The clinic: don't short change a tibial stress fracture.

I'm a 29-year-old female runner (both road and trail marathons), hiking enthusiast, and recreational road cyclist and though I've been competing in sports since the fourth grade, I've never had downtime due to injury. I gave my leg a stress fracture after my long trail run the other week. I got a point pain in my lower left shin about four inches from the top of my foot literally during the last mile of a 47-mile trail that we took at a comfortable pace, taking all day and walking up the steeper slopes.

I iced and massaged it that night. The pain continued throughout the night, constant but approximately a 2 on a 10-point scale--I was able to sleep, though I was concerned about its persistence. I took the next day off from exercise, but after a 20-minute trail run the following day, the flats were uncomfortable and the downhills were excruciating, causing me to cut the run short. Road biking hurt the next day, and after another day off I went swimming--it hurt to kick.

I went to see an orthopedist, and he told me no running or hiking for three months. He also indicated two months without biking, but said that I could start swimming now. Three months of no running is hard for me to accept. Are there any other rehab recommendations that might allow me to return to running earlier?

Fran Dewitt

Gardiner, Montana 

These instructions are commonly given to patients with stress fractures as a firm protocol. The basic premise is to allow the fracture to heal prior to re-exposure to potentially aggravating factors. Healing depends on severity, the presence or absence of complicating conditions (e.g., osteoporosis, an eating disorder), and patient compliance. This last item cannot be overlooked, as is often the case with avid runners anxious to get back to running. This is the reason it is easier and more effective to simply tell the runner to "stay off it for X months" than to aggressively apply a monitored and graded return to activity. My general rules are: 1.) Stay off of it until you are pain-free with routine activities (crutches or a boot may be involved during this phase); 2.) With a therapist's watchful eye, slowly increase activity within a pain-free window. This takes as long as it takes, but will at least allow you to feel that you are doing everything you can to return as soon and as safely as possible.

Robert Scott, MD

Del Mar, CA

As long as you have tenderness at the fracture site, you must not run. This is one of the few times that a sports medicine physician absolutely keeps an athlete out of an activity. Even after localized tenderness ceases, you still need another four weeks before a return to running. It typically takes eight to 12 weeks for a tibial stress fracture to heal enough for three 3-mile runs a week. Your doctor's call for a three-month running hiatus, then, is accurate. In the meantime, swimming should be okay. Avoid diving, however. Most people can ride a bike, but if it is painful, you must not push the leg. Similarly, cross country skiing, rowing, and elliptical training are usually well-tolerated and can be performed early in the recovery process. Once you do hit the roads again, do so on an increasing run/walk basis. Increase mileage by no more than 10 to 15% per week. This may feel frustratingly slow, but it is simply how long it takes to heal the tibia and return to full mileage in the least time. To get to marathon-training distances, you are easily looking at six to nine months.

Klaud Miller, MD