Bone stress injuries in runners: what you need to know

If you’ve ever experienced a nagging ache or sharp pain in your shins, feet, or pelvis during or after a run, you might be dealing with a bone stress injury.

In fact, studies show that bone stress injuries account for nearly 10-20% of injuries in runners (Fredericson et al., 2019).

While these injuries are common, they’re also preventable and treatable. Understanding what they are and how to manage them is key to keeping you running strong.

In this blog, we’ll explore what bone stress injuries are, how they develop, and the steps you can take to both avoid and recover from them.

Whether you’re a recreational runner or training for your next marathon, understanding bone stress injuries is essential to maintaining a healthy, injury-free running routine.

What are bone stress injuries?

Bone stress injuries occur when the bones are subjected to repetitive loading that exceeds their ability to repair themselves.

Over time, the constant loading cycles can cause microtrauma in the bone.

If continued the bone stress continuum may lead to a stress fracture.

In runners, these injuries are often the result of increased training frequency or intensity, insufficient recovery, or poor biomechanics.

Unlike acute fractures, which happen suddenly due to trauma or impact, stress fractures develop gradually.

They’re typically caused by repetitive stress on the bones, especially in weight-bearing areas like the lower legs and feet.

Common areas where runners experience bone stress injuries include the shin (tibia), foot (metatarsals), and pelvis (pubic ramus).

The causes of bone stress injuries in runners

Runners are particularly prone to bone stress injuries because of the repetitive nature of running.

The high-impact forces involved in each stride, combined with the constant loading on the bones, can lead to microtrauma over time.

However, several factors increase the likelihood of developing a stress fracture:

1. Sudden increase in training intensity

A rapid increase in mileage, intensity, or frequency of running can overwhelm the body’s ability to adapt.

If you push your body too hard too quickly, the bones may not have enough time to heal, leading to stress fractures.

2. Poor biomechanics

Suboptimal running form, such as excessive pronation (inward rolling of the foot) or improper posture, can increase stress on certain areas of the body, making them more susceptible to injury.

3. Weak or imbalanced muscles

Muscular imbalances, especially in the legs and hips, can contribute to increased stress on the bones.

For example, weak glutes or hamstrings can force the lower legs to absorb more impact.

4. Inadequate footwear

Wearing worn-out or unsupportive shoes can contribute to poor foot mechanics and increase the risk of stress injuries.

Proper footwear plays a crucial role in absorbing shock and providing stability.

5. Low bone density

Runners with low bone density (due to factors like age, gender, or dietary deficiencies) are at a higher risk of developing stress fractures.

A lack of calcium and vitamin D can hinder bone strength, leaving bones more vulnerable to injury.

Recognising the signs of a bone stress injury

One of the biggest challenges with bone stress injuries is that they often start off as minor aches or discomfort, making it easy to brush off the pain and continue running.

However, as the injury progresses, the pain can become more persistent and localised.

Here are some common signs of a bone stress injury:

• Pain that worsens with activity: Initially, you may feel discomfort or mild pain while running, which may ease with rest. As the injury worsens, the pain may become more persistent and intense during activity, and even at rest.
• Localised tenderness: A stress fracture often causes pain that is localised to a specific area on the bone. You might notice swelling or bruising in that area as well.
• Pain that persists despite rest: Unlike typical muscle soreness that improves with rest, bone stress injury pain may not go away with a few days off. The pain tends to be more constant.
• Pain that increases with pressure: Pressing or palpating the area where the injury is located can provoke pain, making it more evident where the stress injury is.

If you experience any of these symptoms, it’s important to consult with a healthcare professional, such as a physiotherapist or sports medicine physician, to determine the cause and get the appropriate treatment.

Preventing bone stress injuries in runners

The good news is that bone stress injuries can often be prevented with proper training, good biomechanics, and attention to recovery.

Here are some tips to help you avoid these injuries:

1. Gradually increase training load

Avoid sudden increases in mileage or intensity.

Instead, follow the 10% rule, which suggests increasing your weekly mileage by no more than 10% each week to allow your body to adapt gradually.

2. Strengthen your muscles

Incorporating strength training exercises into your routine can help reduce the stress on your bones by building stronger muscles.

Focus on strengthening the lower legs, hips, and core muscles to improve your overall running form and stability.

3. Focus on proper running form

Work with a physiotherapist or running coach to assess your running technique.

Small adjustments to your posture or foot strike can make a big difference in reducing stress on your bones.

4. Wear proper footwear

Invest in high-quality running shoes that provide proper arch support and cushioning.

Make sure your shoes fit correctly and replace them every 500-700 km to maintain their shock-absorbing capabilities.

5. Prioritise recovery and nutrition

Allow adequate time for rest and recovery between runs.

Nutrition also plays a key role in bone health, so make sure you’re getting enough calcium, vitamin D, and other nutrients to support strong bones.

6. Cross-Train

Engage in low-impact activities, such as cycling or swimming, to give your bones a break from the repetitive pounding of running while still maintaining cardiovascular fitness.

Treating bone stress injuries in runners

If you’ve been diagnosed with a bone stress injury, the good news is that with the right treatment and rehabilitation, most runners can recover fully and return to their normal activities.

The key to effective treatment is early intervention and appropriate management.

1. Rest and load management

The first step in treating a bone stress injury is reducing the load on the affected area.

Depending on the severity, this may involve a period of complete rest or a temporary reduction in activity, including cross-training.

2. Physiotherapy

A physiotherapist can design a rehabilitation program that focuses on strengthening the muscles around the injured area, improving running biomechanics, and gradually increasing your activity level.

3. Sports medicine consultation

A sports medicine physician may be required if you have a bone stress injury that is ‘high risk’, i.e. in a location where healing rates are lower.

Sometimes investigations such as MRI scans can guide your recovery process.

4. Gradual return to running

As the pain subsides and healing progresses, it’s essential to ease back into running slowly.

A structured return-to-running program that gradually increases distance and intensity will help prevent reinjury.

Conclusion

Bone stress injuries are a common concern for runners, but they’re also highly treatable and preventable.

By gradually increasing your training load, focusing on good running form, strengthening your muscles, and paying attention to your recovery, you can keep your bones healthy and reduce the risk of stress fractures.

If you suspect you have a bone stress injury, early intervention and professional treatment are crucial for a successful recovery.

At Lifecare Northern Sports Physiotherapy our team of experienced physiotherapists, exercise physiologists and myotherapists are here to help you prevent and recover from running injures.

If you’re experiencing pain or want to ensure you’re running at your best, don’t hesitate to get in touch with us today.

Richard Brock is an APA Musculoskeletal Physiotherapist. Richard’s post-graduate qualifications and participation in endurance running events enable him to educate patients on the nature of their diagnosis, as well as empower them with the best methods to return to their normal level of function as soon as possible.