telling runners to race on a stress fracture 🦴

"In this world nothing can be said to be certain, except death and taxes,"
-Benjamin Franklin

Runners with potential (or known) BSIs can’t run.

A majority of my patients take my advice to stop running when dealing with a BSI, follow my sensible rehab plan, and are back to doing what they love in a few weeks.

But sometimes a patient comes in and says,
“Look, man, I’m gonna run anyway.”

How do we handle those situations?

The worst outcomes

Pain with a bone stress injury means we have to change something.

When symptoms have gotten to the point that I can reproduce a runner’s pain with orthopedic testing, we are likely dealing with “mechanical failure”.

Continuing to run or participate in any activity that produces symptoms could absolutely lead to graver outcomes.

A stress reaction could become a stress fracture (longer recovery).
A 25% femoral neck stress fracture becomes 70% (hello, surgery!)

BSIs can always get worse.

What will you actually get out of the race?

When a runner asks "What would you do in this situation, Nathan?"

I tell them I'd skip the race and go out to brunch.
The risk isn't worth it, and how enjoyable will limping for hours on a Saturday morning really be?

But I also don't care how about running a marathon or getting a collegiate scholarship, making my decision easier.

There are scenarios I understand an athlete's decision to grit their teeth and hobble through the race.

A runner slated to run the Olympic Trials in a few weeks, but recently diagnosed with a low-risk stress reaction.
A runner rehabbing a tibial BSI has completed only a 10-mile run during rehab but wants to run the Boston Marathon in two weeks.
A high school senior returns to racing faster than normal because they need track times to get recruited for college.

There are two key points with these cases.

All injuries are in low-risk locations

If a runner has a potential BSI in their femur, navicular, or anterior tibial cortex, they can not continue to run. And if they choose to, they need to find another PT.

The athletes (or parents) know the risks

If you’ve worked with motivated individuals for a long time, you learn people will do what they want. My job is to explain the risks and potential outcomes associated with with their decision.

Would I ever run on a potential BSI? Absolutely not!
But I've met many runners willing to risk it to finish their key race or racing season. Ultimately, it’s their decision, and my job is to educate them on the risks while also giving them guardrails and strategies should they choose to race.