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Women have an increased risk of stress fractures

How pain recognition plays a significant role in the prevalence of stress fractures

Now, more than ever before, women are running. In a recent National Runner Survey (2018), more than 54 per cent of runners are women. Unfortunately, with rising recreational and competitive runners, the incidence of injury also increases. Due to the well documented anatomical and biomechanical differences between males and females, such as differences in the alignment of hips and knees and bone density, females have a higher incidence of stress fractures than men. 

stress fractures

Due to the increased prevalence of stress fractures in women compared to men, numerous studies have been conducted to understand why, and what, are ways to reduce risk. In a study recently published in Physical Therapy in Sport, researchers looked at female recreational runners and assessed multiple factors that may have caused the development of a stress fracture. The study included looking at well-known markers such as nutrition, menstruation and bone density, but also included mindset and pain recognition. 

Related: The warning signs of a stress fracture 

The study raised awareness of the impact a runner’s mindset may have on their perception of pain, and what different types of pain mean for them. Within the study, there was a group of participants that had suffered a stress fracture and those that hadn’t. The key difference between the two was that those without a stress fracture history had interpreted the pain (unusual discomfort or out of the norm) as a warning sign that they should stop running. Whereas the other group of women – those who had experienced a stress fracture – understood the prior discomfort as a warning sign only after. 

stress fractures

This study significantly highlights the importance of injury prevention and education to endurance athletes. While the inspiration of “no pain, no gain” may have validity when doing hard interval sessions, it does not translate to musculoskeletal pain. Yet differentiating between a nagging pain and a concerning pain is extremely difficult for an athlete to discern. Especially when it comes to endurance sports, where there is a certain accepted threshold of discomfort.

Related: The art of listening to your body

stress fractures

It is therefore important to encourage reflection in athletes, whether you are coached or uncoached, reflecting on how your body is adapting and adjusting to running is important. In the event that you are a coach or healthcare professional that treats runners, it is important to educate athletes as well as train or treat them. One of the lead authors and physicians of the study – Dr. Jeremy Close (Associate Professor at Jefferson University in Family and Sports Medicine) – is quoted as saying, “There needs to be more guidance from healthcare providers for woman runners on how to prevent stress fractures.”

Common warning signs

Stress fractures related to running will largely occur in the lower limbs below the knee joint. If you do have discomfort or pain in this region, make sure you are aware of the common signs of a stress fracture:

Related: Four painful consequences of running in worn-out shoes

  • Localized pain experienced when touching with pressure and ground impact.
  • Visible swelling in the area of discomfort.
  • A stress fracture will often appear following a drastic change in training volume (time/distance) and/or intensity.
  • A significant change in footwear or running surface (from soft to hard surfaces for an extended period of time).


Ways to reduce your risk

Reducing your risk is nearly impossible for endurance athletes as it comes with the territory, as does the risk of concussions in hockey. However, you can significantly reduce the likelihood of a stress fracture by doing the following:

  1. Maintaining a healthy diet. Have your diet assessed by a physician or nutritionist. You may need blood work done to determine if you are deficient in any essential nutrients. If you are deficient, it may be decided between your physician and you to supplement your diet with a multivitamin.
  2. Muscle strengthening and stretching drills. Dryland exercises are not only away to warm up, but also a way to improve muscle and bone functionality.
  3. Replacing running shoes before they wear out. General practice is you replace your shoes every 400 to 600 kilometres.
  4. Avoid sudden increases in running volume and training load. Make sure your training is progressive and gradual while providing adequate rest and adapting to the demands and stress of life.
  5. Heeding the warnings of pain and discomfort in feet, shins, upper leg, hips and lower back. It may not be a stress fracture, but your body does produce inflammation as a way to protect itself from damage. If you do notice ‘unusual’ discomforts not typical with a hard run or training session, make sure you rest and monitor the pain before it becomes a bigger issue.