Deborah Howell (Host): If you hear you have a stress fracture, how stressed do you really need to be? Today we'll hear from Dr. Jesse Shaw, a Sports Medicine Physician with Pullman Regional. He'll break down what stress fractures are, how they differ from broken bones, what they feel like, and how they heal. Welcome Dr. Shaw.

Jesse Shaw, DO, CAQSM, USAW: Thank you so much, so happy to be here.

Host: Just terrific to have you. So what is a stress fracture and is it different than breaking a bone?

Jesse Shaw, DO, CAQSM, USAW: Yeah, so I always say yes and no, right, so it's one of those complicated questions. So when we think of bone injury, bone pathology, I would say there's a continuum that goes from overuse injury to kind of an acute traumatic pathology. So you can think of them ranging from stress response, stress reactions, to stress fractures, and then to your broken bone or bony fracture that you then see.

And so the biggest thing that really separates those two is the acuity of the injury. So with acute trauma, we develop fractures that we can see on x-rays and clinically diagnose. With stress fractures or stress responses, they're really overuse pathologies. So they develop from the inability of the bone to withstand external mechanical load, which ultimately results in structural fatigue of the bone itself.

Which again, we can see on different imaging than we can with regular fractures.

Host: Got it. Now, what types of activities or actions commonly cause stress fractures?

Jesse Shaw, DO, CAQSM, USAW: Yeah, so stress fractures really are going to develop from any activity that causes repetitive mechanical loading. And so not surprisingly, we see this typically in athletes or individuals who are very active. I think the statistics say something like one third to two third of runners have a history of some sort of bone stress injury, which includes stress fractures.

And so the majority of them are found really in the lower extremity from individuals that are just grounding and pounding a lot. So your tibia, your fibula, your metatarsals. But it can also develop in upper extremities. So individuals, again, that do a lot of repetitive mechanics with their arms, such as rowers, people that throw the ball a lot, obviously you're baseball players, but also if you have a dog and you're throwing the ball a lot, you can develop stress fractures in your humerus and other bones in your arm.

Host: And what does a stress fracture feel like?

Jesse Shaw, DO, CAQSM, USAW: So it really depends on where in that injury continuum you're at. I would say normally early on, people usually describe kind of a mild diffuse ache that occurs, usually specifically with activity or with working out. And then as that progresses and as you get closer to developing that real stress fracture, the pain becomes much more consistent with pretty much any activity, and the pain becomes much more isolated.

And so you can typically tell, where in that bone you're having that kind of pathological change.

Host: Yeah. My friend uses a ball chucker to chuck the ball for her dog and developed a stress fracture and can't play pickleball anymore. It's just so disheartening.

Jesse Shaw, DO, CAQSM, USAW: Yeah, and it's so funny that you mentioned pickleball. Pickleball right now is the number one sport in the country that is causing injury to its athletes. And there's a couple, you know, philosophies on why that is. But pickleball is a serious sport nowadays. And again, we're seeing a lot of patients in the clinic that have injuries and problems because of it.

Host: Yeah, and a lot of people are wondering, can stress fractures heal on their own or do they require treatment?

Jesse Shaw, DO, CAQSM, USAW: Yeah, and so it depends on what you classify as treatment. Again, I know none of these answers are very direct. But you know, if you don't change anything, if you don't change your activity, if you don't stop doing what you're doing, if you don't rest, then no, the stress fracture won't spontaneously heal.

So you have to initiate some sort of treatment or some sort of change depending on how you look at that. And so again, it really depends on where you're at in that bone stress response continuum. So, you know, early on, we basically say rest. Offloading whatever bone it is that's starting to develop some of that injury pattern.

There's some, I guess I would say, newer technologies that are currently being integrated into people's treatment plans. So things like bone stimulators, things like vibration plates. They're not really standard of care, I would say. So the current recommendation really is going to be some sort of deloading all the way to complete offloading of that bone that's injured, depending on, again, where you're at within that stress response to stress fracture continuum.

Host: And when you say offloading, you mean just don't use it as much as possible?

Jesse Shaw, DO, CAQSM, USAW: Yeah, so lower extremity offloading really would be, you know, using crutches, using some sort of assistive device to just get the weight and get the mechanical strain off of that bone. Your upper extremities, obviously a little bit different. We don't, offload those, but it would be not using it.

And so it would be looking at either, again, simply avoiding the activity that's causing the strain, like with your friend throwing the ball. Sometimes it can require us to put people in slings to really, really rest that extremity. And so that's a little bit specific depending on which bone we're concerned about or has the specific pathology.

Host: Yeah. But you're not talking about surgical options.

Jesse Shaw, DO, CAQSM, USAW: I would say not in your standard diagnosis of stress fractures. There are surgical options that we do, unfortunately, need to consider in certain individuals that have specific jobs, so military recruits, obviously our professional athletes that are on a typically tight timeline and logistical schedule.

We can do things like intermediary rodding, whereas we put a metal rod into the bone to allow that rod to take some of the weight and strain off of the actual cortex of the bone itself. But again, that's a very small subset of patients that develop stress fractures that we need to go down the surgical consideration for.

Host: Okay. Got it. Now, if someone suspects they have a stress fracture, what should they do?

Jesse Shaw, DO, CAQSM, USAW: Yeah, I think the first thing is to take a look at what's been going on. Obviously, if you can determine that you've had excessive training or you've been exposed to new demand on your body that increases your suspicion. I think the number one thing with all diagnoses that we really deal with is getting an appropriate and accurate diagnosis.

And so really that's coming in and letting us evaluate you, letting us do any type of workup that may or may not need to be completed. X-rays are pretty standard obviously with us here in orthopedics. But they most of the time actually will not show a stress response or a stress fracture and we need to look at advanced imaging.

And so really I would say it's getting an accurate diagnosis and coming in if you have pain, coming in if you have a new training regimen that you just think has, you know, you've done too much for. And we can give you the appropriate recommendations on training modification or specific treatment if needed.

Host: Sure. And what does recovery from a stress fracture look like?

Jesse Shaw, DO, CAQSM, USAW: Yeah, so so not the answer that people are going to want, but usually a long process. Again, depending if it's a stress response or a stress fracture, your stress fractures are going to look more in the range of a 4 to 12 week recovery time and that means 12 weeks of activity modification or restrictions in activity and again that can include different evaluations and considerations if we think that there's also some sort of metabolic process that's causing the stress fracture to be worse or to progress.

But I would say, you know, four to 12 weeks is kind of a wide window. And usually it's on the upper end of that in terms of a road to recovery from these.

Host: That's unfortunate. Is there anything else you'd like to add to our conversation?

Jesse Shaw, DO, CAQSM, USAW: I want to thank everyone for listening and trying to educate themselves. You know, us trying to allow our patients to really know what's going on when they're in front of us is something key and obviously the more that we can educate them and, provide them the knowledge before they ever come in, I think really sets up a good road to recovery.

I know the big things with stress fractures is it seems like and it really is a tricky diagnosis and sometimes it can be really difficult to treat. But ultimately our job and our goal is to allow you to be as functional and active as you possibly can be. We use the mantra that exercise is medicine.

Host: Yes.

Jesse Shaw, DO, CAQSM, USAW: So we really want to push that and we really want to individualize everyone's evaluations and treatment plans. And the goal is to get you back out doing the things that you want to do from a health and wellness perspective, and just living your life the way that you can and maximizing what that looks like.

Host: Got it. Well, Dr. Shaw, thank you so much for being on the podcast today to bring us up to speed on stress fractures. We really appreciate you being here.

Jesse Shaw, DO, CAQSM, USAW: Absolutely. Thank you so much for having me, and I look forward to seeing everyone in clinic and hopefully presenting some more information for you.

Host: Absolutely. And you can learn more about this subject, providers and services at Pullman Regional Hospital at PullmanRegional.org/orthopedics. This has been The Health Podcast from Pullman Regional. I'm your host, Deborah Howell. Thanks for listening and have yourself a terrific day.