Bone Stress Injuries in Runners: Why They Happen and How to Prevent Them

Running continues to grow as one of the most accessible and popular forms of exercise worldwide. Lately, everyone seems to be training for their next 5km, 10km, half or full marathon and posting about it on social media! But as a physiotherapist, I see many runners sidelined each year by injuries that often start quietly and build into something more sinister over time. One of the most common (and most misunderstood) are bone stress injuries. 

Understanding these injuries can be the difference between missing a couple of training sessions or missing up to months of running! 

What Are Bone Stress Injuries? 

Bone stress injuries occur when repetitive loading exceeds the bone’s ability to adapt and recover. Bone is living tissue that remodels in response to load, but when training demands increase too quickly or recovery is insufficient, microscopic damage accumulates. 

Bone stress injuries exist on a continuum: 

• Bone stress reaction  

• Stress fracture 

• Complete fracture 

Early-stage stress reactions can often be easily managed with load modification and rehabilitation. Whereas stress fractures can result in periods of immobilisation on crutches and the dreaded moon boot. Early management is very important in not letting these injuries get out of hand. 

Common Bone Stress Injuries in Runners 

In runners, bone stress injuries most commonly affect: 

• Tibia (shin), commonly referred to as shin splints 

• Metatarsals (foot) 

• Femur (especially the femoral neck) 

• Calcaneus (heel bone) 

Symptoms often include: 

• Localised pain in one specific area 

• Pain that worsens during a run 

• Pain may resolve with rest (initially) but will persist at rest once it has progressed 

• Pain appearing earlier into a run or becoming more intense over time 

• Tenderness over the affected bone 

• Pain that is constant and worsens at night 

Why Do Runners Develop Bone Stress Injuries? 

Bone stress injuries are an overuse injury and are rarely caused by one single factor. They typically result from a combination of training load errors, biomechanical factors and inadequate recovery. 

Training Load 

• Sudden increases in kilometres or intensity 

• Rapid introduction of hills or speed work 

• Inadequate rest days 

Biomechanics & Strength 

• Reduced lower limb strength 

• Poor shock absorption through the lower limb 

• Poor running mechanics (stride length, cadence)  

Recovery & Lifestyle 

• Poor sleep 

• High life or training stress 

• Inadequate nutrition or low energy availability 

Footwear & Surfaces 

• Worn-out shoes 

• Sudden changes in footwear style 

• Increased running on hard or cambered surfaces 

Preventing Bone Stress Injuries 

Proactive management can prevent most bone stress injuries from worsening or avoid them altogether.  

Progress Training Gradually 

Avoid sudden spikes in training load. Increase distances or intensity within sessions gradually and change only one training variable per session. A general rule of thumb is to never increase mileage (kilometres covered per week) by more than 10%.  

Strength Train Regularly 

Strong muscles reduce the load placed on bone by improving force absorption. Strength training should be a consistent part of a runner’s program and not an afterthought. Key factors of a good strength program for runners include: 

• A focus on unilateral (single leg) movements 

• All major muscles (glutes, adductors, quadriceps, hamstrings, calves and foot muscles) 

• Core and pelvic control 

• Plyometric exercises 

• At least 1-2 sessions per week 

Respect Recovery 

Bone adapts during recovery. Ensure your program includes: 

• Minimum one complete rest day or off-feet session (cycling, elliptical, ski erg) per week 

• Adequate sleep 

• Deload weeks within longer training blocks 

Fuel for Bone Health 

Low energy availability significantly increases the risk of bone stress injuries. Runners should ensure they are maintaining an appropriate diet to that meets their training loads. Consultation with a sports dietitian can be beneficial. 

Act Early on Pain 

Persistent, localised bone pain is not normal training soreness. Early assessment and load modification can prevent a stress reaction from progressing into a stress fracture. 

How Can We Help? 

If some of these symptoms are sounding all too familiar, then it is best to consult with one of our experienced physiotherapists at Game Time Performance. We provide detailed injury assessments to identify where you sit on this continuum and provide rehabilitation tailored to you. We can also facilitate referrals for scans and to other health professionals if required.  

Our $99 Sports Injury Assessment is your ticket to understanding what is going on and what the next best steps are. Click here for more information. 

Don’t have a bone stress injury but would just like guidance with injury prevention? We can also provide tailored gym and running programs to help you smash that PB you’re chasing! 

References 

Edwards, W. B., Taylor, D., Rudolphi, T. J., Gillette, J. C., & Derrick, T. R. (2010). Effects of running speed on a probabilistic stress fracture model. Journal of Biomechanics, 43(13), 2537–2543. https://doi.org/10.1016/j.jbiomech.2010.05.022 

Mountjoy, M., Sundgot-Borgen, J., Burke, L., Ackerman, K. E., Blauwet, C., Constantini, N., … Budgett, R. (2018). IOC consensus statement on relative energy deficiency in sport (RED-S): 2018 update. British Journal of Sports Medicine, 52(11), 687–697. https://doi.org/10.1136/bjsports-2018-099193 

Nattiv, A., Goolsby, M. A., Matheson, G., et al. (2013). Stress fracture management: Current evidence and clinical practice. Current Sports Medicine Reports, 12(3), 200–207. https://doi.org/10.1249/JSR.0b013e3182961e2e 

Nielsen, R. O., Buist, I., Sørensen, H., Lind, M., & Rasmussen, S. (2012). Training errors and running-related injuries: A systematic review. British Journal of Sports Medicine, 46(7), 505–510. https://doi.org/10.1136/bjsports-2011-090436 

Warden, S. J., Davis, I. S., & Fredericson, M. (2014). Management and prevention of bone stress injuries in long-distance runners. Sports Health, 6(6), 481–491. https://doi.org/10.1177/1941738114544377