All you need to know: Cortisone.

In orthopedic offices cortisone shots are offered to patients every day. What exactly is a cortisone shot and who needs it? What are the risks and benefits? 

Let’s start at the beginning.  Cortisone is the name used to describe a group of steroid medications we inject into the body. In orthopedics a cortisone shot is given into your knee, shoulder, finger etc… basically any joint space or area. Other names you may hear are methylprednisolone (Depo-Medrol), Triamcinolone (Kenalog) and betamethasone (Celestone). 

I describe these injections to my patients as strong anti-inflammatory medications that are injected into (as one example) your knee.  They work similar to anti-inflammatory medicines you take by mouth (like Advil or ibuprofen) by decreasing inflammation.  However, the mechanism of how it works is different. Also, since we are directly injecting them into the area sometimes they are more effective. 

What does the cortisone actually do? I want to make this super clear- a cortisone injection does one thing only- decrease pain. Cortisone does not fix the injury, repair the joint it is injected into, grow back cartilage or any other magic. Just pain relief. 

How is the shot usually given? Most often cortisone is mixed with a standard numbing medication and injected using a syringe and needle. The numbing medication helps short-term with the pain (just like going to the dentist and getting numb before they pull a tooth) and it also helps distribute the cortisone evenly. My standard recipe is 40 mg of Kenalog and 4 mL of 1% lidocaine in the knee.  Another doctor’s recipes may differ based on their preferences and experience. 

When are cortisone shots needed? That is a difficult question without knowing the specifics of your injury or problem.  That said, the most common thing injected with cortisone are the things that cause us pain. Makes sense, right?  But also keep in mind all things that cause pain do not get a cortisone shot.  One very common use for cortisone is in the treatment of osteoarthritis. Osteoarthritis is the degenerative breakdown of cartilage (a whole topic we will discuss another day) but simply put it is wear and tear on a joint surface.   When someone has pain from osteoarthritis cortisone is often the first go-to for relief. Cortisone also can help with pain associated with meniscal tears, labral tears, bursitis, and several other conditions. Be mindful that there are certain areas of the body, such as tendons, ligaments or soft tissues spaces that either should not have cortisone injected at all or it is at best questionable to do so. 

Who needs one? That is a great discussion for you to have with your doctor!  I would ask the following: What are the goals of the injection? How can I optimize the pain relief to make it better long term?  What are the risks, side effects or alternatives? Remember although very well tolerated any medication we give isn’t a free pass and has risks and side effects. You need to know these ahead of time.  

Here are some of the ways I answer the above. First, how to optimize the pain relief?  I optimize the pain relief after giving a cortisone shot by focusing on the overall function of the body.  If you have a shoulder problem, I want your shoulder to be functioning as close to a normal shoulder as possible.  This is often hard to do! Your shoulder moves differently when you have pain.  Without guidance it is nearly impossible to fix.  Also, with a shoulder problem you are limited in your ability to use that arm normally which can affect other body parts.  This is called compensation.  It can include how you hold your arm, the alignment of your neck or back, and even how you move the other arm. We need to break this cycle for your pain to go away for good!  Cortisone can help with the pain but if the movement pattern is not improved it isn’t a long-term solution. Why? Your body has gotten accustomed to moving the injured way.  If you get cortisone and are having less pain, this is a great time to try to optimize the shoulder movement to keep the pain away. I often recommend physical therapy for this.  Also please note- physical therapy can be fantastic even without a cortisone shot. 

Next, what are the risks? Every medication has risk. I always remind patients every needle stick has a risk of bleeding and infection. The skin is your safety barrier and sticking a hole in it means breaking that barrier.  When sticking a needle into the skin there are structures below the surface.  Depending on where the needle is headed (more for certain injections than others) we need to be aware of blood vessels to avoid bleeding.  These are both very small risks but depending on the person getting the injection.  Another important risk I always discuss applies to patients with diabetes.  We know cortisone injections can transiently increase blood sugar for about two weeks after the injection.  If you are a well-controlled diabetic you can likely still have the injection, but your physician should have you monitor your sugars closely and report any issues. Unfortunately, if your sugars are out of control before the injection it may not be safe to proceed.

How long does the pain relief last?  That is highly variable.  I tell my patients the medication effect lasts a few months. That is how long the medication itself is altering the insides of joint.  However, if you do more (refer back to the above about PT and shoulder pain), then it may last much longer.   Another possible and important ‘risk’ to be clear on is sometimes cortisone does not provide any pain relief at all. 

What if I need to get several cortisone injections to maintain pain relief? This again is variable but could be a concern.  Let’s revisit the knee example for osteoarthritis.  You as my patient have had one the injection every few years and otherwise have done well!  You are able maintain your exercise program, stay at a healthy weight and are maintaining cardiovascular fitness… to me, this is great! Those benefits clearly outweigh the occasional injection.  However, if you notice that you are having repeat injections and the time between them is getting shorter to maintain pain control this may not be the best solution any longer.  There is some data that suggests repeated cortisone injections may advance breakdown of the tissue faster than normal.  So, we must proceed with caution.  

Overall injections of cortisone are safe and well-tolerated in many and can be extremely helpful in alleviating pain. If you have questions about cortisone or whether you are a candidate for one it may be time for an educated discussion with your orthopedic physician.

Ski Season.

The cold winter air on your face, fresh powder under your feet, stillness of the wilderness… Whether you tackle the slope on skis or a snowboard nothing quite compares to the feeling of that first run of the day. But as with all sports, injuries can ruin what started as the perfect alpine morning.  Read on to learn about the most common issues snow seekers face and what can be done to stay as safe as possible. 

Common Injuries

For winter sports enthusiasts of the skiing type, the most prevalent injury is in the knee.  With the feet and ankles locked in a hard sided ski boot, the force is directed to the knees means when you fall on the slope.  This force can cause a variety of knee issues, one of the most feared is the ACL Tear (which I wrote about in depth here… LINK), but you can also injure other areas including ligaments such as the MCL or LCL, the menisci, or even the bones (femur/tibia) as they join at the knee.  

For snowboarders, knee injuries can also occur. However, given the orientation of the board on the slope and the single-sled positioning (feet both fixed to the same board), the most common area injured is the wrist. When a snowboarder starts to fall, they instinctively reach for the ground causing injuries ranging from minor sprains to fractures of the wrist bones. 

For all alpine lovers, injuries to the shoulder can also occur.  During a fall you can easily land on your shoulder or outstretched arm causing injuries to the tendons, muscles, or ligamentous structures in and around the shoulder. Shoulders can stretch out of place (subluxate), dislocate, or break with this mechanism. 

Other areas of the body are also prone to injury from a fall on the slope including the hips, spine, and chest wall. 

The most traumatic snow sport related injuries are those to the head or neck. For experienced and novice skiers alike, barreling down a slippery slope can be hazardous. Conditions that make this worse are crowded areas and other obstacles like trees or rocks.  Hitting another person or a tree can have devastating consequences as can your head on the hard packed snow.  Injuries can range in severity from concussion  to bleeding or fractures to severe traumatic brain or spinal cord injuries.

How to stay safe

Staying safe on the slopes makes for a much better day then ending a run with an injury.  

My recommendations: 

1- know your limits and the trail maps

2- train before you ski

3- save the alcohol for the après

4- wear a helmet, always

1. Know your limits

Staying safe on the slopes requires a level of understanding of what you are getting yourself into as well as a knowledge your ability. If you are a beginner or novice, look at the trail map ahead of time and stick with the runs appropriate for your skill level. You are not competing for a spot on the Olympic team… Even if you are more advanced, remember to avoid putting yourself in a position where you feel out of control.  The number one reason I see patients in the office with an injury is getting themselves into an uncomfortable position.  If you end up in this scenario, it is best to stop and ask for help. Ski patrol is always available to keep you safe.  They would much rather help you down the slope than find you injured. 

Another great tip is to take a lesson. No matter how advanced of a skier you are, lessons can be extremely helpful! During my last ski trip, I took a lesson, and it was worth every penny. The instructor was a true gem, helping me (more novice) and my husband (more intermediate) at the same time by challenging each one of our levels safely.  He was so great that when he ran into us the next day while skiing with his daughter, he skied with us for a bit for follow up tips.  These instructors live for skiing, know the terrain, and know how to teach you to be better. Everyone can learn!

2. Train before you go

If you were going to run a half marathon you wouldn’t just show up race day and expect to finish without problems.  Same goes for snow sports. Even if you are in great physical shape at baseline, some activity specific training can be beneficial.  Skiing and snowboarding are physically demanding sports. You need strong legs, great control of your upper and lower body, and stamina to survive the day.  I can’t count the number of patients who describe their injury as something like, “I was tired, out of control and crashed but can’t remember what actually happened.” Don’t be that person. 

3. Save the Après

Ah yes, the time-honored tradition of that first amazing post-ski après beverage at the lodge. It may be my favorite part of the ski day.  However, studies have shown that alcohol increases the risk of injury for both skiers and snowboarders. (As does any illicit/mind-altering substance use). Save the après festivities for after you are done skiing for the day. 

4. Wear a helmet, always

This one cannot be stressed enough. Head injury can be a devastating outcome of a crash on the slopes. No matter how well you ski, a fall can still happen. It is sort of like driving, even if you drive perfectly, someone else can hit you or cause you to crash. So, we were seatbelts, right? Wear a helmet every time you ski or snowboard. Protect your skull and brain and decrease your risk of tragic outcomes. 

If an injury occurs

Ski patrol is always available for injured skiers. They are all over the mountain and at the base, and most resorts employ trained medical staff. Some even have physicians available. Every ski town I have been to has a local urgent care as well with a team that is used to seeing slope related injuries. If you need follow up after a day on the slopes for a bone, muscle or joint problem seek out your local sports medicine orthopedist. It is always helpful to bring any images (Xray’s, MRI’s, etc…) that were taken on the slopes or after.

And of course, enjoy the snow!

Orthopaedic Injuries of Pregnancy

It is no secret that pregnancy comes with a host of changes for your body. These changes allow you to accommodate making a new life but also can put you at risk for musculoskeletal issues along the way.  This is often because of some combination of loosening of ligaments due to hormones, changes in the center of gravity due to your new “bump”, added weight in general, and increases in overall body stress.

Most common Issues I see in practice:

#1 Injuries from a Fall:

As a specialist, I usually see a patient when they hurt something that needs further investigation.  Injuries happen to even the healthiest of pregnant patients.  One of the most common I see is an ankle sprain (see my full post here on all things ankle sprains) Pregnant patients often feel unbalanced.  A movement as simple as stepping off a curb awkwardly can lead to an ankle injury. The great news is the treatment for ankle sprains during pregnancy is very similar to the average patient, and most do very well without long term issues. 

Another common injury from a fall is a broken kneecap (patella).  Again, these tend to happen because of being a little off balance.  With a slip or fall, you can land directly on the knee causing the patella to break. This is painful! The injury is not usually subtle and makes it difficult to stand or walk.  X-rays will show us the problem, and sometimes the problem needs to have surgery to fix, but often you can get better with a period of resting your leg in a straight position. Though keeping your leg fully straight for weeks is not easy while pregnant… something I appreciate even more now that I am pregnant! But my patients have made it through, and you will too! 

Other broken bones can also happen during pregnancy from falls. The second most common fracture in my practice is a broken wrist. When you start to fall you naturally reach for the ground to brace yourself. Unfortunately with this motion, you can land on your outstretched hand break a bone in your wrist called the distal radius. Again, sometimes these need to be fixed with surgery. The ones that do not are treated in a cast for several weeks. Being in a wrist cast while pregnant also seems absolutely no fun, but it is achievable and safe.  Keep in mind these things can happen in pregnancy (just like outside of it), and orthopedic doctors are trained to do what is best to make sure your bones heal well, and your pregnancy stays safe. It is key to let your OB know if you have had a fall or are seeking care with another doctor. This allows us to all work together to be sure we are optimally treating you and keeping everything as pregnancy safe as possible.

#2 Aches and Pains

Ah yes, the joys of pregnancy…  Sometimes if feels like everything hurts whether you move or sit still! Joint pains, achy muscles, and stiffness all over are very common.  Muscle imbalance mixed with a growing belly often leads to a very common complaint, back pain.  It is estimated that 50-80% of patients experience back pain during pregnancy (2). Other super common areas of pain are the hips/pelvic girdle, knee, and neck. Most of this can again be attributed to the normal changes that occur during pregnancy, and keeping active throughout is the absolute best way to keep these issues at bay.  

#3 Wrist and Hand issues

Again attributed to the changes of pregnancy, wrist and hand pain is also very common. One specific condition that plagues pregnant patients is carpal tunnel syndrome.  This condition usually experienced as hand numbness and tingling in the thumb, index and middle fingers and has been estimated to occur in up to 62% of women who are pregnant (1). Great news, this most often resolves on its own after delivery. Until then, stretches and braces for the wrist usually help relieve the symptoms. 

How to stay safe:

First and foremost, listen to your body! The changes of pregnancy alter so much about your function and physiology. You should avoid risky activities where falling could occur, be careful on wet ground and ice, and always be extra vigilant of where you are walking. Stepping off a curb requires attention as does hurrying across a street or walking on a dirt road/path. Be careful! 

Another great tool is a daily body “check in” to see how you are feeling. Is your back tighter today? How do those hips feel? If you can catch an ache or pain early before it becomes severe, you can likely fix it faster. Add in stretches or targeted exercises for your problem areas, and keep moving throughout pregnancy.  Another tip is to remember to take a break if you are sitting for a prolonged period. This helps keep your body from becoming stiff.  It is important to avoid heavy lifting, and be sure you are using proper techniques to lift with your legs (not your back) to stave off further back pains and injuries.  Avoid reaching far away from your body as much as possible to keep your center of gravity stable.  Sadly, since your balance is a little off, retiring your high heels short term is the safest thing to do. 

As always on this website I preach an overall healthy, active lifestyle. In pregnancy this doesn’t change! If anything, it means more focus on these techniques to keep you fit as everything changes. Daily stretching, strengthening, and cardiovascular exercise help keep your body healthy and strong all pregnancy long. This helps you avoid injuries, keeps a better mind-body connection to avoid falls, and keeps aches and pains away.

Finally, what to do if you have pain or get hurt:

First, think about the severity (how bad is it?). If on your daily body check you noticed some general soreness and aches and pains, start with easy-to-do changes at home. Sit in a more proper position while working, remember to take standing breaks, and be sure you are getting proper exercise and stretching.  Always keep in mind your daily routine and that you may need to change something if your body is aggravated by these activities. Also, as always, talk to your OB! Bring up these concerns at appointments or even before if you feel they are significant.  Many small aches and pains are common and not a big deal, but you should always discuss with your doctor to be sure something further doesn’t need to be evaluated. Also know that even for general aches and pains, sometimes braces or other supports can be used to ease the discomfort.  Sometimes your doctor may recommend a pregnancy-safe medication such as Tylenol or even refer you to physical therapy to aid in your recovery.

If you have a larger amount of pain related muscle or joints or if you have had a sudden injury, an urgent/emergency evaluation is the way to go. You should also absolutely reach out to your OB as they can work with your orthopedic team to be sure you are optimally treated as a whole by coordinating specific recommendations based on pregnancy. If you need an X-ray, don’t panic. You can use a shield, and the doctor will do everything possible to keep you safe by only taking x-rays that are necessary to treat you properly. Trust your doctor, and ask questions along the way. I never feel bad when a pregnant patient asks about the necessity of a test or treatment. 

Sources:

1. https://pubmed.ncbi.nlm.nih.gov/19753825/

2. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3306025/

3. https://www.cedars-sinai.org/health-library/diseases-and-conditions/b/back-pain-during-pregnancy.html

The ACL Tear.

As we approach the end of football season, there is one injury that we have heard of several times throughout the year (and past years as well). The ACL tear.  Most sports fans have seen this listed on the injury report and heard the announcers talk about concerns for this when a player goes down on the field, but what is it? Why is it a big deal, how does it happen, and what is typically done about it?  

First, knowing a little anatomy of the knee is important. The ACL – or anterior cruciate ligament – is an important structure inside your knee joint.  We have 4 ligaments in and around that area, named for where they are located. Anterior (front) and posterior (back) cruciate ligaments, and medial (inside) and lateral (outside) collateral ligaments.  Today we focus on the ACL because it is usually the most ‘tragic’ when injured in sports. By tragic, I mean the one that is the most worrisome for an athlete because of the long treatment and recovery process that often alters one’s career short and long term. 

The ACL connects the bottom bone in the knee (tibia) to the top bone of the knee (femur) from front to back.  It plays a key role in stabilizing the knee. In medicine we would say it “resists anterior translation of the tibia on the femur.”  Stick with me here… this means in regular language that it stops the bottom bone of the knee from sliding forward in relation to the top bone during normal movement, aka inside the knee joint where it bends.  This bending is what allows us normal knee motion needed for walking, running, jumping, playing.  But we need something to help keep the bones attached to one another or else the knee may feel unstable (jelly-like) when we put stress on it.  [Think of the knee as a door hinge where the ACL is the pin that connects the two pieces of the “hinge”; without this the door can swing open and closed gently, but if it’s pushed too hard the hinge may not line up properly and may become damaged].  Not an ideal situation if one is interested in getting back to doing higher impact activities like playing football. 

If the ACL is torn the knee becomes unstable because the bottom bone can shift away from the top bone.  The cool thing the human body is that there are often redundant systems.  For the most part (although not always for every person) normal walking and low-impact day-to-day life can still be achieved without the ACL because the other ligaments and muscles around the knee can pick up the slack to provide stability.  This means even without an ACL, for daily life activities, many people move about fine.  The problem is with any sudden or shifty movements, such as cutting in sports or in high-impact jobs like law-enforcement or firefighting where folks are required to do movements that aren’t straight forward or backwards. These types of movements are more complex and require more stabilization, so without an ACL the knee can feel unstable and even give out.  For football and other sport athletes, one also would not get the control or explosive power she or he needs to play.   

An ACL tear most likely occurs when the leg is forced in a way that stretches the ligament too far.  Remember, the ACL blocks forward movement of the bottom part of the knee.  Consider a  a football player whose foot is planted to the ground when his knee gets pushed backwards, pushing the top bone away from the bottom bone. Pop!  The ACL is overstretched and gives way.  This is just one example, and there are of course other ways this happens.  Sometimes it involves a collision with another player (as described above) and sometimes it involves getting the leg in an awkward position when a person is running or jumping with the knee buckling inwards/backwards due to the force of the jump or a bad landing.  In this case, it is simply the lack of control and force of the jump landing or cut that causes the tear.  We tend to think of these “non-contact” tears occurring most frequently in young female athletes (maybe a teenage basketball player) that hasn’t developed full hip/knee control. 

The tearing of an ACL is an abrupt injury and not usually subtle.  Sometimes people hear a pop (but not always), feel a pop, have sudden onset of significant pain, and usually fall to the ground.  Most of the time the injured can’t walk easily (if at all) and don’t usually keep playing the game after.  The knee swells up from the inside due to the trauma (effusion).  I usually ask patients if it swelled up like a water balloon as an analogy.  A former mentor of mine taught me when I was learning about knee injuries that a young person running or cutting during sports with a sudden burst of pain with a pop in the knee and large swelling is an ACL injury until you prove otherwise.  This still rings true for my patients today.  #mentor

To diagnose the ACL tear we first talk about what happened when the injury occurred in great detail.  Then, we do an office examination of the knee, as well as the hips and lower legs.   Looking at the other nearby joints is important! Just because it seems that it might be an ACL tear it doesn’t always mean that is our answer.  We complete a few special maneuvers that help clue us in to what possible problem could be happening inside your knee. These maneuvers are helpful to distinguish other injuries that present in the office like an ACL tear.  This exam also helps us determine what next steps to take or if there is concern for other associated injuries (ACL tears often occur with other injures such as MCL tears, meniscus problems, and bone or cartilage injuries).

So you tore your ACL, what now?  Since it is such a crucial ligament for knee stability, most highly active people or athletes should discuss surgery to repair or reconstruct the ligament in the knee.  It does not grow back. It does not scar into place or heal. That said, it is important to note that older patients or people who are less involved in side-to-side/cutting sports or activities may not need surgery.  Be sure you have a discussion with your doctor about what the benefits of surgery are for you, the associated risks of the procedure, as well as the expected long term outcomes.  We practice medicine using the guide of high quality research, and if the studies show that you may do just as well without surgery, that may be the best way to treat your specific injury. Most important is to have these discussions with an orthopedic sports trained surgeon.  They will discuss options, the optimal timing to have surgery if it is thought to be best for you, and also very importantly your rehabilitation and expectations for recovery.  

Whether one has surgery or is treated without operation, he or she will need extensive physical therapy/rehab.  It takes many months for one to get back on the field!  One has to be patient.  For professional athletes that have dedicated athletic trainers and rehab specialists, these are season ending injuries. Often with great rehab, they can return in 6 months (at the earliest) though it can take 1 or more years to reach the prior level of sport.  But these are gifted individuals with many many resources.  For the average injury, it will be at least 1 year before one may feel 100%. And keep in mind, once a person has had an injury, and then had surgery, it is quite possible the knee will never feel 100%.  [Stay tuned for my article discussing preventing injuries like ACL tears.]

Stay healthy-

What is a stress fracture? And when should I worry?

Given the state of the world, people are increasingly turning to outdoor recreation and exercise. More people than ever are out running! This is awesome. However, with this, comes the possibility of new injuries. Runners are some my favorite patients because as a runner myself, I see the motivation and time commitment as well as the joy that being a runner can provide. Unfortunately, when I am seeing patients in the office, usually, they are having pain or have had an injury. An injury that has presented more often recently due to people turning to the streets for exercise is something called a stress fracture.

A stress fracture is essentially breakdown of the bone that occurs from repeated small forces. When we run or do other high-impact activities (jumping, plyometrics, or other exercises when both feet are off the ground at once) our bones break down and then heal when we rest. This is a normal process that happens on the microscopic level and is the way the bone stays strong by regularly “remodeling” itself. When the balance between breakdown and healing becomes unequal, we can develop a stress fracture. This stress fracture is a weakness in a small area of the bone that does not have a chance to heal before the next round of impacts, an overuse injury.  

Other factors sometimes contribute to the development of the fracture.  Remember I said that they start by a disruption in the balance of breakdown and healing of the bone. For a person training for their first marathon it seems that an increase in the breakdown forces would be the cause.  Well, what about the other side?  What if the breakdown hasn’t changed, but the healing side can’t keep up?  This can also be a reason why stress fractures occur.  Why does this happen?  The reason we have slower healing can often be attributed to nutritional factors, hormonal factors, weakened bones from medications, or simply aging.

The main symptom of a stress fracture is pain usually described as an achy sensation deep in the area of the body that is affected.  What can be tricky is most people can continue to run but then experience this achy pain after the run or even at night. The lower extremities are where stress fractures usually develop.  This makes sense as are often due to the impact of running.  Common places are in the lower leg bone (the tibia) and the foot bones (metatarsals).  Occasionally, one can also develop stress fractures in the small bone on the side of the leg (fibula), in the upper large leg bone (femur), or in the hip socket or pelvis. How serious the stress fracture is depends on a few factors, and one of the most important is where it is located – that is, some locations are more high risk than others for bad problems!

When I see someone in my clinic that has a stress fracture, the story they tell usually goes a little something like this… they have increased their mileage, or they changed their running routine in some other way.  They may have started to train for a marathon having never done one before, or maybe they are just training harder to get to a faster race time. Maybe they are new to running… 

They usually report pain in a small area in one of the body parts we mentioned before.  

After we talk, I do a physical examination.  We get an x-ray that gives me a basic overview of the bone shapes, structures and the space between them. 

Sometimes we can see the stress fracture on the x-ray. If we do see it, we see a slight change in the contour of the edge of the bone that I like to refer as a “scaffold” (think scaffold on the side of a new building being built). This is what your body does in response to a stress fracture developing. It works overtime to build this scaffold to try to patch (heal) and protect the bone. If that scaffold continues to get abused by your activities (i.e. you kept running despite the pain), the body can’t keep up and the scaffold breaks down as well.  This shows up on the x-ray as a dark black line through your bone and is a more serious problem, the so-called “dreaded black line.”  This means that the stress fracture has progressed, is no longer microscopic and is a more serious problem.  In this instance, x-rays are great tools.  But keep in mind not seeing a stress fracture on an x-ray does not necessarily mean you do not have a stress fracture.  If only things were easy right!  So, what do we do if we highly suspect you have one and don’t see anything on the x-ray? Sometimes we need more information, and in this instance, we may do an MRI to evaluate the bone structures further. The MRI gives us more information because it not only shows us the bone but also can show swelling in the bone, the bone matrix in more detail, and any “black line” cracks are very apparent. Both imaging modalities can be helpful, and you don’t always need one or the other.  (We try to be thoughtful about ordering tests in medicine, so if things will not change the treatment, we just use the history and physical examination!)

To heal a stress fracture, we must first rest from the insult that was causing the problem.  Second, we must address what if anything in your body that caused a deficiency that the bones couldn’t keep up with. That is very important. If we just allow you to rest from running, and then you start back doing the exact same thing at the exact same speed and pace that you were before without addressing all the other factors, it is extremely likely that the stress fracture will recur. 

We also investigate why the stress fracture developed. This may mean you need an evaluation of your running gait and the strength and control of your lower extremity muscles. Sometimes all we need to do is discuss your specific training program and see how their progression and amount of running, volume of training, volume of cross-training, and rest all may have contributed to the injury (as a sports medicine physician my favorite part is to help you get back to running and sport ASAP!)  We also discuss nutrition, and whether finding a way to optimize this or other associated factors (think hormones, vitamins, blood tests, etc…) are needed as well. More on these topics another day.

If you have, questions about stress fractures let me know!