Bone is alive. Like muscle and skin and blood, it is composed of cells. When cells become old or damaged, new, larger and healthier cells take their place. As with muscle, that turnover makes bone tissue healthier. This is partly why lifting weights, which initially damages the muscle tissue, ultimately makes biceps bigger and stronger. "Bone cells have a certain amount of turnover," says Dr. Micheli. "If bone is stressed slowly and gradually, it will get stronger and stronger." Says Dr. Peter Jokl, associate professor of orthopedic surgery at Yale, "It's like wind on trees. If it's constant over time, the trees will adapt. If there's too much at one time, they'll crack."
Most of what is known about stress fractures comes from studies of male ballet dancers and soldiers. Dancers develop their injuries by jumping and landing and moving with the added weight of another person in their arms. Soldiers get them from pounding their feet for hours while carrying heavy backpacks. For that reason stress fractures, first described in 1855, have often been referred to as "march" fractures. "If you take new recruits and march them enough, each of them will probably get one," says Jokl.
If a basketball player follows a night game with an afternoon game, he may feel as though he has just finished a 25-mile hike with a full pack. This is also when he might feel the first signs of a stress fracture. "It's a dull ache that won't go away," says Walton. "The more you play, the worse it gets, until you can't play anymore. Mostly you just feel pain. With continued activity the dull ache gets more intense and sharper until it hurts all the time." That dull ache is caused by the microscopic cracks and the body's reaction to them. The more intense, sharp pain usually indicates that the crack is growing.
Pain is the primary symptom of a stress fracture. And thanks, in part, to Walton, athletes these days tend to be taken more seriously when they complain of severe pain in their legs and feet. On April 21, 1978, an hour before a playoff game against Seattle, Dr. Bob Cook, Portland's team physician, twice injected a painkiller into Walton's left foot. It wasn't the first time Walton had taken such injections, but it would be the last. The day after the game, X-rays revealed that Walton had broken a bone. He sued the Trail Blazers and Cook, claiming that the injections had masked the pain—the symptom that might have prevented him from playing and from breaking the foot. The suit was settled out of court four days before the trial was to begin.
If painkillers were used indiscriminately in the NBA before the Walton suit, they aren't now. Says Cook, "Anything that masks pain, that is not therapeutic, is a definite no. The patient has to have a physical complaint. You have to know where to look." Conventional X-rays don't always help. In fact, X-rays of Walton's foot taken immediately after that Seattle game were negative. A more exacting measure today can be made by a special X-ray procedure called a bone scan. When Cook was searching for the source of Walton's pain nine years ago, bone scans were not routine diagnostic tools. "If I could have done one thing differently [in Walton's case], I would have gotten a bone scan," says Cook.
In this procedure, a patient is injected with a radioactive element that is incorporated into new bone formation. Because new bone forms at the injury site, the radioactive element collects there. That spot will show up on an X-ray. "If the scan shows no increased uptake, there is no stress fracture," Daly says. "If there is increased uptake, you have to decide if it's from an old injury. It can be positive for two years."
An area of increased uptake is called a hot spot. "I would bet that every player in the NBA has had a hot spot at one time," says Dr. Cook. Envision a wire hanger as a bone. If you bend the hanger back and forth, the weak point that develops would correspond to the bone's hot spot. If the bending continued until the wire broke, you would have the equivalent of a stress fracture.
The problem with Bowie's left leg is more complicated than that with most other stress fractures, but it indicates how difficult diagnosis and treatment can be. August 1981: picture day for the Kentucky basketball team. A photographer asks Bowie to jump a little higher. Bowie can't because his left leg hurts. Two weeks later X-rays reveal a fracture. Sept. 15, 1981: His left leg is put in the first of two casts he'll wear for a total of 11½ weeks. He sits out the 1981-82 season. July 29, 1982: X-rays show weakening in the area where the fracture had been detected a year earlier. Aug. 3, 1982: Another cast is applied, this one for six weeks. Oct. 20, 1982: After 10 days of tests at the Campbell Clinic in Memphis, bone graft surgery is performed. Parts of Bowie's hipbone are grafted to his left shin—on the side opposite the crack—to strengthen the leg. He sits out the 1982-83 season.
"I never thought for one minute that I would miss two years of basketball in college," says Bowie. "For a little hairline crack to heal? I missed one year to try the natural healing process. I missed another year after the surgery." If he had to do it over again, Bowie says, he would have opted for immediate surgery. "Hindsight's 20/20, but I got nothing out of that year in the cast."
After reviewing Bowie's medical history, Cook agrees. "I would try to avoid the prolonged cast time," he says. "It's hard to overcome the atrophy." But, says Dr. George Gumbert, who was Bowie's doctor at Kentucky, "I would still try the conservative technique. In a pro athlete, where his bread-and-butter depends on his ability to play, I would operate sooner. In a college athlete, I'd be less inclined to operate since the complications of surgery aren't insignificant. In a way I'm sorry I didn't operate sooner in Bowie's case." Gumbert's uncertainty is shared by many of the doctors who treat stress fractures. "If we operate sooner and we're successful, then everything's great," he says of Bowie's case. "If we operate and there are complications, then we may have ruined this lad."