"If it Warms Up, it Can't be a Stress Fracture"

And other things I've found to be all wrong about bone injuries

I sat in the orthopedist’s office and rattled off my list of stress fractures: “tibia, femur, sacrum, second metatarsal, calcaneus (three times…), femoral neck.”

Yikes.

If stress fractures had a resume, mine would be an exceptional one. Believe me, it’s not something I’m proud of¹ but sometimes the best way we cope is to laugh about it. At this point in my running career, I may as well put “professional rehabber” on my skill list considering the number of times I’ve done the return to run.

When I suffered my first stress fracture (tibia), I was 27, training for the Chicago Marathon with ZERO idea of what I was doing, zero experience in running, and zero knowledge of what the term “stress fracture” meant. Over the years, I slowly (unfortunately) became more well-versed in the world of bone stress injuries, as well as the things that athletes are taught about how stress fractures present, how they feel, and how they heal. Like so many others, I started off reading Runner’s World articles on “Stress Fracture vs Tendonitis,” where they repeated the same old tropes around how to tell if it’s a stress fracture. Pinpoint pain = bad. Diffuse pain = ok. Warms up = ok. Gets worse = bad.

Doctors and physical therapists would all too often repeat these same maxims.

But somewhere along the not-so-fun road of eight stress fractures, I started to realized that so many things that I had learned about stress fractures were flat out wrong based on my experience. And the more I talked to other runners, the more I realized they also were experiencing the same disillusionment.

I don’t blame the medical profession: I’m sure they have to distill something down into general trends and symptoms and there are some things that won’t fit the mold. The problem is that we, as runners, want absolute clarity, which is not often something you will get with injury.

With the massive caveat that I am not a medical professional, and I seriously love doctors and PTs and everyone who cares for us (and I am SO SO thankful for them!), here are some things I’ve learned along the way that have been true for me and that I wish I had known a decade ago. Please note that this is all my personal experience as a patient and may not hold true for you - as always, listen to your doctors because they know WAY better than I do.

There is a lag on MRIs

In August 2016 I was running through the neighborhoods of Eastern Long Island, cursing the humidity, when a lightning bolt went through my sacrum. It stopped me dead in my tracks and left me breathless. I paused and attempted to continue my run - the sharp pain came right back. Still 2 miles from my boyfriend’s house, I considered whether I could even walk that far with this amount of pain.

I called my ortho, flew back to California the next day, and got an MRI of my sacrum a day later. Clean as a whistle. Ok, must be SI joint, we thought.

But over the next two weeks, any kind of attempt at running would send the searing pain down my sacrum. I walked with a limp. Putting on shorts was unbearable.

2 weeks later, we repeated the MRI and there it was - a grade 4 stress fracture of my right sacral ala.

Clearly, the stress fracture had occurred on that run on Long Island, but for some reason that every doctor acknowledges but no doctor can explain, MRIs won’t show a stress fracture until approximately 2 weeks after the pain first starts (Note: if you are a medical professional and can explain to me how/why this is, please do. I’ve yet to hear a doctor know why this happens and would LOVE to hear!).

For this reason, I will always wait at least 2 weeks after pain starts to get an MRI if a stress fracture is suspected.

A same phenomenon happens at the healing end of stress fractures: there is a lag between actual healing and what your MRI looks like. It’s for this reason my ortho won’t let me get an MRI of my femoral neck before week 12 from the original - chances it, the fracture line will still be there, which will send me into a panicked state of thinking that it’s not healing (this time I’m even waiting longer - 14 weeks!). It is healing, but the MRI isn’t the best at showing that. So if you are a getting an MRI to confirm healing before you return to run, don’t do it too soon. Don’t get one at 6 weeks just to “check on healing,” because chances are, it may look worse than the original. (note: CT scans don’t have this issue - they are the gold standard for bone healing. But you have to consider the radiation dose before you go getting a lot of CT scans).

Stress fractures CAN “warm up”

One of the oft-repeated maxims we hear is that muscles and tendons will warm up and get better as a run goes along, and a stress fracture will get worse as you continue a run. I do think there are classic cases of this, mainly for bones in the foot (my second metatarsal stress fracture definitely did NOT warm up). But for bones higher up the body, or that don’t take as much impact from running, I’ve experienced early stress responses that mimic how muscles and tendons behave - super stiff at the beginning of a run, goes away as the run goes on, and then gets worse after you are done.

This is because your body is a master at compensating. So while your “adductor strain” may warm up during the run, your glute med and TFL are going to get super tight as you subconciously alter your gait to avoid pain. And the more days and weeks you run on it, that “adductor strain” won’t warm up and you’ll find out that it was actually a femoral stress fracture all along (not that I’m speaking from experience…)

So be cautious - just because something warms up in a run it doesn’t mean you are in the clear for bone.

Pain may not present in the “classic” location

I was coming down the Dipsea steps at the end of a long race in 2018. Landing on one, I felt a weird bruise feeling underneath my second toe. “Weird,” I thought, “must have stepped on something.” I limped to MH Bread and Butter to meet up with my friend Devon, thinking it was an odd location.

Over the next few days, the pain persisted. But everything I’d read about metatarsal stress fractures said that they presented on the top of the foot. The top of my foot felt fine - it was underneath my second toe that felt like I was stepping on a pebble.

A clean MRI, a clean CT scan, and then finally another MRI later, there it was. A second metatarsal stress fracture without a lick of pain on the top of my foot.

If there’s one thing I’ve learned, pain is a very odd thing - where we feel it may not be where the pain is actually coming from. So don’t rule something out just because all the literature you read or the doctors you see write it off as not being that because of the location of the pain.

Stress fracture pain can be, and often is, diffuse and not pinpoint

I find this especially true the more proximal your stress fracture is: feet will often be pretty pinpoint, but when you are getting into the femur/hip/pelvis/sacrum the pain may shift around a bunch, which makes sense because your muscles are trying to protect an area of weakness (the stress fracture). For example, my femoral neck stress fracture presented in my quad, then my TFL, then my psoas, and then continued to shift. Our bodies are masters of compensation which is a wonderful thing sometimes when it comes to feats of endurance, but a tricky thing when it comes to injuries.

The “hop test” doesn’t tell you shit

If I had a penny for every time a health professional asked me “does it hurt to hop on it?”, I would not be rich, but I’d have a lot of pennies.

What’s the problem with the hop test? Sure, it’s pretty sensitive for a metatarsal stress fracture, it’s not very specific. Many things will cause pain with hopping, not all related to bone. The fulcrum tests for femoral stress fracture may be marginally helpful, but only if the stress fracture is more distal. These tests may indicate that something is wrong, but then again, 99% of runners I know would probably fail the hop test right now even when they are healthy. Doctors will warn you of this, but in our laser-focused brains, we think these physical tests will give us answers. They can help guide, but please don’t put a lot of stock in them.

Side note: the only test I’ve ever found accurate is one doctors don’t even use (but should): the “putting on your pants” test. I have never had that fail to diagnose a sacral stress fracture in any runner I know.

Plan on recovery taking longer than doctors tell you

This one is mainly for your own sanity. You’ll see numbers thrown around 4-6 weeks, 6-8 weeks, 10-12 weeks, based on the grade of the stress fracture. It’s always good to have some frame of reference and idea for when you may be back to running, but in most cases I find that these numbers are pretty optimistic. And “return to run” in 12 weeks doesn’t mean that you are running 8 miles a day that first week…it means you are probably do a 1 min jog/1min walk progression that will take you several weeks to get through. When doctors told me non-weight bearing on crutches for 6 weeks, what they really meant was that I would actually be on crutches for closer to 9-10 because I would have a several week “crutch-weaning” period.

The weaning and slow progressions make sense, but they can be maddeningly frustrated for a highly-motivated athlete who is used to going full-speed, all the time. So I take every timeframe a doctor gives me with a grain of salt. There has been a stress fracture or two where my timeframe as been shorter, but they have generally always been longer.

Well, that was depressing, wasn’t it??

I didn’t intend for it to be, so I’ll finish with the GOOD news about bone stress injuries: in general, bones are way less complicated than tendons or joints. Bone typically heals pretty well and without complication as long as you are compliant and stay off of it (either full non-weightbearing or some other reduced load as your doctor may recommend). Even with all of my stress fractures, I haven’t had any lingering issues (knock on wood) from any of them. That’s something you generally don’t hear when it comes to torn ACLs or achilles or labral repair surgeries. Bone is frustrating because it heals slowly and your activity is substantially more limited, but a little patience goes a long way.

May your bones be strong and your stress fracture resume never be as long as mine.

1. fwiw, I know this isn’t a good thing. After this most recent one, I’m making some substantial adjustments in how I’m approaching training now than I’m 40+ and realize I can’t keep doing the stress fracture thing. Stay tuned for more on that!