I’ve been running at a pretty advanced level for quite some time now. I ran Division I cross country and track in college for five years (I had a redshirt year), and now, for the past two years post-collegiate, I’ve been a sub-elite marathon runner. During this time period, I’ve been at my peak fitness point three times, and all three times I haven’t had any races to show for it because of the two ugly, dirty words that runners hope their doctors never utter: stress fracture. I’ve been battling the female athlete triad—not enough calories replenished for the amount of energy spent, therefore not getting my period, therefore decreased bone density—for a long time. I’ve seen several nutritionists in the past to try to combat the volume of training and supplement it with the right nutrients. Each time, they’ve found that I do, in fact, eat enough (my friends call me the human garbage disposal) for the amount of energy I’m expending.
I also eat well—tons of fruits, vegetables, and protein, and pretty much nothing processed. I’ve had bone density tests and extensive blood work done. I’ve been taking calcium and vitamin D supplements. I’ve sort of fixed the problem temporarily; I now get my period when I’m not training as hard, which is a positive indicator. But it always leaves me when I’m at the peak of a training cycle. All of the doctors I’ve seen in the past have told me that I just train really hard and run a lot of miles, like that’s a bad thing. This year, it happened again, about a month and a half ago. I felt the pain. It’s trigger point, tender pain, which worsens with activity. It eventually hurts to touch and to walk, if you let it get to that point. I was pretty sure I knew what it was no matter how much I tried to ignore, and, after the MRI showed my self-diagnosis was correct (most stress fractures don’t show up in x-rays), I was forced to forfeit my Boston Marathon bib number, right when I was at another peak in my fitness and training. I was fed up this time. I wanted to know how I could keep training hard and prevent stress injuries from sabotaging my racing goals at key moments in my running career. I decided to reach out to two experts in field to find out where my knowledge of stress fractures was falling through the cracks (in my bones, apparently). A stress fracture is just that; a tiny crack in a bone that occurs when there’s too much loading force on it, as Jordan Metzl, a sports physician who’s worked with hundreds of runners, including Olympians and professional athletes, says. First, the bone starts to swell—referred to as a stress reaction, or a stress injury. The more stress you continue to place on the bone without giving it the appropriate time to heal, the worse that injury can get. When we ignore the signs of a stress injury is when it can turn into a fracture. It can happen to any bone, but, in the case of runners like me, doctors see it more in the metatarsals, tibia, femur, hip, and pelvis—but especially the metatarsals and tibia (both the areas I’ve had fractures in).
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So why don’t some professional runners—who train even harder than me—not crack their bones? “Runners are like snowflakes,” Metzl says. “They all are similar but with different variations in their makeup and pattern. Everybody gets different injuries for different reasons, and no two injuries are the same.” Comforting. Naresh Rao, a New York-based physician who has worked with Olympians, agrees, but adds that there are certain runners at higher risk for stress fractures than others. “If you have a risk factor for weakened bones, it will predispose you to a greater risk of stress fractures,” Rao says. “Having low estrogen, an eating disorder, history of stress fractures, calcium deficiency—those are all metabolic risk factors. There are also related reasons that vary in each and every runner. You could be putting too much pressure on one part of your foot.”
Metzl names a lot of variables that could foil a runner’s plans, some of which include not getting your period regularly and being just being young (hence, having a lower bone density). “Also, the lighter your skin, the lower your bone density, so if you’re of English, Irish, or Scandinavian descent, your functional bone mass tends to be lower. If your stride is very long, and you’re popping off the ground, you’re more likely to get this injury.” He also tells me that if a runner’s muscles are weak in any way, they’re not absorbing enough stress from the ground and strength could be a problem. And the list goes on. I get it. Not one person prone to stress fractures is prone for the same reason. It’s just unfortunate for us runners who are at a greater risk. And here I am: Irish, buys the lightest shade of any type of makeup, with a history of running a lot as a young girl—long stride at that. I am walking (or running) risk factor. What do I do? Runner’s World notes that birth control has been tossed around in conversation among some doctors—although never mine before—to help regulate periods and combat the low bone density issue among young women who are super active and in turn lose their monthly periods. “We know that not getting your period for months is not good for bone density, but we’re also not sure that going on birth control fixes that problem,” Metzl says. “We want young women who are affected to go see a nutritionist. The problem tends to be with caloric intake—not getting enough calories for the amount of energy they’re expending.” Rao says the same, that it’s important to get to the root of the problem. Both doctors recommend the natural method of getting your period back: increasing your calorie intake, over birth control. “In some cases of extremely low estrogen, I would prescribe it,” Rao says. He has the same take when it comes to for supplements: Get your calcium and vitamin D from foods as much as possible. “I try not to ask people to take things unless they are proven deficient in their diet,” Rao says. Metzl is a little more lax on this one—he would still take calcium and vitamin D rich foods over supplements, but thinks supplements could be helpful, especially if you’ve had a stress fracture before. Combating chronic stress fractures means changing what’s going into your body, but it also means being aware of how our body adapts to our training. “It’s rare that running too much is the isolated variable,” Metzl says. “Often times, it’s stride or foot mechanics that are screwy. Someone could be running 30 miles a week and get injured, but when we fix their stride or foot mechanics they could stay healthy running 50 miles a week.” If you do feel that that running too much is your problem, Rao recommends lots of cross training—such a swimming or biking—that has less of a high stress impact on your bones than running does but still keeps you in top form. “Make sure there’s enough time in training plan to account for potential pitfalls,” Rao adds. “That way, if you get injured, you still have plenty of time to get your physical therapy in and get healthy and ready for the race.”
I never looked at my run mechanics as a potential pitfall reason for my injuries. Since exploring my mechanics, I’ve found that it’s not my stride but the way my foot is shaped that's one of the contributing factors of my chronic problem. And I would’ve never known anything at all about my feet had I not inquired—over and over again. Ignorance can be very blissful, especially if running is your happy place, but figuring out what’s behind the pain instead of trying to walk-run it off is key to getting better, staying better, and getting a day closer to wearing that race bib.
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