Forums >General Running>Two doctors don't agree on what to do with my femur stress fracture - Anyone been through this?
I was diagnosed with a 12mm grade 4B stress fracture in the shaft (middle of my leg) femur bone on 11/22/16. The first doctor I went to said I needed to be on crutches for 12 weeks and then I could start to gradually do things like elliptical and the Alter G and build up from there. He also sent me in for a second MRI 6 weeks into the stress fracture and it showed that the stress fracture had gone down to an 8mm grade IV stress fracture (so I was healing). I stopped using crutches 3 weeks into it because it did not hurt to walk and I am a mom of two small kids so it was so hard to take care of them (dad travels for work but did stay home the first three weeks to help). My doctor flipped out on me for going off my crutches and told me I was going to break my leg. I did not do any running and I was primarily just water jogging which he told me I could do. My walking was super minimal. The doctor also asked me if I took laxatives about 100 times and I eat a ton of food and do NOT have an eating disorder. I got a little feed up with the doctor so I went in for a second opinion at 8 weeks in. The second doctor looked at my MRI results and said I could start running in 2-3 weeks. I was shocked!!! He said to start elliptically hard and walking for 30-60 minutes to prepare my bones for running again. He said I had a low risk stress fracture and that he saw no reason why I would ever have to be on crutches for 12 weeks. So my question is has anyone had a stress fracture in the femur bone and what was your return to running time like? If I go by the new doctors orders I will start SLOWLY (like a mile the first week) running again at 11 weeks. Before the injury I would average 40 miles a week and I am on the local race team in my town so I would train hard. Track, tempo, long runs which is why I think I got this injury in the first place. I am 37 and female and this is my first running injury. All my bone scans & blood work came back normal. Any stories/advice is helpful! thank you!
I would start with walking for a few weeks and see how it feels. That would be a compromise in-between Doctors. Then mixing walk-run for the next few weeks after that. Sucks but you know it will be healed by the time you start running full time and will not have to second guess yourself. You could bike\water jog\ even Alter G in-between (if you have access) along with the walking and running. No need to have a set back after waiting 11 weeks to come back!! Good Luck
Thanks! Good advice! I just found a gym that has an Alter G so I am going to give that a try with 60% body weight for short run/ walk next week. Maybe 2 minutes of running only at first.
runktrun
Pain is generally a good guide when dealing with bone stress injuries. No pain during OR AFTER activity means you can probably safely continue GRADUALLY increasing activity.
Rather than thinking of your return to running in terms of miles at a time, think minutes. I'm serious. If you cannot walk pain free for a full day, you are not ready to weight bear. Use the crutches a bit more. After you have been walking around normally pain free for a week, you can try to incorporate a few MINUTES of running every other day (maybe every day if you feel great). Start with 5 x 1:00 jog/1:00 walk. Stop if you feel pain during activity and wait a few days before you try again. If you feel find during AND AFTER (no achiness, no pain the next day, etc), try adding a minute or two of running to each session, is: 8 x 1:00 jog/1:00 walk. Once you're up to about 10 x 1:00/1:00, try increasing the run duration to 2:00. Progress until you can string together about a mile of straight running. Pain during or after does not mean you're back at square one, but it does indicate that you're adding stress faster than the bone can heal and you need to back off.
What is more worrisome is the degree of fracture. 4B is a pretty big crack. The tibia is a low risk location for a stress fracture, but it sounds like you had a significant one. Hopefully it truly is from ramping up the mileage and intensity as you trained with your racing team and a more conservative training plan is all that you need to prevent another sfx. By bone scan, you mean dexa scan? If your scores were above 0, you probably don't need to worry about bone density. Score between -1.0 and 0.0 are still technically above average and your doc will tell you that's "normal," but your on the lower range of normal and may need to be careful about sudden mileage increases.
Your first doc was probably just being overly cautious because bad stress fracture can occasionally "heal" as non-union fractures (kinda like having a permanent crack in the bone). Your current timeline sounds reasonable. Just be careful. A follow up x-ray would be sufficient to show healing in the form of a bone callous. Additional imaging wouldn't be necessary unless things aren't improving.
Not running for my health, but in spite of it.
Thanks Kilkee that was super helpful! Yes a dexa bone scan was over 0, it was 1.045. I also did my first Marathon in 9 years and I cut off over an hour from my time so I was training hard and I don't think Marathons agree with me so I am going to stick to half marathons or shorter. 5k's are my favorite so not too heart broken about giving up that distance.
Then you likely just did too much too quickly! And congrats on your marathon PR. Don't worry about swearing off marathons just yet; with some careful rehab and rebuilding your base mileage, you should be fine!
SMART Approach
I have worked with many athletes and patients with proximal femur (hip) stress fractures over last 12 years and they can be tricky and an increased risk of avascular necrosis. The mid shaft femur stress fracture is more rare but also less risk of AVN. I have seen it twice so not a lot of history. Kilkee, gave excellent advice. Be very gradual in your return. You should be able to hop one legged without pain before running. Curious, where do you live and what was your vitamin D level number? You may have just severely over trained but generally we have a great ability to adapt to added stresses (without developing stress fracture if nutritionally optimal) unless you have a great pain tolerance. Sub optimal D levels can make you a bit more susceptible. I believe you need a blood level higher than 30. This would be a normal level but normal is not optimal. Above 40 or even 50 is more optimal. Be smart. Good luck.
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I read "Tibia"...not sure why. You actually said "Femur." Given that it's your femur and NOT tibia, I urge even more caution. Femur sfx are rare and are more difficult to heal because that bone is taking loads and stresses with nearly every movement. The hop test and fulcrum test are telling. Femurs ARE high risk areas for fractures. So, at 6 weeks you had an 8mm grade IV sfx...grade IV is the worst, it means the entire cortex of the bone has cracked to some degree. At 8 weeks, 2 weeks after confirming the 8mm break, you may continue to show signs of healing in the followup MRI, but starting to run in another 2-3 weeks seems rushed.
Taking a calcium + D supplement might help and very likely wouldn't hurt. D levels are tricky, but if you're otherwise healthy and feeling good and your bloodwork is normal, save for a low D level, supplementing might help.
Yes all my blood work is normal, normal vit D levels. Taking supplements to help with Calcium and Vit D. So the doctor said I would light up on the MRI for a year even if I'm healed. There was no breakthrough of the cortex. I do have a very high pain tolerance. I don't want to rush it, I may wait a little longer then the second doctor says. I also found a gym with an Alter G so I can start running with Half my body weight and do a minute on, a minute off at first.
which is worse the IV fracture or the grade 4B I was first diagnosed with?
You were diagnosed with the most severe, but even diagnoses aren't an exact science. This is a pretty good overview: https://radiopaedia.org/cases/fredericson-mri-classification-of-medial-tibial-stress-syndrome
Yeah, I get the high pain tolerance thing! I had some issues with tibial sfx in high school (bad shoes, too much intensity too soon) and by the time I was finally diagnosed, it looked like I had a crack spiraling up my tibia for a few inches! I had no idea.
Thank you Kilkee you know your stuff! So I will be going back to slowly running at 12 weeks (yes I will do a few minutes at first) which according to this is link you sent me is pretty spot on!
I forgot to say, I live in Maryland.
I did not have the same type of stress fracture, but I have a couple of experiences. I was having severe pain on the top of my foot and finally went into the doctor. I had a stress fracture on my foot and was put in a boot. I can't recall how long I kept the boot on, but it did help relieve the pain. I returned to running after 8 weeks. My last stress fracture was in my tibia and there was some discussion as to whether or not I needed surgery. My doctor opted to see how I healed on my own. He did not want me running (or exercising) for 3 full months due to the severity of the stress fracture. I never used crutches. I reduced my walking to a minimum amount and healed fine. I resumed running 3 months after diagnosis.
My primary doctor recommended a dexa bone scan of my spine and hips. My spine had a T score of -0.4. My right hip had a T score of -0.5 and the left one was -0.7. T-scores at the femoral necks of the hips were -1.3 on the right and -1.4 on the left. I also had blood work done and I did have a vitamin D deficiency. I'm sure living in Seattle doesn't help me with Vitamin D. I'm now on a supplement.
I'm late to this party. I had a similar stress fracture of my right femur in 2005. A little higher up, and not quite as severe.My doctor was more like your second doctor. I never used crutches, actually (although I was off my feet completely for two weeks except going to the potty). Walking in 6 weeks. Started running very gradually in 8 weeks. It probably took 3ish months to "feel" resolved.
As the knowledgeable people have noted, femur is a lot more complicated than tib-fib.Good luck.BTW, that was proudly my only real running injury for many many years of high volume running... until it came crashing down toward the end of 2012. I wish you luck!
Thank you!!! That is very encouraging news, thanks for sharing your story with me!