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731 Views 6 Replies Latest reply: Jan 10, 2013 2:38 PM by JamesJohnsonLMT
timeasterday Rookie 5 posts since
Dec 4, 2012
Currently Being Moderated

Jan 10, 2013 4:40 AM

Stress Fracture?

I started the C25K program back in the beginning of December. I skipped to week 3, possibly a foolish move on my part but I had been doing 6 days a week of pretty hard strength/cardio intervals all of 2012 so I thought I was able to handle it. My legs felt strong, I wasn't laboring to finish the runs and the first few weeks were overall pretty easy. At the end of December I decided to just try to run 5k in the neighborhood one day and finished it in 26:29. After that run I felt a little pain in my lower right leg, on the inside of the tibia (or is it fibia, I can never remember) just 3-4" above the anke. The pain got better and I ran 5k again just 3 days later but slower. The rest of the day I had that feeling like "I shouldn't have done that." My leg hurt even more so I iced it during the day a few times. After a couple of days the pain was nearly gone, just a little going down stairs. After 4 days I ran again, taking it easy and staying only on the flat parts of the road. The pain came back, but not at the level of the last run. It was just a dull annoying pain, nothing sharp. And it's more of a localized pain in a very small area. I can't seem to find a place that hurts when I press on it and I don't feel any bumps. Does this sound like a stress fracture?

 

Right now I have backed off my running schedule to just twice a week at a slow pace. I have my first 5k next weekend and I plan on going even if I have to walk it. After the race I am going to stop running for at least 6 weeks while I do low-impact stuff to keep up my fitness level. Sucks to have a setback like this when I was just starting to make good progress. But I am definitely not going to push too hard too fast when I resume running again!

  • rcuriel Pro 178 posts since
    Mar 2, 2011
    Currently Being Moderated
    2. Jan 10, 2013 11:13 AM (in response to timeasterday)
    Re: Stress Fracture?

    Sounds familiar...I developed a similar problem in November.  Pain is about 2-3 inches above left ankle horizontally across the tibia.  Saw GP day after thanksgiving and response was stress fracture or tendonitis.  X-ray didn't show much, so her best guess was tendonitis.  RX stay off for 1 week and if no better will refer to ortho. Stayed off it 2 weeks and did a slow 3 mile run.  Saw ortho, she looked at x-rays and said there was "stress reaction", plus tendonitis.  So, before the bone cracks/breaks it turns to mush.  RX, no impact activity until pain free for a week, start slow and on soft surfaces (avoid concrete, asphalt, hard packed trails in that order where possible).  My brother (he's a personal trainer) likes to say I've shredded my tibia...

     

    Ray

  • JamesJohnsonLMT Legend 1,167 posts since
    Aug 23, 2009
    Currently Being Moderated
    3. Jan 10, 2013 11:38 AM (in response to timeasterday)
    Re: Stress Fracture?

    The general rule of thumb is that during exercise, fractures will tend to hurt more as time goes on. This should apply as well to other structural injuries or degeneration when there is an inflammatory component, whether these are due to trauma or repetitive motion. Fractures are often detected by pressing directly on the suspected location and/or bending the bone at that location to produce pain. This test is hard to do yourself and should be done by a professional, a coach, trainer, or somebody who knows how.

     

    Some injuries referred to as fractures are actually a separation of muscle/tendon from its attachment to bone, or the skin around the bone known as the periosteum. The bending test would not produce pain in this case, but direct pressure should. However, if this were the case I think you would feel it more consistently during exercise. Feeling it going down stairs implies damage to flexor-related tasks, as there is a longer range of eccentric contraction in the plantarflexors during this movement, and little or no loaded extension.

     

    There are tendons wrapping around the inner ankle, and the potential for tendinitis or tenosynovitis at the suspect location, but pressing (palpation) should reveal pain.

    https://upload.wikimedia.org/wikipedia/commons/thumb/9/92/Gray442.png/250px-Gray442.png

    Graphics like this one show structure with muscles stripped away for viewing purposes. Some people, even professionals, stop there and say, "ahah, pain is felt there, so the problem is the Flexor Digitorum, Hallucis, or Tib P. Tendon." Not so fast, there is other very important stuff not shown. The most important part is conceptual. The brain often represents pain as joint pain, even when it is derived from muscles remotely operating the joint.

     

    If the problem is muscular, but minor, it often feels better after exercise has warmed up the muscle(s) involved. Less minor muscular problems can result in a group of muscles stiffening in an attempt to "splint" the area. The stiffening often lessens after exercise brings blood flow, even when the tissue is still compromised, but can also increase to limit damage. Splinting can also happen in response to a fracture or other structural problem for the same reason. Major muscular problems will usually stop you in your tracks even better than a hairline fracture. When my Tib/Fib were broken in an accident, I got up and walked until the leg bent inward ala Joe Theismann. There was no complaint from the muscles at that time, which were uninvolved, and the bone did not hurt -yet. By this I mean to illustrate that the link between injury and pain is not direct. There can be pain without serious injury, and vice-versa.

     

    Tendons can degrade over a period of time with little pain involved (tendinosis). If the tendon surface becomes rough and begins to irritate the surrounding sheath, what we call tendinitis or tenosynovitis is the result after repeated use. This then goes beyond structural changes, to irritating inflammation. The resulting condition should be easily found and felt. Other subtle injuries may only be revealed by MRI.

     

    Muscles tend to throw their pain around into uninvolved locations, so the fact that there is no muscle where you feel the pain is not that important. What is important are the specific actions/stresses that invoke the pain, and what is being stressed at that time. Consider the entire power train from muscle through tendon, attachment, periosteum, finally ending at bone. All, some, or one of these members can represent pain in an area that does not reveal pain on direct palpation. When pain appears where it cannot be directly invoked, this is most surely the case. An abstract diagnosis based on pain and location alone is not enough.

     

    My gut feeling, based on your exercise history and symptoms, is involvement of the plantarflexor power train, most likely involving the Soleus muscle or Tibialis Posterior. Minor stiffening of these muscles is frequently misdiagnosed as tendinitis or tenosynovitis involving the achilles or above shown tendon group. Your workout history of "pretty hard strength/cardio intervals all of 2012" should be felt in these muscles before there is any danger of the other pathologies. If we can rule out sudden trauma (which you surely would have noted), a gradual dysfunction in the plantarflexor muscle group should have become evident by now, and could respond favorably to lighter workouts. Fractures and tendinitis would probably not care as much about intensity, as long as there is movement and your weight is roughly the same. Sure, you might have shredded a tendon or two over the last year, but your muscles would probably have complained before then, and probably are now.

     

    Icing often dulls the pain, and can to a certain extent bring warming flow of blood to an area, but icing the pain site is not the same as icing the actual injury. In addition, too much icing can slow the healing that blood flow is intended to produce. Hopefully you have not tried to stretch it out too much, since that reproduces the same strain that may have led to the injury. What you need to do, regardless of the actual pathology, is to relax the power train so it can heal. You can't relax bones and tendons/sheaths, but you can ease the stress on them by relaxing the muscles that supply the stress. Don't overdo this, but putting pressure into the belly of the rear calf muscles, which are your primary plantarflexors, can help. You should feel some texture differences in there, perhaps a few taught bands of muscle that do not relax. Enough pressure in the right spots should cause them to release, and gentle movement through your range of motion should complete their return to normal tone. Circulation in muscle is enhanced by normal tone and gentle movement. It is inhibited by stiffness and inactivity. Regardless of what you or others may believe about your injury, you can believe that better circulation will result in faster recovery.

     

    In the meantime, I'd only use ice sparingly when there is evidence of swelling. Avoid using it as pain control, along with anti-inflammatory meds, because sometimes, pain is your only sign that things are healing, and your only motivation to forbear. Inflammation hurts, and is the only natural way injuries get torn apart and rebuilt. Learn to differentiate between this type of pain, and the type that communicates impending injury or serious trauma that require direct intervention. Arthritis and other auto-immune inflammation are a different type with a different cause and solution, and I think you are not likely in danger of this now.

     

    Regarding your workout, jumping to week 3 is a sign that you tend to push things a bit. Any time you push ahead of your body's ability to adapt, the rate of wear and tear will exceed the rate of recovery. Then, you spend a lot of down time losing whatever you gained. I know it sounds like I'm schoolin you, but it's better to push too little, than too much. Overall, you get more training in that way, and a stronger body with less compensatory adaptations that lead to chronic pain and frequent injury. Pro athletes who err on the wrong side spend too much time on the sidelines, and eventually lose their source of income. We can learn from their example. I'd rather go down due to unexpected causes like Joe, than to redshirt myself by pushing too hard. Live to fight another day!

  • JamesJohnsonLMT Legend 1,167 posts since
    Aug 23, 2009
    Currently Being Moderated
    4. Jan 10, 2013 11:46 AM (in response to timeasterday)
    Stress Fracture?

    Arch and heel pain are primary symptoms of Soleus muscle tightness. The pain often manifests in the area of the Achilles tendon as well. Myofascial pain of this type has nothing to do with the actual arch, heel, or tendon.

  • JamesJohnsonLMT Legend 1,167 posts since
    Aug 23, 2009
    Currently Being Moderated
    6. Jan 10, 2013 2:38 PM (in response to timeasterday)
    Stress Fracture?

    Just be careful not to overdo it. Too much massage can make things worse. Aim for release and nothing more. Good luck!

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