Stress fracture or calf/soleus strain?

author : AMSSM

comments : 0

After two stress fractures, does new pain mean bad news?

Member question from trigirl74:

"I've had two stress fractures in my right tibia, one in 2003, one in 2006. I've got orthotics, a different pair after both times. Each time the pain was totally different. The first time I couldn't bear weight at all. I had run 18 miles the day before. The second time it was just a nagging pain that wouldn't go away.

I've had some pain, mostly the day after my runs, for the last two to three weeks. I don't run on consecutive days because of this. I would feel slight discomfort after waking up and bearing weight first thing in the morning, but the shin would "warm up" so to speak and not bother me at all for the remainder of the day. I wear running shoes all the time to have maximal support.

I ran 10 miles on Tuesday last week, then four or so on Thursday. The shin started bothering me during the run on Thursday which was new, so I did a bit of a walk/run.

The next day and every day since last Friday, the shin seems to really bother me. I can run my finger along the inner edge of the tibia and I find NO pointed pain spots. None. However, it's more the back of my shin/calf area (and possibly soleus) that is so tight. I can best explain it sometimes as feeling a deep ache. I have tried the one leg hop test and sometimes I can do five and sometimes just one. Regardless, it's slightly uncomfortable.

Clearly I'm not going to run with this happening. I just plan to pool run this week and until I can get in to see my ortho.

Any thoughts on not feeling any pointed pain along the inner side of the tibia (whereas I was able to feel this in the two previos stress fractures), and this deep ache that I sometimes feel in the calf/soleus area? Does this sound like a stress fracture to you?

Thanks for your advice and input!"

Answer from George G.A. Pujalte, MD, CAQSM
Member AMSSM

I would agree with you that your pain is suggestive of a possible stress fracture. It is a little worrisome that you have had two previous stress fractures and now potentially a third. Your description of the pain being totally different during each episode, leads me to question how you were diagnosed each time and the certainty of your physician of his stress fracture diagnosis. Was the level of certainty high by the treating physician based on history, physical exam, and perhaps imaging studies (particularly on the second episode)?

It is possible that you are a little too aggressive with your training load and have just maladapted a few times. If there was no change in your training stress, the recurrence might warrant further investigation of your history, a physical exam, and possibly laboratory studies to rule out co-morbidities or inadequate nutritional status.

Pain from stress fractures usually comes in a gradually increasing manner, though this is not absolute, of course. It is possible for some athletes to run long distances and have just minimal, "bearable," pain during their run, only to have a lot of pain the next day. A "nagging" pain can be just as good a description of a stress reaction or fracture as any. The location is important, though, and this is where a more thorough history and physical exam would be very useful. You can have a stress fracture without point tenderness on exam. People's exams change with time and you may develop more localized tenderness further into the process.

Pain in the back of the leg with stress fractures/reaction is possible. In particular, proximal tibia stress fractures commonly manifest as calf pain. A lot of the exercises aimed at preventing pain from stress fractures/reaction involve stretching and strengthening the gastrocnemius and soleus, particularly the soleus. Increased activation of these muscles, if they are not strong or flexible enough may lead to the pain that you are experiencing.

However, new-onset posterior leg pain needs to be carefully examined. Although rare, triathletes, particularly those who travel or stay sedentary for prolonged periods of time in between training sessions, may develop blood clots. Again, a thorough history and physical exam with the possible aid of an ultrasound can rule out a clot. I also don't want you to forget that your pain can be from something as straight forward as a muscle strain.

At our institution, after a third time with this similar problem, we would consider further work at making a diagnosis, such as a bone scan -- though an MRI may be better, given this new-onset pain on your calf muscles or other diagnostic testing to rule out co-morbidities.

A final thought: your case actually reminds me of a few cases we have seen in our institution, where runners have tried different shoes and shoe inserts for a variety of conditions. With shoe changes, we have often seen one problem replaced with a different problem.

What seemed to work for these runners was a gradual introduction to "barefoot" or "minimalist" running. These "less foot supportive" running styles are believed to result in less transmission of forces known to lead to running injuries, such as stress fractures. Our few results so far have been remarkable.

You may want to discuss this option with your physician, and see how he feels. Please note the emphasis on the word gradual. None of the patients I mentioned above got to the point of "barefoot" or "minimalist" running within one month. Yet, all of them have been pain-free since fully acclimating to this way of running. More studies are needed to determine if "barefoot" or "minimalist" running does result in fewer injuries in a large population of runners followed over time.

Assistant Professor
Primary Care Sports Medicine
Departments of Family and Community Medicine, and Orthopaedics and Rehabilitation
H154
Penn State Milton S. Hershey Medical Center

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date: June 28, 2011