Member Case Study: Tibia Stress Fracture and ITB Syndrome

author : AMSSM

comments : 1

Besides the obvious rest and strengthening/PT around the ankles, what can I do to further find the root cause and correct it? Also, what are doctors’ stances on active release?

Question from hjmiii
First a bit of history.  I got a stress fracture in my right tibia just above the ankle back at the beginning of April. Though I suspected it at the time, I didn't know for sure that it was a break until I recently confirmed it. It was about a week before I left on a 2 week vacation to Hawaii. While on vacation I could barely walk at times. I stopped most training except a few swims and aqua jogs. Since it was too close to leaving when it occurred to get an appt, and it stopped hurting by the time I got back, I never saw a doctor about it. I mostly stayed away from running after that, just in case it was a stress fracture, and instead did an aqua jogging routine to work the same muscles whenever my training plan said run.

As of the 21st of May I was cruising along just great on my road to Ironman Coeur d'Alene. That weekend I did a whole Ironman spread over 3 days in a confidence building workout. (2.4 mile swim Friday, 116 mile bike on Saturday, and ran the Cleveland Marathon Sunday) Everything went fine and I felt great. 
 
That week I took it easy to recover, and the following Saturday I ran in a 5mi road race. After the race my right IT Band was a bit sore, but I figured I had just gone out a little too hard so soon after the marathon. My shoes were only at about 150miles, with new soft arch supports that had previously worked fine. Historically I have had a pretty neutral stride, but I had 1 short bout with ITBS in April of 2005 after which I started using this brand of insoles.

At that event I knew immediately that I wouldn't be running. The pain kicked in at about the 1/2 mi mark. I walked the whole event, which didn't hurt at all, but by the end I was feeling the pain.

Now we’re at the present. The ITB is nicely flared up, I still have the occasional pangs in the lateral right foot (no worse), and to top it off (probably due to the doubled insoles, but also possibly a flare up of what the masseuse felt), my right ankle has a case of shoe lace tendonitis.

Besides the obvious rest (my season is over now anyway) and strengthening/PT around the ankles, what can I do to further find the root cause and correct it? Also, what are doctors’ stances on active release? Is that a long-term solution, or is it a soft tissue of equivalent of a chiropractor?

Answer by Darrin Bright, MD
Sorry to hear about your recent problems with your stress fracture and IT Band. I know it can be very frustrating to put so much time and effort into your training and then have an injury undermine everything.

You provided a lot of history that likely all plays a role in your current symptoms. One of the first things I like to address with endurance athletes is the shoes. Whenever your foot strikes the ground, three to eight times body weight has to be absorbed by the body. Your shoes represent the first-line of defense against these forces. You mentioned that your shoes had limited miles on them, however, given the history of a tibial stress fracture in combination with IT band syndrome I feel that your foot mechanics could certainly be playing a role. Most communities have at least one running specialty store that specializes in shoe fitting.

Being properly fit for running shoes is essential if you have not done so already. As for the inserts, over-the-counter orthotics can be effective for a lot of people. I’ve seen estimates that 1/3 of people needing orthotics would benefit from over-the-counter versions. However, I would not recommend doubling up on the orthotics. Most manufacturers of orthotics recommend taking the sock liner out of the shoe prior to inserting their product. The reason for this is simple – as you add more supports inside the shoe, the foot is no longer positioned properly in the shoe and you lose the support/stability that the shoe provides. It is also important to have your physician look at your gait mechanics and determine if you need custom orthotics.

Now for the IT Band Syndrome. Again, it is essential to address gait/foot mechanics with ITB. It is important to continue physical therapy to maintain an active rehabilitation program. However, physical therapy programs frequently focus only on IT Band flexibility. I am always surprised how frequently I see IT Band Syndrome in runners who have normal flexibility within the IT Band. There is some very good literature suggesting that the gluteus medius plays a large role in IT Band Syndrome. Therefore, I always ask the therapist to address gluteus medius strengthening in combination with a flexibility program.

Finally, what do physicians think of ART (Active Release Technique)? I can’t answer for all physicians but I can tell you my impression – I’m a believer. I have an ART therapist that I work very closely with in the Columbus area. I think it works very well for chronic hamstring, calf, IT Band, and other musculotendinous disorders. However, as with all areas of medicine, it is important to understand the limitations of the modality. ART is mostly a passive modality. I firmly believe that it needs to be used in conjunction with active therapeutic exercises.

Good luck with your rehab and hopefully next year will be a better year!

Darrin Bright, MD
Member AMSSM Director of the MAX Endurance Academy at MAX Sports Center (www.maxsportscenter.com),  Medical Director for the John Bingham Racing Columbus Distance Classic

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date: July 30, 2006