Triathletes And Stress Fractures

When it comes to injuries caused by too much use in running or triathlons, stress fractures can be the most terrifying of all, and with good cause. Stress fractures can put a fast stop to any running or triathlon season.

Stress fractures have been quite common this year among the triathlon community, with both Lucy Charles-Barclay and Linsey Corbin affected by them.

Though it mostly affects professional athletes, up to 30% of injuries from running activities are stress injuries to the bones, which can cause age group athletes to be out of action for a significant amount of time. What are the symptoms of stress fractures, and how can they be prevented?

Stress fractures

The repeated mechanical strain on the bones that outpaces the capacity of the bones to restore and fix itself can lead to fatigue, damage and tiny fractures, which are referred to as bone stress injuries.

Typically, at the beginning of the loading process, certain cells called osteoclasts begin to break down bone. If appropriate rest is taken, the body’s osteoblasts will come in to fix the damage and make the bone stronger. If not, osteoclasts outpace osteoblasts, and bone weakening occurs.

Where do stress fractures occur

It doesn’t come as a surprise that a majority of bone strain injuries in people who run or compete in triathlons are located in their lower legs. The shin bone, known as the tibia, is normally the most common place where the metatarsals, femur, navicular, fibula, and sacral bones are found. These bones come in behind the tibia in terms of frequency.

The lumbar spine or pelvis may also be affected.

Distance runners whose primary style is a rearfoot strike tend to experience more stress on their long bones (tibia, femur, fibula), whereas those who use a forefoot strike and participate in shorter distances concentrate the load in their foot bones (metatarsals, navicular).

Every person has different biomechanics and way of loading, so it is necessary to take into account stress injuries to bones when looking at any area.

Risk factors for stress fractures

Increasing the chances of an athlete suffering from bone stress injuries can be grouped into two categories: those caused by intrinsic features of the athlete, and those resulting from conditions outside of the athlete. Intrinsic dangers are typically associated with an athlete’s bones being able to withstand the pressure, as well as their physical or movement-related features.

The following conditions may increase the chances of an athlete developing bone stress injuries due to weakened bones: genetics, metabolic bone ailments, excessive cortisol levels, specific medications (especially corticosteroids), inadequate vitamin D and calcium, and insufficient energy supply for the energy expended (which is a common cause among distance runners and triathletes).

Women are more likely than men to be affected; this is especially true of those with late-onset menarche, and those who have abnormal or non-existent menstrual cycles. Males with low levels of testosterone may be at risk.

A history of stress fractures can result in further problems for athletes as it is a sign that they are more likely to experience them again in the future.

It has been suggested that some physical aspects that affect the amount of pressure on bones have a correlation with the chance of getting a stress injury to bones, such as differences in leg lengths, either flat or high-arched feet, and a low circumference of the calf muscle.

Those who overstride and those with knees that tend to collapse inwards during the midsize stage of their running gait may be more prone to injuries due to the higher initial force at impact.

Many external factors associated with training are believed to lead to bone stress injuries. It is not surprising that injury typically occurs when the running load is increased, particularly with increased training.

Larger quantities of activity create more pressure on the bones as the cycles are repeated, whereas faster rates of movement lead to greater forces acting on the bones. Moreover, when muscles become exhausted, their capability of blocking shock is reduced and different body postures start to appear, thus raising the strains put on bones.

The research on the connection between running surfaces and footwear is inconclusive, yet certain examinations have revealed a higher chance of injury related to running on harder surfaces and wearing old running shoes.

It appears that while more training could increase the likelihood of a bone stress injury, having been active for an extended amount of time could be beneficial in guarding against one. This is likely because prolonged physical activity would likely have strengthened the bones due to long-term exposure to pressure.

How to diagnose a stress fracture

Bone stress injuries are best treated when caught early. What might raise suspicion? At first, signs may be difficult to recognize and be mistaken for other, less dangerous illnesses.

Pain is most often a symptom of the problem when during physical activity, particularly running, and doesn’t get better over time. This is often the first sign, which will soon be followed by pain when bearing any weight, and will eventually happen even when resting or while asleep.

In some areas where the bone is closer to the surface (shin, foot), there will be a specific location where the bone is achy, while a deeper bone injury (like the femur) may be causing a more widespread sensation of discomfort.

A few fast checks can point to a potential bone stress injury. One can perform an accurate self-assessment for bone stress injuries by taking the aptly named Single Leg Hop Test. This test has been highly effective in this regard.

The occurrence of discomfort when landing could be an indication of a strain injury in the bones of the lower limbs.

The Fulcrum Test is a beneficial method for detecting potential femoral bone stress problems. It includes pressing down on the knee while keeping the forearm underneath the thigh in question and gauging the amount of pain felt. It is tough to figure out an ailment on one’s own, and imaging will be needed to make sure.

General principles of treatment

It is essential to identify those stress fractures that may experience delayed healing, that may not heal at all, that are displaced, or those with an intra-articular portion.

Generally, if a stress fracture is determined to have a high risk, it should be immediately identified, treated aggressively, and sometimes requires surgery to fix the affected area.

Breaks that are not as severe or do not constitute a hazard can be managed with two two-steps. Phase 1 entails managing pain using local physical therapy, taking non-steroidal anti-inflammatory drugs, giving ice massages, and employing physical therapy techniques.

Normal activities that do not cause pain are permitted when it comes to weight bearing. The offending activity, such as running, is discontinued. If the athlete is feeling pain while they walk, they should use something like a walking boot to limit their movement until the discomfort goes away.

An altered workout plan has been crafted, preserving muscle power and overall health but reducing the amount of stress on the bones.

Engaging in exercises like swimming, using an elliptical, biking and climbing stairs on a StairMaster can retain muscle power and physical fitness before taking up actions involving high-impact loading again.

Our clinics use both underwater and antigravity treadmills as an effective means of reintroducing the body to running gently.

Phase 2 of returning to sports starts off when the athlete does not have any pain for between 10-14 days. The amount of time required will be determined by many elements, including how intense and longstanding the issue is as well as the athlete’s capability before the injury occurred.

Generally, after the disappearance of localized bone discomfort, the athlete can go back to jogging, but initially at half of the usual speed and length of the run, engaging in it only every other day for the first 14 days.

Throughout 3 to 6 weeks, an advancement in the amount and occurrence of exercise is allowed. Once they can manage to go the distance needed for practice, they should be able to speed up the rate.

The chances of further stress fractures occurring in athletes who have knocked in or out their feet can be lowered if they use an orthosis.

Functional foot orthoses can be used to decrease excessive turning inwards of the heel in those who have a significantly inverted heel or to facilitate an appropriate level of an inward roll of the foot in athletes whose heel stays rigidly turned out.

If the stress fracture (normally occurring in the fifth metatarsal or fibula) is caused by insufficient shock absorption and the athlete cannot plant their heel vertically (as opposed to an uncompensated or partially compensated hindfoot varus), measures should be taken to decrease the shock experienced by using a softer type of orthotic material.

It is important to examine the athlete’s shoes thoroughly.

One should inspect their shoes regularly and switch them out to keep them from losing their ability to absorb shock. Usually, after a distance of 300-350 miles covered running, by considering the kind of shoes and running route in addition to the runner’s weight, this problem happens to athletes.

There are now shoe styles available for all kinds of foot shapes. The factors to consider when attempting to keep the subtalar joint in a neutral position for an athlete who overpronates include features of the shoe such as correct heel width, efficient counter-heel assistance, a strong midsole and a straight-shaped last.

A foot with rigidity should be fitted with an air cushion, a midsole of softer material, a narrow design and curved stitching on the insole.

Many female runners with stress fractures experience delayed onset of menarche, fewer menstrual periods per annum, and reduced bone mineral density of the spine. Those who experience a cracked tibia due to strain usually have reduced tibia bone mass.

It is suggested that female long-distance runners who have a stress fracture be asked if they have recently begun menstruating late if they have an inconsistent menstrual cycle, or if they have no periods.

If there is prior evidence of a positive outcome, it would be wise to acquire a bone mineral density evaluation and an endocrine examination.

Prescribing calcium supplements and/or hormonal replacement therapy in the form of birth control pills should be done when deemed necessary. Taking birth control pills containing oestrogen for a single year could safeguard against bone breakdown; however, the preferred tactic would be to re-establish normal menstrual cycles and maintain healthy eating behaviour.

Moreover, female long-distance runners tend to have a greater likelihood of developing eating disorders, which can cause a lack of a menstrual cycle or nutritional inadequacies. This should have a thorough assessment performed and psychological and dietary advice should be given if necessary.

One possible treatment of note for stress fractures is pamidronate, a type of bisphosphonate that is often used to handle osteoporosis, hypercalcemia, and metastatic bone disease.

Stewart and their colleagues presented details on the application of intravenous pamidronate to five collegiate athletes complaining of tibia stress fractures.

Out of the five participants, four made a recovery and were able to keep working out without any issues in three days. The investigators feel that the treatment could be successful and are prepared to conduct a future trial.

How long does it take to heal a stress fracture?

If you think you have a bone stress injury, cease any activities that can cause it to worsen (especially running), and contact your medical care provider right away. You cannot attempt to keep exercising while having this injury.

X-rays are usually the initial imaging test used, however, they have low accuracy for picking up bone strain injuries, as only those that are more serious with visible fracture lines or scarring can be seen.

A bone scan can detect activity in bones, but cannot show the exact extent of an injury.

Magnetic Resonance Imaging scans are viewed as the highest level of imaging for bones with stress-related issues since they can demonstrate signs of periosteal swelling, bone marrow oedema, and breakage lines and can aid in knowing the extent of the damage.

MRI readings can be used to rank bone stress injuries on a scale, which can help to figure out the potential outcome and how long it will take to heal. The length of recovery and the amount of exercise and activity restrictions for a fracture depend on where the fracture is located and how serious it is.

Certain areas which have either high pressure on the bones or poor circulation in the blood are generally thought to be vulnerable spots, indicating that displacement of the bone, hindered healing, or a lack of mending can happen.

The following areas are included: the femur neck, the front of the shinbone, the inner ankle joint, the knee cap, the navicular bone in the foot, the sesamoids, and the bottom of the fifth metatarsal.

The least dangerous places consist of the lower end of the shinbone, the thin long bone on the outside of the lower leg, and the majority of the bones in the foot. Accidents involving the pelvis, bottom of the spine, and long bones of the thigh usually take place in between these areas.

An analysis of all kinds of bone stress traumas indicated that the expected time needed for a comeback to the field would be approximately seven weeks for those with the lowest grade of injury, 10-12 weeks for injuries of a moderate level, and 14 weeks in the most serious cases when there is a fractured line.

It takes approximately 6-8 weeks for the healing of minor, low-risk injuries and 4-6 months for more serious, high-risk ones.

Regrettably, some high-risk fractures cannot be corrected without undergoing surgical procedures, using devices to stimulate the bones, or being given medications, resulting in an extended recovery period.


Stress cracks are ordinarily seen among athletes, mostly amongst those who run a great deal, as a result of an excessive amount of strain. Evidently, it is preferable to take preventative measures or intervene early on.

A thorough review of the situation which takes into account all potential influencing elements, such as improper training methods, biomechanical weaknesses, muscular and suppleness disparities, and unsuitable footwear, is essential for evaluating properly.

A great deal of caution is needed to identify these types of injuries quickly because they often go unnoticed.

Once the diagnosis has been ascertained, the sports medicine doctor must figure out the severity of the injury to be able to come up with the right treatment plan – whether it be critical, less significant, or non-critical.

Radiography, MRI, and bone scanning using radionuclides all play an important part in the discovery and classification of bone stress injuries. CT may be used as well in some cases to ensure the accuracy of fracture lines and to assess the healing progress in specific patients.

Radiologists who specialize in sports-related imaging should understand the origins of various kinds and locations of stress injuries to guarantee that athletes can get back to vigorous activity in a prompt and problem-free manner.


Related Articles

Leave a Reply

Your email address will not be published. Required fields are marked *

Back to top button