How to Overcome a Bone Stress Injury the Right Way

By Dr. Christina Schultz, DPT, CSCS

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 you can and should be doing to help your fitness, your performance, and 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 to 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 three questions to help guide that conversation.

1. What grade BSI is this?

This helps give you and your rehab team an idea of how long it should take until you can begin running again. Bone stress injuries are graded 1 to 5; a rough rule of thumb is an additional 48 days until a return to running is expected 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, and generally takes 4 to 12 weeks to recover.

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. It can take about 200 days to recover, and it is largely influenced by nutrition and hormone function, so it can serve as a red flag for dysfunction of other systems.

3. What is the bone’s risk level?

BSIs in various areas of the body can carry a low, medium, or high risk of poor healing, and could possibly require surgery. In a high-risk area, the injury needs to be closely monitored and your return to sport will be more conservative. In a low-risk area, you can expect a quicker, smoother recovery.

Take time to assess your nutrition intake

Low energy availability (LEA) is when the amount of fuel you provide your body doesn’t meet the demands of your activity level. Even if you don’t think this is you, it’s worth double-checking; research suggests this applies to roughly 31% of female runners and 25% of male runners.

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 only to have it delayed because the bone isn’t healing well, or to refracture the bone within months and have to start over.

I highly recommend consulting a registered dietitian to identify any insufficiencies and help guide your nutritional needs going forward.

Work with a clinician

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

If you’ve been told to take three months off from running and should be good to go afterward, pay attention here. If you’ve sat on the couch for three months and then begin running without properly preparing, you’ll find yourself significantly deconditioned, which makes returning to running a much larger challenge, before you even think about performance goals. Bones also require stimulus to build; add no stimulus, and the bone gets weaker. If an athlete makes a big jump in training load, there’s an increased risk of BSI, which is likely how you got here in the first place. So a gradual build-up is what prepares you for a successful return to running.

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

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 from running, great care needs to be taken in how much load is added when you return. It is slow, so go in prepared for that. Research shows a drop in bone mineral density after sustaining a BSI, and it doesn’t reach baseline again for nine months. If you’re in an LEA state and dealing with symptoms of the athlete triad (low energy availability, hormone dysfunction, and low bone mineral density), bone mineral density can take over a year to restore.

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

We love keeping runners running, and getting injured runners back to running as quickly and safely as possible.