Running Injuries, Pt 2: Stressed Out By a Stress Fracture?

Welcome to part two of common injuries seen in runners. It’s time to talk about bone stress injuries, sometimes referred to as stress fractures. We will discuss what this injury is, potential reasons why it occurs, how it presents, and how we treat it. Keep in mind that this injury does not ONLY occur in runners! So, if you’re someone that participates in sports and stays very active year round with very little time off, this blog is for you. 

As someone who had a tibial stress fracture in college, I can very confidently say that I wish I had this information available to me at that time. These injuries can be daunting, but our aim is to help you feel more confident about how you can prevent a bone stress injury and what your rehabilitation process should look like if you are currently recovering from one. 

What is a BSI?

Bone stress injuries are commonly due to overuse. One of the reasons that this injury is more often seen in the running population is due unfortunately to the nature of the sport. 20-30% of injuries in runners every year are bone stress injuries. Why? Running is a very repetitive sport. There isn’t a lot of variation, so our bones are more susceptible to be overused in the same way, day in and day out. On top of that, runners love to run. We don’t like to take time off. We think we’re doing ourselves a favor by pushing through discomfort or even pain, because “no pain, no gain”… right? WRONG. There is a certain level of pain that we should not push through because, at a certain point, our bones may not be able to tolerate repeated forces. This can result in an imbalance between the damage to the bone and the remodeling of that bone after stress has been applied. Once there is too much damage without enough healing, our bone becomes fatigued and has a much more difficult time accepting load. This causes local bone pain and tenderness and can lead to fractures. 

How does a BSI Present?

Now that you’re more familiar with what a bone stress injury is, let’s talk about how this injury presents. Typically, you will feel a lot of pain when someone presses directly on the area of injury. Standing on one leg, jumping, and other instances where you’re loading a lot of weight through your bone will likely also cause pain. Another key symptom is that stress fractures don’t have a “warm up” phenomenon; meaning your pain will be constant no matter what activity you’re doing. 

Are you dealing with a bone stress injury of your own? Do you know someone that has one? Just curious about what the rehabilitation process looks like? Let’s get into it! 

When to Seek Help

First and foremost, it is extremely important to see a medical professional if you believe you have a stress fracture. You may need to be non-weight bearing on that bone, depending on the extent and location of your injury, to ensure proper and timely healing. If you are put in a boot or have to use crutches, you will slowly progress to eventual weight bearing through the injured bone once you are pain free with the help of your healthcare provider. 

HOWEVER, if an athlete is non-weight bearing for a period of time, there is still so much you can do! We believe that complete rest is NEVER the answer and our goal is to keep you from getting deconditioned, despite having a difficult injury.

Rehabbing a BSI

Let’s get back to the rehabilitation process after a bone stress injury. One of the most crucial things that we stress is the importance of avoiding pain. Unlike other injuries where we emphasize that it is okay to have some discomfort, after a stress fracture, the athlete should not perform any painful activities. So, on a scale from 0-10, with 0 being “no pain” and 10 being “OMG I NEED TO GO TO THE EMERGENCY ROOM I’M IN SO MUCH PAIN”, the athlete needs to remain at a 0 out of 10, no matter what task they are performing. We need to ensure that their bone heals properly, and pain is a red flag that the athlete is doing too much before their body is ready. Before ANYTHING is progressed, whether it’s walking or sprinting, the athlete must be free of any sharp, pinpoint bone pain. Check out the visual below from Chris Johnson, a prominent physical therapist in the running world, that shows a pain scale for a soft tissue injury versus a bone stress injury.

Here, you can see the difference in pain scale values that are “safe”, “acceptable”, and “high risk”. For a soft tissue injury (like a muscle strain, for example) there is a wide range of pain values that are safe and acceptable throughout the rehab process. This is not the case with a bone stress injury. There isn’t even an “acceptable” range on that pain scale. ZERO PAIN is the only safe number. Period. 

When we find movements and exercises that aren’t painful, we incorporate both injury site specific and total body loading 2-3 times per day with a long rest period between workouts of about 4-8 hours. This incremental approach to loading the bone regularly throughout the day, has been found to be extremely successful in the rehabilitation process of a bone stress injury. In addition, we need the athlete to lift HEAVY. Bones like to be loaded!! They respond very well to heavy weight, and in fact, are made stronger when they are challenged by heavier loads. 

Getting Back to Running After a BSI

Because this is an injury seen very frequently in runners, we also have to consider the return to running side of their rehabilitation. As soon as the athlete can tolerate it, we will introduce straight line, pre-running activities such as marching, skipping, and light jumping. These activities will be progressed as long as the athlete remains pain free, and soon enough they will be jogging, running, and even sprinting! BUT, an important part of rehab after a bone stress injury is to not make huge jumps in intensity. So from a running standpoint, we always start the athlete out with easy intervals where they alternate between walking and jogging for a certain amount of time or mileage, and then progressively decrease the amount they walk and increase the amount they jog until they are running with no breaks. From there, we work on increasing their mileage and intensity respectively. 

Keep in mind, even if you really only consider yourself a runner, just running is not good enough when recovering from this injury. You need to improve the structural integrity of the bone with different stimuli: progressive weight bearing, high load, low rep strength training, and plyometrics. Do these things and you’re on track for a full recovery!

If you’re experiencing these symptoms and are curious whether or not you have a bone stress injury, OR if you’re already in recovery from this injury, we would love to get you back to pain free running (or whatever your sport may be)! We offer a free injury screening where we can answer any questions you have, professionally assess you, and organize a personal treatment plan to get you on the road to recovery. 

Find Help

Don’t end up with a broken bone! Come see us today!