Running Mags: Multiple Stress Fractures

[peterslovo]

My wife likes to run.

She has done a bunch of marathons, and about 5 years back, got her first tibial stress fracture.

She just got the results of a bone scan, and got her fourth - another tibial stress fracture. So that makes 3 tibial, and 1 hip stress fracture.

Last season, she ran 99% time on trails - with only 1 or 2 long runs on the road. The last fracture came from one of those long road runs, she thinks.

She has changed her diet, takes supplements, cut out Diet Coke (tough withdrawal!) and does a dedicated return to run program each time. She's had bone density testing with normal results.

So here we are again. She's been on the bike a lot now, and is starting a return-to-run program...again.

What else can she consider? 100% trail running? Gait analysis? Change her shoe type? Anything else?

Any other runners deal with multiple recurring fractures?

[jesski]

how much meat/dairy does she eat? going vegan made my bones denser.

does she practice yoga? this helped me with gait.

does she use compression on recurrent fracture spots even when no swelling or pain? this might just be placebo effect.

[jerlane]

Gait analysis isn't a bad idea and it might lead to a different shoe selection. Any idea if she has flat feet or really high arches? Orthotics may be worth considering as well. Does she pay attention to the mileage she's putting on her shoes? In general, they should be changed every 300 miles or so, regardless of how they look. After that the foam that supports the foot starts to break down and doesn't support you properly. A lot of avid runners are surprised how quickly they reach this point when they do the math.

[skatha]

Hmmmm...over 30 miles of running a week doesn't do anything to improve your aerobic capacity but exponentially increases your risk of injury. A long distance runner has dramatically weakened bones and, according to a recently published study, the same cardiovascular risk as a completely sedentary person (limitation of study-men only). The injury study came out in the 80s, when I ran, and, as a result, I ran 6 miles 5 days a week. Your wife needs to realize she needs to stop long distance running, she needs to check a FSH/LH/estrogen level test, get a bone scan, and possibly take drugs to reverse her osteoporosis induced by overtraining. Just my $0.02 as a board certified general internist

[peterslovo]

She's got orthotics, and changes shoes on time.

Her estrogen levels are fine (had that checked) and her bone density appears to be ok as well. Not sure what FSH or LH are?

Could staying off the road altogether, i.e., just run trails, be the trick for her?

[crackboy]

i was going to suggest getting her estrogen checked but was beated. fsh and lh are other sex hormones but its really estrogen that is more important with bones. maybe get her vitamin a and d levels checked

well nevermind if her bone density is ok. likely something in her stride is of since she is getting them in more than one location. that could cause a chain reaction. injury develops, stride is adjusted to compensate new location is injured, etc etc.

[Elkhound Odin]

When I was younger (teens & 20's), almost every year I got stress fractures. The running surface didn't matter, orthotics didn't help, diet didn't make a difference, stretching didn't matter. There was only one thing that stopped the factures - cut down on the miles. I found if I ran over 30 miles/week routinely, then I would get a fracture. (especially when I pushed over 40 miles) So now I maintain miles in the upper 20's. If I train for a marathon, I can get away with mid 30's for a few weeks, but not sustained.

I've been running for 30 years. It took me 10 years to finally accept the limits of stress I could put on my bones. I've been fracture free for 20 years. Your wife should look at the pattern of mile/week vs when the fractures occur. Then, regulate the miles down to find how much she can run w/o injury.

[hitek79]

It's all about her stride. Humans are NOT supposed to run and land on your heel. If that's what she's doing, that's probably the problem.

http://www.dailymail.co.uk/home/mosl...ste-money.html

[Dantheman]

It's all about her stride. Humans are NOT supposed to run and land on your heel. If that's what she's doing, that's probably the problem.

http://www.dailymail.co.uk/home/mosl...ste-money.html

This ^^^^^

If her bone density is fine, 99% chance it's her stride. Fuck the orthotics and big cushiony shoes, all they do is weaken your feet, encourage heel-striking and make you more prone to injury. Get a minimalist shoe like the Nike Free or Vibram Five Fingers and run like your body was meant to run, with the caveat that she needs to work the mileage up slowly because initially your feet and lower legs are not strong enough to support high mileage.

Also, some good stuff here

[Vinman]

4 stress fractures in that amount of time is certainly fishy. While stride and shoes are couple things to consider, there are other hormones that can effect bone density and risk for stress fracture, specifically parathyroid hormone. Vitamin D can also have some impact. Maybe a blood study for PTH? There could also be other hormones that effect bone density or maybe it is more of a healing issue?

Pete check your PMs

[peterslovo]

Thanks folks, all good suggestions that we'll talk about.

I'm not a runner myself, so will have to check on her overall weekly mileages (she keeps logs, so we can probably go back and see what the mileage was like in the weeks coming up to the stress fractures).

Some folks in her trail running group is adopting the 5finger and barefoot technique, so I'm sure she'll go down that path at some point. (As an aside, several of them also had multiple stress fractures from road running - now they solely run on trails, and have worked up to 50 and 100 miles races, and hardly ever have problems).

Thanks for the pm vin, i'll look for it.

[crackboy]

well if her density is good more than likely its something physical affecting shock absorption/transfer to the leg. or it could just be over use.

when i first saw this thread by you i was like man that guy just needs to get dragged out into a meadow and shot like a lame horse

[XtrPickels]

Peter, where in Maine do you live?
Working with people such as your wife is what I do for a living. I'd love to meet with you guys, but I'm afraid the distance would be too far. Its really really hard to answer these questions online without a full evaluation.

I would second Vinman in looking into those causes.
In a sense I agree with DTM and Hitek in principle, but probably not in implementation.

Some things to think about:
- What is her return to running plan and is it an appropriate progression.

- DTM pointed out that the body may not be strong enough to run barefoot initially and to ease into. I would expand that and say that if its not strong enough to run barefoot... its not strong enough to run in shoes either. I would also say that most people have muscle imbalances that cause a majority of their issues. The problem is, without meeting your wife I can't really give more insight than that.

- Over use injuries such as this occur when the body is ineffective at dealing with forces. The issue is rarely at the location of "injury". The injury site is merely a scapegoat for deficiencies elsewhere.

- Barefoot running is an excellent tool, but people need to understand that it takes a lot of time, effort and progression to be able to do it for even modest amounts of volume. In my opinion the best thing you can do is get your body strong enough to run barefoot, learn good running technique.... and run in shoes. You'll be getting the of each world.

- The benefits of trail running: The ever changing surface does a couple things 1) It places abnormal loads on the body for it to adapt to. This makes it stronger. 2) Because the loads are always changing they cause less irritation of the same tissue. Think about scratching your leg lightly 100 times. If you do it in 100 different places it no big deal. If you scratch the same exact place 100times, its going to freakin' hurt after a while. Additional the softer surface can lead to less Ground Reaction Force (impact force).

[sparkletarte.]

thanks so much for that article! I've just starting using the treadmill and have been thinking that I 'should' get proper running shoes for it. I prefer to do my work outs and balance board stuff in socks or barefeet, not shoes, and have been feeling a block about getting new shoes because I've thought that they aren't going to be right for my feet. I'm still going to look more closely at the skate shoes I'm running in now, but am not so concerned that I might be causing problems. I only do 20 mins a few times a week.

[hitek79]

I will say that I'm not a runner so much anymore, but barefoot running has worked for me. I ran cross country in high school and played soccer, so running was on the menu every day. I never had any injuries during that time, but I snapped my fibula and tore all the ligaments in my ankle playing soccer, and a few years later tore my ACL, all in my left leg. I pretty much resigned myself to cycling at that point, but I just couldn't make my self sit in the trainer during winter to stay in any kind of cardio shape, so I started jogging again. I went and bought shoes based on a gait analysis, and ran for like a week and the pain was out of this world(I have a plate on my fibula). I started hearing about barefoot running and bought some Five Fingers, and to this day I've never had any pain other than sore calves.

I would recommend to the OP to start doing a lot more research on running shoes and why they're so bad. There's a wealth of info out there, and it all makes sense. Like that video above says humans have run for thousands of years without issue. The modern running shoe came out in 1972, and running injuries have steadily increased since then.

Oh yeah, and as an aside, I have MUCH less pain after skiing or snowboarding, and I think it's because my feet are a lot stronger than they used to be. Good luck!

[Dantheman]

- Barefoot running is an excellent tool, but people need to understand that it takes a lot of time, effort and progression to be able to do it for even modest amounts of volume. In my opinion the best thing you can do is get your body strong enough to run barefoot, learn good running technique.... and run in shoes. You'll be getting the of each world.

We definitely agree here, and I am not a "barefoot runner", but the shoe you pick matters. Too much cushion and external support makes it difficult to run barefoot-esque and easy to slip back into bad habits. It also seems self-defeating to work and work at drills to strengthen your feet, but then run in shoes that weaken them.

[peterslovo]

XtrPickels,

Thanks for this insight - helpful stuff. We're in Portland so that would be quite a hike!

I'm not sure of the specifics of her RTR program, but I'll get them and either post up or pm to you. She's just been biding her time at this point and enjoying the road bike - hasn't even started the program yet.

Thanks,
pete

Peter, where in Maine do you live?
Working with people such as your wife is what I do for a living. I'd love to meet with you guys, but I'm afraid the distance would be too far. Its really really hard to answer these questions online without a full evaluation.

I would second Vinman in looking into those causes.
In a sense I agree with DTM and Hitek in principle, but probably not in implementation.

Some things to think about:
- What is her return to running plan and is it an appropriate progression.

- DTM pointed out that the body may not be strong enough to run barefoot initially and to ease into. I would expand that and say that if its not strong enough to run barefoot... its not strong enough to run in shoes either. I would also say that most people have muscle imbalances that cause a majority of their issues. The problem is, without meeting your wife I can't really give more insight than that.

- Over use injuries such as this occur when the body is ineffective at dealing with forces. The issue is rarely at the location of "injury". The injury site is merely a scapegoat for deficiencies elsewhere.

- Barefoot running is an excellent tool, but people need to understand that it takes a lot of time, effort and progression to be able to do it for even modest amounts of volume. In my opinion the best thing you can do is get your body strong enough to run barefoot, learn good running technique.... and run in shoes. You'll be getting the of each world.

- The benefits of trail running: The ever changing surface does a couple things 1) It places abnormal loads on the body for it to adapt to. This makes it stronger. 2) Because the loads are always changing they cause less irritation of the same tissue. Think about scratching your leg lightly 100 times. If you do it in 100 different places it no big deal. If you scratch the same exact place 100times, its going to freakin' hurt after a while. Additional the softer surface can lead to less Ground Reaction Force (impact force).