any fracture or microfracture that occurs as a result of repetitive loading to the bone rather than from a single traumatic event. Essentially, the athlete starts to train, there is not enough rest in between training events, the athlete may not be in the best condition, the bone gets overloaded, pain increases, and after a doctor’s visit they are diagnosed with a stress fracture. Unfortunately, stress fractures take a long time to heal. The most common areas of stress fracture include the tibia or the shin bone, the metatarsals, which are the small bones in the feet, the calcaneus, which is the heel bone, and the fifth metatarsal and navicular. Navicular stress fractures and fifth metatarsal stress fractures are generally extremely hard to heal and may require surgery.

So, how do we know if we are developing a stress fracture? The No. 1 symptom is pain. Initially, the pain occurs while running and subsides after the training event. As this gets worse and worse, pain continues after the training event is over and can continue into the next day until it becomes chronic. Frequently, x-rays will not show a stress fracture and the stress fracture will be only evidenced on an MRI or bone scan.

Lastly, the treatment for most stress fractures is to cease training, rest, and allow the fracture to heal. Stress fractures take a much longer time to heal than conventional fractures and have a high risk of recurrence. The best hedge against stress fractures is a significant recovery phase in between training events. This may include taking two days off in between runs until complete conditioning occurs to go along with a healthy diet as well as normal mechanics. If there are abnormal hip, knee, ankle or foot mechanics, this can overload portions of the foot and tibia, and create malalignment and a stress fracture. If pain does not resolve quickly or continues to be a problem after interval training, you need to see your physician for an x-ray and probably an MRI, to rule out the dreaded stress fracture.

Dr. Rick, I have had pain in the back part of my ankle for about four months and recently noticed a lump where my shoe hits the back of my leg. In the morning when I get up, this is extremely stiff and painful. Please help.
– Jason G., Chesterfield, MO

Jason, Thank you very much for participating in our column. You have the beginning of a tear of your Achilles tendon and the ball that you notice is scar tissue with your body trying to heal the tendon. The tendon has been breaking down for a period of time and it seems to have gotten worse as this hypertrophic area is creating a large ball in the posterior aspect of your Achilles. Treatment for this generally is physical therapy with eccentric exercises, stretching and decreasing the activities that seem to be problematic. Ballistic activities, running and jumping should be eliminated until this resolves. If physical therapy and rest do not resolve the situation, you would be an excellent candidate for a PRP injection, which is platelet rich plasma that can actually heal the partial tear of your Achilles. Make sure you have correct shoe wear and that you are trying to stretch two to three times a day, even if it is for very short periods of time.

Dr. Rick, I am a triathlete and wonder if you could help me with my pre-exercise and pre-race nutrition as well as my post-exercise and post-race nutrition?
– Michelle K., Clayton, MO

Michelle, thank you for your question. This is very, very important in terms of conditioning, maximizing your effort during your exercise and race, and optimizing your hydration. Dehydration and depletion of energy are generally the result of failing to recover from your training and allowing yourself to be prepared nutritionally for your activity. In general, pre-exercise meals are used to top off or complete muscle glycogen stores and prevent the onset of hunger and possible weakness during exercise and race events. Eating a large meal three to four hours prior to your activity is generally the most accepted method, but it is important to continue to hydrate throughout the activity. It is also very important in terms of recovery to optimize your carbohydrates and replenish lost stores. It is important to recover muscle glycogen and this can be done taking in an increased percentage of carbohydrates as well as protein-based drinks and nutrient-based drinks, which generally are Gatorade or some form of replenishment, hydration during the race, hydration after the race, and hydration prior to the race. It is not sufficient simply to drink water; some type of energy drink or nutrient-based drink is imperative. These principles are very important to maximize training and race performance.


Dr. Rick’s medical tip for June: Work out a program where aggressive interval training can be part of your weekly routine to maximize your cardiovascular tone and improve your performance

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