Return to Running after a Stress Fracture:

The initial stage when treating a Tibial stress fracture is a cessation of weight bearing activity, followed by a gradual return to running after a tibial stress fracture has healed. It is important to return to running on a gradual basis, the pace to which you return to running depends on a number of variables; age, initial injury, past injuries etc.

We have taken a look at a piece of research published in 2015 that looked a 15 different research articles to assess what is the best evidence-based guideline and treatment plan to treat a tibial stress fractures and suggested protocol to return to running after a tibial stress fracture.

The published article can be found here, we have put together some of the main points of the article and made some short videos of the type of exercises they mention as part of the overall treatment plan and have shown to be most effective.

Overuse injuries and Stress Fractures in Runners:

In general, most overuse injuries occur in the lower extremities in runners and this is due to repetitive tissue stress. Edwards et al2 estimate that 26% of recreational and 65% of competitive runners will sustain some form of overuse injury in any given year. In addition to this a higher incidence of injury has occurred in runners with previous lower extremity injuries.

Of these injuries stress fractures account for 15% to 20% of overuse injuries in runners. A stress fracture is a mechanical failure of the bone, in which repetitive loading of the bone, with inadequate recovery and rest, resulting in the bone being unable to repair itself between exercise sessions.

There are additional factors that can contribute to the development of stress fractures:

  • increase in training intensity and weekly high mileage (60K per week)
  • running on hard surfaces
  • inappropriate footwear
  • poor bio-mechanics

The tibia is reported to be the most common site of stress fracture occurrence, accounting for 35% to 56% of all stress fracture injuries. Tibial stress fractures in runners are most commonly located in the lower half of the shaft of the tibia.

Research suggests that improper training programmes are a key extrinsic factor in the occurrence of stress fractures. A study by Matheson et al8 states approximately 30% of athletes who had stress fractures incurred the injury within 12 weeks of a change in training regimen e.g. training for a marathon.

Similarly, poor running mechanics are common intrinsic factors contributing to stress fracture. Females are more likely to develop stress fractures, this may be due to lower bone density as compared to males.

Treatment of Tibial Stress Fracture:

Once you have been diagnosed with a Tibial stress fracture it is important to cease all weight bearing activity, you may be required to have an MRI to diagnose the extent of the injury. If the injury is significant you may need to spend a number of weeks on a soft boot (6-8 weeks) to immobilise the foot and ankle to reduce further stress on the tibia.

The proposed treatment plan is not a “One size fits all” and we recommend you attend your doctor or therapist in advance of starting any treatment plan. The following treatment plan starts from the time the stress fracture is diagnosed and these exercises can be started straight away.

Phase I: Rest 3 – 10 days (depending on extent of injury)

During this phase the athlete is NWB until they are pain free at rest and cleared to weight bear by a doctor. The focus of phase I is on education, pain management, assessing muscular imbalances, strengthening and stretching.

  • Non-weight bearing exercises only, until walking is pain free
  • Control pain and swelling through Rest, Ice and Elevation of leg
  • Progress to Phase II when walking ½ mile is pain free

Phase I: Exercises

  • Clams and Shoulder Bridges to strengthen hips
  • Bird Dog quadruped to maintain core strength
  • Stretch Hamstring and Calf

Exercise Video: [embedyt][/embedyt]

Phase II: Cross-training 4 – 7 weeks (Cleared for Weight Bearing Activity)

The focus of this phase is to progress strengthening exercises and introduce cross-training as tolerated.

  • Begin to introduce high impact activity
  • Remain pain-free through-out plan
  • Complete 10 minutes of pain free light jog­ging before final phase of the protocol.

Phase II: Exercises

  • Stretch Hamstring and Calf in standing
  • Heel raises
  • Plank & Side Plank
  • Side stepping with band
  • Shoulder bridge progressions
  • Lunges

Exercise Video:[embedyt][/embedyt]

In addition to above exercises athlete should be working up to 30 minutes of pain free low Impact cardio: such as Swimming, Water Walking, Walking , Cross trainer or Cycling. The athlete should also be maintaining upper body strength in conjunction with lower body strength exercises. Cardio and strength exercise should be alternated every other day.

Athlete should not start jogging until at least week 3 of this phase, if any pain then athlete must regress back a week in their training. Research suggests that one full cycle of bone healing will take 16 to 24 days (about 3 weeks), and that extra care should be taken during the last 6 to 10 days of this cycle to avoid over­stressing the new deposition

Phase III: Return to Running: 4 weeks

There was no specific evidence-based return to running protocol found, however research does suggest that when an athlete is returning to running after a stress fracture they must make adjustments to running speed and stride length.  Increasing athletes running cadence allows for the reduction of stride length and impact forces, without effecting speed. With this in mind an athlete can be working up their speed over a 4 week cycle.

The first couple of weeks of this phase are about increasing high impact activity and introducing different running surfaces while building in sport specific exercise.

Phase III: Exercises

  • Forward Hops
  • Bounding
  • Step Hops
  • High Knees
  • Marching drills

Exercise Video: [embedyt][/embedyt]

The 10% Rule is a well recognised way of increasing training load among runners, however there was no evidence-based research found for using the 10% rule.

Similarly, at we like to use a Walk/Run progression with our athletes, this also is not validated or tested but we do find it is a good way to regulate an athletes return to their normal running levels.

Walk/Run program:

Day 1: 2min Walk & 2min Jog = 4 mins x 6 sets = 24 mins

Day 2: Rest: Access if any pain from day 1, no pain and progress to day 3

Day 3: 1:45min Walk & 2:15min Jog = 4 mins x 6 sets = 24 min

Day 4: Rest: Access if any pain from day 3, no pain and progress to day 5

Day 5: 1:30min Walk & 2:30 Jog = 4 mins x 6 sets = 24 min

Day 6: Rest: Access if any pain from day 3, no pain and progress to day 7

Day 7: 1:15min Walk & 2:45 Jog = 4 mins x 6 sets = 24 min

Continue above program of reducing Walk slot by 15 secs and add to Run slot until you are running nonstop 24 mins, pain free. If you have pain after a walk/run day, regress to previous level and remain at that level until pain free. Use this protocol and monitor your pain as an indicator to progress.

When an athlete gets to 24 minutes running pain free they should continue to increase their run time gradually for a further 2 – 4 weeks as they get back to their normal level of trainin

Please contact us if you are recovering from a Stress fracture and need additional information.