How to Overcome a Bone Stress Injury The Right Way

Bone Stress Injury Jul12th 2023

By: Christina Schultz, Doctor of Physical Therapy, Certified Strength & Conditioning Specialist

You were diagnosed with a Bone Stress Injury – Now what?

Unfortunately, this means you’re going to be hanging up the running shoes for a while, but there is still work to do! – Fortunately, there are things that you can and should be doing to help your fitness, and performance, and better yourself in general.

Important questions for your orthopedic doctor:

You have likely been sent for an MRI to confirm your stress fracture. It’s important you ask your doctor the right questions to help your coach and physical therapist determine the severity, timeline, and needs of your specific bone stress injury (BSI). Here are 3 questions to help guide your conversation with your doctor.

1) What grade BSI is this?

This is going to help give you and your rehab team an idea as to how long you should expect
it will take until you can begin running again. Bone stress injuries are Graded 1 to 5, a gross
rule of thumb is an additional 48 days until a return to run is seen per point on this scale.

2) What type of bone is involved?

Cortical bone, the dense outer surface of the bone, is typically stronger and more resistant.
Generally, it takes 4-12 weeks for cortical bone recovery.

Spongy bone, the inside of the bone, is less tolerant to stress and plays a large role in bodily
functions, like producing red blood cells. This can take about 200 days to recover. It is also
largely influenced by nutrition and hormone function and therefore can serve as a red flag
to dysfunction of other systems.

3) What is the bone risk level?

BSIs in various areas of the body can have a low, medium, or high risk of poor healing and
could possibly require surgery. If it is in a high-risk area, this BSI will need to be closely
monitored and your return to sport will be much more conservative. If it is in a low-risk area,
we can expect a quicker and smoother recovery.

Take time to assess your nutrition intake

Low energy availability (LEA) is when the amount of fuel you provide to your body does not
meet the demands of your activity level. Even if you don’t think this is you, it’s worth double-checking because you may not be quite where you think you are in terms of proper fueling.
There is research suggesting that this applies to 31% of female runners and 25% of male

Why does this matter? Even short periods of LEA can put your bone health at risk. LEA can
disrupt hormone function putting your bones at higher risk of injury. The last thing you want is to spend all this time carefully returning to running and it either be delayed because the bone is not healing well, or for you to refracture the bone in a matter of months and have to start over.

I highly recommend consulting with a registered dietician to identify any insufficiencies and to help guide your nutritional needs going forward in this process.

Work with a clinician

Work with a clinician who has experience with BSIs and regularly works with runners to develop a safe and effective training program.

If you have been told to take 3 months off from running and you should be good to go after that rest, pay attention to this section. First, if you have sat on the couch for 3 months and then begin running without properly preparing, you will find yourself significantly deconditioned. This will make returning to running a much larger challenge to your body- forget performance goals. Secondly, bones require stimulus to build. If you add no stimulus to your bone, the bone will become weaker (spoiler alert: this is not what you need). If an athlete makes a big jump in training load there is an increased risk of BSI, which is likely how we got here in the first place. So as you can see we want a nice, gradual build-up to prepare for the return to running so that it is successful.

Prior to beginning a return-to-run plan, each athlete should have completed:

1) A progressive cross training program
2) A progressive walking program
3) A progressive strength program loading the affected area
4) A progressive jumping program

Even after the required time off of running, great care needs to be taken in how much load is added when running. I hate to have to tell you this but it is SLOW- so go in prepared for that to be the case. Research shows us that there is a drop in bone mineral density AFTER sustaining a BSI, and it doesn’t even reach baseline for 9 months. If you are in an LEA state and are dealing with symptoms associated with the athlete triad (1) low energy availability, (2) hormone dysfunction, (3) low bone mineral density), BMD can take over a year to restore.

This doesn’t mean no racing or even running within the year, but your training WILL be delayed and different. An experienced clinician can help guide you through this process in order to get you there safely and effectively. This means helping you maintain and restore as much performance ability as possible.

We love keeping runners running and getting injured back to running as quickly and safely as possible. Please give us a call so we can get you into our Zone PT Soggy Sock Endurance Lab to help you maximize your running!

Are You Experiencing Physical Limitations? 

Zone Physical Therapy would love to help answer your questions about any limitation you are experiencing and we hope we can get the conversation started on the next steps to help you solve any pain or discomfort and find what is causing you issues. 

In our clinic, we work so our patients can enjoy the things they love while pain-free. If you are experiencing pain or noticing any physical limitations, come see us!

To arrange a visit to our office – Request An Appointment or call us on (864) 351-7254.

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