One of my runners sent me an inquiry today that I get all too often. While suffering from pain in her shin, she asks if I think this is a stress fracture or a shin splint. Below was my reply to her, which others may find helpful. I use an analogy below to a pane of glass to help explain how a stress fracture forms and then what happens if with continued running on it. First, her question:
“….I have either a tibial stress fracture or a posterior shin splint… I’m hoping it’s just a shin splint, but my gut is telling me it’s a stress fracture… I have an x-ray scheduled for Friday… Running is unbearable right now. I tried it yesterday after taking a week long break and I felt like I was limping the whole time, so I figured I should stop. Instead, I did 30 minutes of intervals on the elliptical.
I don’t want to take 6-8 weeks off if she tells me that it is indeed a stress fracture. My dr’s a runner too so I think she’d understand my frustration. Is there anything you would suggest to speed recovery? How do I keep up with my current fitness level without running? This is the first time I’ve ever had anything like this…”
Oh, how often I’ve had this question. The first thing that I want everyone to read is that if you are in this situation, please go see your doctor. As I’ll explain below, although stress fractures are much less common than shin splints, they are very serious injuries. If you continue to run on a stress fracture, there is a strong possibility of doing permanent damage and there is no reason to inflict that on yourself. So now that you’ve all read my caution (go see your doctor!), I’ll answer the question.
For the sake of definitions, a shin splint is an inflammation of the tissue running along the bone in the shin. Shin splints develop when the muscles and tissues tear due to the repeated pounding of running. This is usually caused by inflexible calf muscles in the back of the lower-leg, improper shoe choice, shoes that are not providing enough cushion, or ramping distance too quickly. (For more on shin splints, click here.) A stress fracture is a very small crack or group of cracks that forms in the bone itself, like a crack in a window.
The major difference in differentiating between a shin splint and a stress fracture is usually what we call “point tenderness”. With a shin splint, if you run your fingers along the shin, it will usually hurt all along the bone as you pass your fingers down the leg. With a stress fracture, there is usually one specific spot (or multiple spots) that hurts really badly. These spots are usually about the size of dime. As you go along pushing with your fingers, you’ll find a specific spot that you say “ooowwweee” when you touch it. The rest of the area will be much less tender.
Another test for a stress fracture is called a “hop test”. Here you stand on one foot (the one that has the hurt leg) and hop. Generally if you can hop on it, it is probably not a stress fracture. Your mind will essentially prevent you from hopping on it if it is a stress fracture, because you know how much it is going to hurt. This isn’t really a very scientific test, but it does seem to work with some people.
Stress fractures are much less common than shin splints. In most cases, a shin splint is a more likely explanation for shin pain, especially in new runners.
A bit of bad news in diagnosing stress fractures, because they are very small cracks they may not show up on an x-ray. A bone scan or MRI are often the only way to actually see them. This often leaves a definitive diagnoses up to the doctor’s judgement, rather than hard and fast pictures. This may be a reason to see a Sports Medicine Doctor, because they may see more of these types of injuries than a generalist.
With that said, if you have a stress fracture, you will need to stop running until it heals. No ifs and or butts about it. The best way to explain this is that is to imagine your bone like a pane of glass. Now imagine tapping on it lightly with a hammer. Eventually there will be a small crack or a series of cracks that develops right where you are tapping on it. At this point, your stress fracture has appeared. If you keep tapping on it, what is going to happen? Eventually the pane of glass is going to shatter. So when that stress fracture appears, you either stop tapping on it and let it heal or if you keep on tapping (running) then the bone itself is going to break and you’ll have a real fracture to deal with — which is a far more serious problem.
If you do have a stress fracture, then the best method to keep training is aqua jogging or aqua running. This means running in a swimming pool, usually wearing a flotation belt. It isn’t a lot of fun or very interesting (imagine swimming laps by in the jogging position and going much more slowly than a swimmer). But it is very effective at keeping up your cardio and maintaining running muscles in the legs, with zero impact on the lower-leg. Swimming is also a great way to keep up fitness, because again it is non-impact on the lower-legs.
So if you find yourself in this situation, first get things checked out by a doctor and see what she says. If she does diagnose with a stress fracture, then you’ll need to come up with a non-running training plan while you are recovering. If this is a shin splint, then you’ll likely need some time off and probably stretching, new shoes maybe and ultra-sound therapy — but you should be back to it in a fairly short order.
Coach Joe English, Portland, Oregon, USA
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