MTSS or Stress Fracture? Does it Really Matter?


Photo by Steel City Hobbies obtained from Wikimedia Commons

It feels so good to be able to progress from a red to green theraband and from couch surfing (+some suuuper easy stationary bike) to pool running last Monday. When I tried to actually swim a couple of strokes, my foot let me know that it wasn’t a good idea. But I was incredibly stoked about being able to pool run on Monday. I was also able to start walking barefoot with next to no pain (just going downstairs sparked some pain spontaneously) last weekend. Fast forward to this weekend, I am so thankful to have been able to attempt a 10x1min run/walk (with walking warm up). My left foot was a bit sore from riding to work with cycling shoes for the first time on Saturday in a couple of weeks. So after 8.5 minutes, I called it quits. BUT, I was able to get past the muscle guarding and fear, as I worked into my 5th rep and really felt like I was running smoothly again. I’m surely not out of the woods yet, but if it’s anything like my limited shuttle run workouts coming off my Lgr2+ hamstring strain, I think I’ll be back soon. (Fingers crossed.)

But while pool running for 30 minutes on Monday, I thought about what I learned at the running injuries course, as mentioned in my previous blog post. JF had talked about whether it was truly important to differentiate between MTSS (medial tibial stress syndrome) and a tibial stress fracture. If symptoms were the same, ie. same sort of stage in the injury, why would he need to send his patient for a bone scan, wasting money and increasing radiation sort of exposure, if his treatment would be identical regardless of the diagnosis? Most patients and competitive athletes might want to know anyway, just so they have something concrete that they can google and hopefully have a timeline for return to activity. However, I think JF has a point.

I for sure don’t have a stress fracture or MTSS. It’s likely just dysfunctional foot alignment and weakness in the structures. And my newest theory is that it’s glute amnesia, which was already sort of affecting my left glute in relation to my right shoulder dynamic instability near the end of my triathlon training last summer. The hours spent writing papers and then right into studying for finals might have just made it worse. And when I walked and ran especially, too much load and torque was put onto my left foot. But anyways, it kind of almost felt as if I had a stress fracture while I was pool running. It’s been about 4 weeks with this injury that came out of no where in the tail end of my finals before I even started to run, which obviously exacerbated it. Only last weekend was I been have to walk barefoot without much pain, after my fifth metatarsal was adjusted by the locum chiropractor I was working with. And my rehab has been kind of similar, as if I had a stress fracture, in trying to return to running.

I really wanted to try a walk run workout today to get my foot stimulated. This way, as JF really stressed, my foot can begin to adapt to the stress and the structures in my foot can receive stimulus to promote healing and strengthening. Similarly, as I mentioned, it’s probably why 2nd hamstring strain (also grade 2+ but opposite leg and ~6 months apart) recovered much faster than my 1st strain. I started a shuttle run protocol as soon as I could (as per the SFU varsity physiotherapist) and I recovered much, much faster even though when I initially started, I felt like I was running through maple syrup. My muscles weren’t firing as well as usual, so I felt like I was stuck in slow mo and my ROM (range of motion) was very limited. I felt insanely awkward like I wasn’t accomplishing much, but my body was very much fatigued after each workout. Thus the shuttle runs helped stimulate my hamstring to heal and got me back to running form quicker than when I didn’t do much of anything after my 1st strain.

Currently, even though my physiotherapist and I haven’t been able to pinpoint the exact “mechanism”  that led to this injury, what’s clear is that my left glute isn’t firing well in proportion to other muscles. And, the instability (and weakness) in my left foot is still present. So I’ve been patient and religiously working on my foot strength, proprioception and now glute strength. Nothing exciting, just trying to get my motor control and feet strength back.

It’s really all about getting back to the basics, especially after being affected by an injury for this long. I decided to test out my eccentric heel drops last week, and found that my left calf had ridiculously weak motor control that was nearly half of the control in my right calf. I’ve already been doing this for less than 7 days and today I could tell that the asymmetry has decreased. I’ve also been training a 2xMVA (motor vehicle accident) client at the gym for over 8 months now. Although her core and leg strength have gone up considerably, her neck and shoulder issues have been flaring up again the last while. As she is very aware of her own body, even she suggested to go back to basics. We’ve been working on a lot of scapular clocks lately for proprioception and motor control.

During the time that I was rehabbing my shoulder(s) (left was also a bit unstable), I was initially limited to glenohumeral centering and scapular control. I did this supine, then standing with therabands. -Next to people attempting to deadlift with good form, and with weight that was less than my warm up. I then came up with this phrase to help keep me patient and motivated: “Regress to Reinforce, Progress to Propel.” Following any injury, it’s wise to recheck your foundation. Is that transverse abdominis firing as it should? What about the big trouble maker, glutes? My good friend and former coworker, who is an RMT and fellow kinesiology student, came up with another good one in parallel: “Simple to Stabilize, Complex to Challenge. – Christin Sadler.

So I think no matter what injury you suffer from and no matter what the “true diagnosis” is, whether it’s MTSS vs. stress fracture, you have to start from the bottom and make sure that the foundation is there before you progress. This will lead to a more steady return to activity and less chance of re-injury. With that being said, no matter how long it takes, single leg box jumps, I’m comin’ for you!