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Health & Exercise Forum


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Jun 14, 2021


After enduring the challenges of a cold and snowy winter, late spring and early summer is the time of year when long distance runners ramp up their training in preparation for the some of the best half and full marathons in the fall: Steamtown, Philadelphia, New York, Marine Corps in DC to name a few. But, runners beware; overtraining can lead to stress fractures.

I would like to introduce this topic with some marathon history. In 490 B.C. Athens was under attack by the Persians and was outnumbered more than two to one. The Athenians fought bravely and defeated the enemy in the town of Marathon to keep the intruders 26 miles away from their families in Athens. To keep the anxious citizens of Athens calm, leaders immediately ordered a foot soldier, Phedippides, to the capital to share the news. Phedippides ran, in full armor, for 26 miles from Marathon to Athens, delivered the message and died immediately. Now, people do the same thing of their own free will!

In the modern age, marathon and recreational runners enjoy testing their mental and physical stamina in pursuit of fitness and wellness. If not careful, many runners (and other competitive athletes) will develop pain in their shins (shin splints). Unfortunately, in many of these well-intended athletes, this problem can lead to a much more severe and advanced problem with shin splints called a stress fracture. Some very good athletes have been hindered by this problem.

What is a stress fracture?

A stress fracture is fatigue damage to bone with partial or complete disruption of the cortex of the bone from repetitive loading. While standard x-rays may not reveal the problem, a bone scan, and MRI will. It usually occurs in the long bones of the leg, mostly the tibia (shin) but also the femur (thigh) and foot. Occasionally, it occurs in the arm.

Who is at risk?

10-21% of all competitive athletes are at risk for stress fractures. Track, cross country and military recruits are at greatest risk. Females are twice as likely as males to have a stress fracture. Other athletes at risk are sprinters, soccer and basketball players, jumpers, ballet dancers are at risk in the leg and foot. Gymnasts are also vulnerable in the spine while rowers, baseball pitchers, golfers and tennis players can experience the fracture with much less frequency in the ribs & arm.           

The problem is much more prevalent in weight bearing repetitive, loading sports in which leanness is emphasized (ballet, cheerleading) or provides an advantage (distance running, gymnastics).

Stress fractures usually begin with a manageable, poorly localized pain with or immediately after activity such as a shin splint. Over time, pain becomes more localized and tender during activity and then progresses to pain with daily activity and at rest.

Causes of Stress Fractures

  1. Overuse, Overload, Overtraining – is the number one cause. Running too many miles with too much intensity with too much frequency is the perfect formula.
  2. Inadequate Fitness Level – or inadequate activity level prior to the stress fracture. For example, the high school runner takes the summer off and then quickly accelerates his/her program too quickly for cross-country in August/September.
  3. Poor Biomechanics – when your feet hit the ground the forces are absorbed and transferred to the rest of the body. If the biomechanics of feet are not perfect, then the forces are not absorbed and another body part bears too much force. For example, flat or pronated feet poorly absorb the shock and pull the tendons of the foot and shin.
  4. Recent Change in Training Schedule – sudden increased intensity or speed
  5. Recent Change in Running Surface – sudden change to a hard or soft surface
  6. Recent Change in Footwear – shoes too hard or too soft, too much control or too little control, too much pronation or too much supination
  7. Overweight – running with an extra 10 pounds and attempting to return to running as a method of weight loss
  8. Underweight – the underweight female athlete is at high risk for stress fractures. If underweight and have a history of menstral irregularities or and eating disorder, the risk of stress fracture increases significantly
  9. History of Stress Fractures – makes the athlete two times as likely to have another

Treatment & Management

  1. Alternate Training – cross train with non-weight bearing activities: bike, swim, elliptical
  2. Gradually Build Up Fitness Level – wean into activity 1-2 miles, then add ½ mile at a time
  3. Correct Biomechanics - Orthotics, Running shoes, see a Podiatrist
  4. Gradual Change in Training Schedule
  5. Gradual Change in Surfaces – ½ run on soft surface, ½ run on hard surface
  6. Gradual Change in Footwear – walk in new shoes first, then run 1-2 miles
  7. If Overweight – gradual exercise with diet, not too much too quickly. Mix run & walk every 10 minutes
  8. If Underweight – improve diet maintain healthly body fat%
  9. Consult Family Physician – Early management often involves immobilization, rest, pain medicine 4-6 weeks for healing. non weight bearing cross training such as the recumbent bike, swimming, elliptical.
  10. Physical Therapy- Physical therapy modalities such as ultrasound, cold with electrical stimulation, biomechanical taping or orthotic supports, and exercises for foot, ankle muscles.

Visit your doctor regularly and listen to your body.

NEXT MONDAY – Read Dr. Paul J. Mackarey “Health & Exercise Forum!”  

This article is not intended as a substitute for medical treatment. If you have questions related to your medical condition, please contact your family physician. For further inquires related to this topic email:

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Paul J. Mackarey PT, DHSc, OCS is a Doctor in Health Sciences specializing in orthopaedic and sports physical therapy. Dr. Mackarey is in private practice and is an associate professor of clinical medicine at GCSOM.