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3/3/2016

How Do You Know When You Have a Stress Fracture? | Runner's World

RUNNING TIMES (/RUNNING-TIMES) INJURY TREATMENT (/TAG/INJURY-TREATMENT)

How Do You Know When You Have a


Stress Fracture?
Plus: Info on cortisone shots and orthotics.
By Brian Fullem, D.P.M. (/person/brian-fullem-dpm) MONDAY, MARCH 28, 2011, 12:00 AM
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Sometimes the conventional wisdom isn't so wise. In


running, among the many supposedly ironclad "rules" are
three sports medicine matters that merit debunking. First,
that cortisone shots are an inherently bad treatment and that
you shouldn't receive more than three shots for any injury.
Second, that you can't run on a stress fracture, so if you
have an injury but can still run, then it can't possibly be a
stress fracture. Third, that orthotics can cure every injury.
Let's look at each of these and sort fact from fiction.
MYTH: AVOID CORTISONE SHOTS

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Cortisone is the commonly used term for all corticosteroid
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injections. Cortisone and similar types of drugs are known


as catabolic steroids. Corticosteroids, of which cortisone is
one type, mimic the effects of naturally occurring hormones

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produced by the pituitary gland and serve to reduce


inflammation. The drug can be delivered topically, orally

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(such as prednisone) or injected. My focus here is on the


injectable corticosteroids used to treat running injuries.

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Let me start by acknowledging that, like many myths, the


one about cortisone shots doing damage has some basis in
fact. The contention that you shouldn't receive repeated
injections is valid if many injections are performed at the

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same location in a short amount of time, because in this


concentrated delivery corticosteroids can cause breakdown
in the tissue. For this reason it's important that injections be

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performed around a tendon and not directly into the tendon


itself. (Because there's so little matter around it, one area

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that should almost never be injected is the Achilles tendon.)


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Getting the Shot?


Nerve, tendon, joint and fascial injuries seem to respond
best to a local corticosteroid injection. Some examples
include an interdigital neuroma, plantar fasciitis, peroneal or
posterior tibial tendinitis and any inflammation in or around
a joint. I've found that if there is an acute area of pain about
the size of a quarter, then there's a good chance than an
injection will be successful.
Steroid injections also work better in the earlier stages of an
injury. If an injection has resolved a lot of the pain but there's
still some discomfort, then I might recommend a second
injection. If, however, there's little to no relief from the first
injection, then I typically won't recommend another at the

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same location.

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CORTICOSTEROIDS

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Corticosteroids are described as banned substances if


administered orally, intramuscularly, intravenously or

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rectally. Steroids injected into a joint or around a tendon are


acceptable, but a declaration of use must be filled out by the
athlete.
ANABOLIC STEROIDS

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Anabolic steroids are a different class, and serve to build


muscle and foster faster recovery from workouts. These are
always banned substances in track and field.

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MYTH: YOU CAN'T RUN ON A STRESS FRACTURE


It's simply not true that you can't run on a stress fracture.
Runners typically have a high pain tolerance, and when
endorphins are released during a run this will mask the pain
of most injuries, leading to a false sense of security. It's

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important to pay attention to some of the signs that may

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indicate a stress fracture, including more pain as a run


progresses and a throbbing type of pain after a run is
completed and the endorphins are subsided. Metatarsal

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stress fractures will also be accompanied by swelling;


anytime I have a patient with pain and swelling on the top of
the foot, then I consider a stress fracture as a possibility.

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It's important to note that X-rays often may not show any
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signs of a stress fracture. If you have the above signs of a


stress fracture and an X-ray is normal, follow up with
another diagnostic test such as a bone scan, CT scan or
MRI.

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While you can run on a stress fracture, you shouldn't--doing

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compensatory injury from altering your running form. The


sooner a stress fracture is diagnosed and treated, the faster

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the athlete can return to activity. Consider the case of Rich

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Kenah, who won bronze medals at 800m in the 1997 indoor


and outdoor world championships. When he resumed

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so simply delays healing and will probably lead to a

training for the 1998 season, he developed pain in the


middle of his foot. Kenah was able to run for another month,
albeit in pain, and began compensating, which led to pain
on the outside of the foot. It turns out that Kenah had a
navicular stress fracture (bone in the midfoot) and
compensation for this injury led to a stress fracture in the
fourth metatarsal bone. A long layoff ensued, which
included crutches, a walking cast and a bone stimulator.
Kenah had to miss the 1998 season, but was able to return
to competition in 1999, and he made the U.S. Olympic team
in 2000.

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Some stress fractures, such as of the navicular or cuboid


bones, require more aggressive treatment, including
complete non-weight-bearing and a cast. The most common
stress fractures in a runner include the metatarsal and tibia.
While treatment varies based on the severity and symptoms,

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these two areas usually allow the patient to avoid using


crutches.
MYTH: ORTHOTICS ARE A CURE-ALL

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Orthotic devices aren't a panacea and shouldn't always be


considered a first-line treatment. Unfortunately, in some
podiatry offices plantar fasciitis automatically equals custom
orthotic devices. The reality is that the devices should never
be prescribed for a specific injury without considering the
biomechanics of the patient. Your physician should provide
a good explanation why you should consider a custom
orthotic device; typically, the decision should be based more
on the shape and function of the foot with consideration also
given to the injury being treated.

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Be wary of a medical professional who makes the same


type of device for every patient or restricts the choice of

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materials. I can think of a sports medicine "expert" who has


stated in a public forum that runners should never run in
hard, rigid orthotic devices. In fact, at least three of my

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patients ran in the 2008 Olympic marathon trials in


polyethylene or graphite devices, which would be classified

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as rigid or semi-rigid.
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The fabrication and prescription writing for an orthotic


device is a combination of science and art. The fabrication
of the device is the most important part. If a device is being
made with the intention of correcting a biomechanical flaw,
then stepping in a foam box to fabricate the device isn't
going to provide as good a device as the use of plaster will.

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There are certain injuries that classically respond better to a


custom orthotic device, including plantar fasciitis, medial
tibial stress syndrome (shin splints) and posterior tibial

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tendinitis. However, it's extremely important to combine the


injury history with a thorough biomechanical and gait
examination to determine if the injury is related to how the

foot is functioning. If a device is prescribed, it should be only


a part of the treatment plan rather than the sole treatment.

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There are certain conditions or injuries in which the medical


literature recommends custom orthotics, even though there's
little to no scientific evidence to support these claims. Two
of the conditions that come to mind are iliotibial band
syndrome (ITBS) and hallux abducto valgus (bunions).
Some physicians may claim that the custom device may
help prevent the progression of bunion deformity, but there
are no studies to support this assertion.
ITBS may in some cases get worse with use of a custom
orthotic device. Michael Fredericson, M.D., at Stanford
University has clearly shown in several studies that the most
important component to treating this injury is to strengthen
the core muscles, in particular the hip abductors. I would
seriously question any medical professional who uses a
functional custom orthotic device as a first-line treatment for
ITBS. The condition is more commonly found in
underpronators with a high-arched foot type. If an orthotic
device is for this injury, then most times it should be a softer

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device to aid in shock absorption and possibly promote


more pronation.

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It's also possible to eliminate the use of custom devices if an
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injury has resolved and your mechanics are sound. I always


ask patients who have used orthotic devices for a long time

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why they were originally prescribed and if those parameters


still apply. Occasionally I'll recommend that a patient stop
wearing the devices, but this should be a gradual process,

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as the feet may need to be strengthened. Unless there's


pain throughout the day, I almost always recommend my
athletic patients use the devices only when working out

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because of the weakness that can develop from constant


wear.

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Sports Med Caveats

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One of the most important concepts an injured athlete needs


to consider is the choice of medical specialists.

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Check out advertising for medical providers and most will

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list sports medicine as their interest or one of their


specialties, particularly podiatrists, orthopedists,

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chiropractors and physical therapists. Unfortunately, there


are no guidelines required to proclaim oneself a sports
medicine expert. Fellowship training programs do exist,
wherein doctors can train under acknowledged top sports
medicine practitioners. For a podiatrist, becoming a fellow of
the American Academy of Podiatric Sports Medicine is the
top credentialing that can be obtained to show competency
in sports medicine.

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When trying to find a good sports med doctor, remember that


it's the medical professional's duty to provide their patients
with a diagnosis and a treatment plan that not only heals the
injury but also identifies the cause in order to prevent
injuries. That big-picture approach is the essence of sports
medicine.

www.
Brian Fullem is a fellow of the American Academy of
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Podiatric Sports Medicine whose medical practice is located


in Tampa, Fla. A longtime runner with a 14:25 5K PR, his
website is docfullem.com (http://docfullem.com).
SEE ALSO:
A Stress Fracture Primer
(http://www.runnersworld.com/injury-treatment/stressfracture-primer)
Avoid Shin Stress Fractures
(http://www.runnersworld.com/injury-treatment/avoid-shinstress-fractures)
What is the difference between a shin slint and stress
fracture? (http://www.runnersworld.com/injury-preventionrecovery/ask-doctor-shin-splints-or-stress-fracture)

howTags: RT April 2011

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Achilles Tendinitis
Lower Leg

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(/tag/achilles-tendinitis)

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Stress Fracture

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