Four weeks ago I learned I have a stress fracture of the tibia in my right leg. I am not your typical triathlete: 6’3” and 240 pounds (at the beginning of the season). I am relatively new to triathlons and am training for my third sprint (with hopes of an Olympic distance this fall).
Last season I was heavier and running more and was injury free. This year I am in better shape, running less with new shoes and wham, injury.
Since the stress-fracture diagnosis, I have not run and have been solely focusing on swimming and biking. I miss the convenience and intensity of running. What advice would you recommend to help me get back on the road and avoid re-injury.
Sincerely,
Peter
Eden Prairie, MN
Dear Peter,
I understand your frustration. Few injuries test an athlete’s patience more than a tibial stress fracture. There are few who can resist the temptation to run before the injury is fully healed. I speak from experience, as not so long ago, young Dr. Baldwin tried to make an early comeback on this same injury, and despite all his hopes, he ended up more broken than when he started. It pays to be over-conservative when treating this kind of injury. Most people say a stress fracture requires two to three months to heal, but the reality is that up to six months may be needed to restore the bone to normalcy and remove most traces of pain. Some athletes may even require a year or more for full recovery.
Tibial stress fractures most commonly occur two to three inches above the bony prominence on the inside of the ankle. Tenderness and swelling over this site after running long distances is suggestive of a stress fracture. Unlike in shin splints, where the pain usually radiates up and down the length of muscle bordering the shin, a stress fracture will be more localized on the bone. Sometimes the bone will hurt when it is tapped near the damaged area, and occasionally a hard nodule will appear on the surface of the bone at the trouble site. If a person continues to run on the stress fracture, pain often worsens and can persist throughout the night.
Often, an X-ray will not show any signs of a fracture initially. It is only after it has begun the healing process that the fracture site will show up on X-ray as new bone formation. A more costly procedure that uses radioactive markers to detect a stress fracture is called a bone scan. Most of the time this test should not be necessary as a diagnosis can be made by identifying the focal pain and swelling on the tibia bone.
Stress fractures are usually not accidents -- they happen for a reason. Peter, a few things in your profile jump out at me as possible causative factors. You are a big guy, relatively new to the sport, and you have been racing more and more over the past year. You say that you are not the “typical triathlete,” but I would beg to differ. More and more people are getting involved in the sport of triathlon, and although these people may be training every day, I guarantee you they don’t all have the lean physique of a pro triathlete. As a result, pounding the pavement day in and day out can be a leading culprit behind the development of stress fractures in the lower leg for those new to the sport.
The tibia bone bears almost all of a person’s weight with each stride, and, eventually, the muscles surrounding and supporting the tibia fatigue and the stress distribution in the bone is altered. Continuous pounding adds up over time, until one day the bone cannot hold up to the stress any longer and it fractures. Even more stress can be transmitted to the tibia in those who have poor arch support or new sneakers that have not been properly broken-in. Athletes with flat feet many times will benefit from custom orthotics.
Another common scenario that can cause a lower-leg stress fracture is a sudden change in running surface: for example going from long, easy road or trail running to doing hard track workouts. Although losing weight can decrease the amount of force placed on the tibia, improper nutrition may also be a cause of stress fractures, as seen in runners who do not take in enough protein or bone-building materials such as calcium and magnesium. The straw that broke the camel’s back for me was getting up to run one cold winter morning, knowing I was overtrained and that my leg was sore, but pushing myself to get more miles in. Sound familiar?
Doing too much, too soon is at the root of almost all stress fractures. Athletes become fixated on achieving their goals and don’t listen to what their body is telling them. When part of your body is in pain, identifying why it is hurting and allowing it to heal are far more important in the long run. In the meantime, there are many non-impact or low-impact exercises that one can do to stay in shape. Simple exercises such as shin pulses can be done just about anywhere, sitting or standing. Just bring the top of your foot rapidly up toward your shin and then back down again. Do pulses of 30. These help to strengthen the shin muscles, which support and stabilize the tibia. When I had my stress fracture I found that running in the deep end of the pool allowed me to retain my stride form. Swimming and weight lifting also helped me to preserve my cardiovascular fitness and strength. After some healing time I was able to move onto the elliptical trainer and exercise bike, which are still relatively low impact. The key is to let pain be your guide. If it hurts, don’t do it.
Those athletes who allow the body time to heal and rest will ultimately come out on top. Patience is a virtue.
References
Tibial Stress Fractures. The Family Practice Notebook. Ch. 408. Pg. 22-24. 3/5/05
Anderson, Owen. Tibial Stress Fracture Prevention. Injury Prevention Tips 2005
Dr. Andrew Baldwin is a three-time Ironman finisher, a two-time USA Triathlon All-American and a physician in the U.S. Navy. More information can be found at www.tribaldwin.com.
If you have a question for Dr. Baldwin, please e-mail Triathlete Magazine Interactive. Please include “Dr. Baldwin” in the subject line.