Bone Stress Injuries

Bone stress injuries (BSIs) are a common overuse injury, particularly among runners and athletes involved in high-impact sports. While they can be frustrating and sometimes require significant time away from activity, understanding the warning signs and managing training loads appropriately can help reduce your risk.

What Is a Bone Stress Injury?

A bone stress injury occurs when repetitive loading on a bone creates microscopic damage faster than the body can repair it.

Our bones are constantly adapting to the demands placed upon them. Normal physical activity causes tiny amounts of stress within the bone, which stimulates the body's natural repair and strengthening process. However, when training loads increase too quickly or recovery is insufficient, the rate of damage can exceed the rate of repair. This imbalance can lead to a bone stress injury.

Who Gets Bone Stress Injuries?

Bone stress injuries most commonly occur in people participating in high-demand activities such as:

• Running

• Basketball

• Soccer

• Gymnastics

• Dance

• Military training

They often develop following a sudden increase in training volume, intensity, or frequency. For example, increasing your weekly running distance too quickly or returning to sport after a period of reduced activity.

Changes in training surfaces can also contribute. A runner transitioning from roads to trails, or a soccer player moving from natural grass to artificial turf, may place unfamiliar stresses on their bones and increase injury risk.

The Different Stages of Bone Stress Injury

Bone stress injuries exist on a spectrum, ranging from early bone stress to an actual fracture.

1. Bone Stress Response

This is the earliest stage. Changes may be visible on medical imaging, but the person may not experience any symptoms.

2. Stress Reaction

At this stage, the bone has become irritated enough to cause symptoms. Pain is typically localised to a specific area and worsens with loading, exercise, or sporting activities. The affected area is often tender to touch.

3. Stress Fracture

This is the most severe stage, where a small fracture develops within the bone. Pain may occur even during everyday activities such as walking or standing, and imaging will typically confirm the diagnosis.

Common Symptoms of a Bone Stress Injury

Symptoms can vary depending on the severity of the injury, but may include:

• Pain during exercise or loading activities

• Pain that progressively occurs earlier during activity

• Pain with walking or weight-bearing

• Night pain

• Localised tenderness over the bone

• Swelling, redness, or warmth around the affected area

If you are experiencing persistent pain that follows this pattern, it is important to seek assessment early to prevent progression.

How Can Physiotherapy Help?

Physiotherapists play an important role in both the prevention and management of bone stress injuries.

Your physiotherapist can:

• Assess and diagnose suspected bone stress injuries

• Identify contributing factors such as strength deficits, reduced mobility, movement patterns, or training errors

• Develop strategies to reduce pain and manage symptoms

• Create a graded rehabilitation program

• Guide a safe return to running, sport, or exercise

• Help optimise training loads to reduce future injury risk

Early diagnosis and appropriate management can significantly improve recovery outcomes.

How to Prevent Bone Stress Injuries

While not all injuries can be avoided, several strategies can help reduce your risk:

• Increase Training Loads Gradually

  • Avoid large spikes in training volume or intensity. Gradual progression gives your bones time to adapt to increased demands.

• Prioritise Good Nutrition

  • Bones require adequate energy, protein, calcium, vitamin D, and other nutrients to stay healthy and repair effectively.

• Include Strength Training

  • Strength training improves the body's ability to absorb and distribute forces, reducing excessive stress on bones.

• Wear Appropriate Footwear

  • Footwear should suit your activity, foot type, and training environment. Worn-out or unsuitable shoes can contribute to excessive loading.

  
  

When Should You Seek Help?

If you have persistent pain that worsens with activity, tenderness over a specific bone, or discomfort that is not improving with rest, it may be worth having it assessed by a physiotherapist.

Early intervention can help prevent a minor bone stress injury from progressing to a stress fracture and get you back to doing what you enjoy sooner.