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Bone Stress Injuries in Runners

Written by James Telford - B. Physiotherapy (La Trobe) Director/ Senior Physiotherapist at Physiolife & Run2PB Athlete.

What is a Bone Stress Injury?

A bone stress injury is basically when the load being put though a bone exceeds the bones ability to remodel and repair. There is a grading system from:

Gr 1: Perisosteal oedema

Gr 2: Bone marrow oedema

Gr 3: More bone marrow oedema +/- slight fracture line

Gr 4: Discrete fracture line

Then complete fracture

These can be diagnosed using a combination of clinical assessment and MRI/CT/bone scan/xray.

Most common areas in runners in order of popularity: (numbers vary across literature)

  • Tibia (23.6%)

  • Fibula (23%)

  • Navicular (17.6%)

  • Metatarsal (16.2%)

  • Femur (6.6%)

  • Pelvis (1.6%)

What are some of the signs I might have a Bone Stress Injury?

First signs of a bone stress injury can include an ache or pain in a specific point in a bone with activity. In the early stages it might only come on after or during longer runs or harder sessions. Then it might ache on easier stuff and may also ache when not running eg. at night.

Opinion should be sought at the first sign of anything bony from your allied health professional or sports doctor. I would highly recommend seeing someone with experience in running and related injuries. Your physio may refer to a sports doctor for relevant scans and team care.

I have a bone stress injury, now what?

The where to now depends highly on the severity and how early diagnosis occurs as well as the exact location of the injury. For instance a distal tibia stressy is very different to a mid shaft stressy.

The general guidelines are to offload the affected area. This may be via a period of non-weight bearing eg. Crutches or moon boot. If caught early enough just rest can be enough. This should be guided on an individual basis by your health professional.

Depending where and how bad the bone stress injury is, you may be able to continue to do some modified training.

  • swimming

  • aqua jogging / alter G

  • spin bike

  • elliptical

  • strength training

Return to running will depend on your individual injury and the guidance of your health professional. Generally this will occur once you have ticked off a period of pain free walking (1-2 weeks). Then graduated introduction to running. -1min reps of jog/walk with a rest day in between and build from there. Not increasing load by more than around 10% a week.

Importantly when returning to running post bone stress injury, honesty is the key. Not every return is a fairy tale. It is better to catch a re-aggravation sooner than later. The down time will be less the sooner it is caught. Be patient and don’t compare yourself to the elites.

It is important the whole team is on the same page with clear lines of communication. Your physio/doctor should provide an update directly to your coach where possible when you are able to progress. Injured runners can’t always be trusted to accurately convey messages to their coach!

There are a multitude of causes behind bone stress injuries. These should be investigated with your care team.

James Telford - B. Physiotherapy (La Trobe) is a Director/ Senior Physiotherapist at Physiolife

James graduated from La Trobe University with a Bachelor of Physiotherapy in 2011. James

professional interests include treatment of sporting injuries and other musculoskeletal conditions, migraines, TMJ dysfunction and general aches and pains. Utilizing a wide range of biomechanical assessment techniques to diagnose musculoskeletal disorders / diseases hands on manual therapy, exercise programs and massage as well as some alternative therapies including taping and dry needling to assist patients recover and achieve their goals.

James is also a sub 3hr marathoner, most recently running 2:56 at the Melbourne Marathon, he is passionate runner who loves treating and talking runners.

Follow him on strava here

He available on email via

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