Once I went through the various stages of acceptance (and yes, many times I have thought “you teach both prevention and how to diagnose these types of injuries to other physiotherapists and to patients”), I grabbed a set of crutches from the clinic and began my two weeks of non-weight bearing. I knew that trying to work while on crutches was going to be a huge hassle, but perhaps didn’t realize how much of an inconvenience crutches would be in my day to day life. I consider myself extremely fortunate that I only had to be on crutches for 2 weeks, while many others are on them for much longer than that. Trying to make meals while on crutches is difficult, trying to carry a glass of water to the table is next to impossible, stairs of course are not fun, and trying to get into the shower stall can be dangerous (I do not recommend the single leg hop method that I tried the first time!). Covering any great distance with the crutches was exhausting, so in order to visit a family member in the hospital and to see my daughter’s cross country meet, I purchased a knee scooter called a Knee Rover which did help me get to these “far off places” (though in truth, perhaps may not constitute as non-weight bearing in this case).
The first 3 weeks after my diagnosis I took off of the gym completely.
Although I could theoretically workout my upper body, I made the decision that my body clearly needed the time (metabolically) to heal itself.
I did, however, continue to go into the gym at my clinic and ride the exercise bike for about an hour and a half each morning to maintain some level of cardiovascular fitness.
Although I was unable to bear weight on the stress fracture, there is some evidence that encouraging blood flow in unweighted activity (in this case the exercise bike with little to no resistance) can be helpful with healing.
In addition to this, I continued to supplement with vitamin D3/K2, collagen, creatine, and added a calcium/magnesium supplement in order to hopefully give my body its best chance at healing.
I was to progressively increase my weight bearing after the 2 weeks, so I used one crutch for an additional couple of days. Generally, my knee was feeling quite good (and truly it generally has felt good for the last several weeks as long as I didn’t run on it) so on the 3rd day I got rid of the crutches altogether. That day, I spent a lot of time on my feet walking and doing a lot of stairs while taking my oldest daughter on a university tour. My knee was a bit more sore afterwards necessitating some ice and a reduction in activity for the next couple of days. At the beginning of the third week, I reintroduced some upper body and core work at my typical twice weekly intervals (without any consequences). It was nice to be back to some sort of routine at Thrive Fitness where Steve Coons puts me through the paces. Obviously, these workouts were significantly scaled back as I really should not be doing any weight-bearing strength exercises at all.
Interestingly, as I moved into my fourth week since the stress fracture diagnosis, I finally started to feel what I believe to be the pain from the actual fracture. Leading up to this time, I had some pain in various places throughout my knee, but aside from the pain I had when I contracted my hamstring, I am not sure how much of the pain was from the actual fracture and how much of it was from the other areas of my knee that I had irritated. I interpreted this as a positive (though I would certainly rather be pain-free), that some of the other other areas were settling down with the reduction in activity, so I could now localize the biggest area of concern.
With a bit more time on my hands, and a masterclass coming up for the Real Running Course, I decided to take a deeper dive into the evidence for returning to running after a bone stress injury of the tibia. What I found was that the location of my stress fracture was not common (I know I have never seen one) and that the literature providing recommendations on returning to run after an injury like this is largely based on clinical commentaries and expert opinion as opposed to sound research (George et al. Criteria and guidelines for returning to run after a tibial bone stress injury: a scoping review. Sports Med. 2024). The article did provide some insight and some guidelines that are certainly useful in planning my own return to run program. Between the article, my own previous knowledge, and the knowledge of my colleagues and the orthopedic surgeon caring for me, I now felt like I had an idea of how to progress myself (hopefully) without experiencing many setbacks.
For the next several weeks, my typical routine was to ride the exercise bike for 60-90mins six days per week and weight training (upper body and core) twice per week. As the weeks progressed, I started to introduce some intensity and some resistance twice weekly while on the exercise bike (mainly to start to increase my heart rate) while also adding some non-weight bearing lower extremity strength work initially, and eventually (in weeks 6-8 post stress fracture diagnosis) adding some body weight (and eventually weighted) lower body strength.
Throughout this entire process, I had to be mindful of “doing too much” (which evidently I had never been mindful of in the past), as taking myself into pain is not beneficial. The old adage “no pain, no gain” does not apply when recovering from a stress fracture, so caution and gradual progression is key. That said, focusing on the pain can leave you questioning your own perception of pain; “I felt something, was that pain?”. We know that becoming pain focused can contribute to a phenomenon called central sensitization, and lead to chronic pain symptoms. So, while being aware of pain and not pushing through it is important, becoming hypersensitive to pain can be detrimental.
As the process wore on, I continued to have some discomfort in the knee. On occasion (after doing “too much”), I would experience pain at or near the fracture site. I would often have the feeling of “pressure” in the knee which I interpreted as swelling. An injury like this is a constant back and forth where if you experience increased discomfort or pressure, you need to back off and let the injury settle down before moving forward. The important part of the rehab for a stress fracture is rest. In many injuries, experiencing some discomfort is expected and can actually be necessary, but in a stress fracture that is not the case. We must let the fracture heal before we can move ahead. To the athlete, it is a long, drawn out process but absolutely critical to successful rehab of the injury.