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by Cuyler Hudson, PT, DPT, FAFS

Posted in Blog.

August 17th, 2020

Bone Stress Injuries: How to identify them and what to do about it

Runners get hurt, it happens.

Studies on the percentage of runners who get injured during a given year have varied widely from 20% to over 90%, so let’s just split the difference and say you have a slightly over 50% percent chance of developing some type of injury if you’re a consistent runner. So this begs the question I get from a lot of friends/patients, is running BAD for your body? The answer to that is an unequivocal NO! Runners have been shown to have a 35% decreased risk of heart disease, 50% decreased risk of type 2 diabetes, eat better, use less alcohol and tobacco, and are happier and less anxious! So keep up the running, we just have to be smart about how we manage injuries that are more likely than not to pop up. This blog will help you make smart decisions when you feel an injury coming on.


The first thing to note is that running completely pain-free is not the goal. Aches and pains are a part of running and are perfectly normal. If, however, your pain starts to reach a 4 out of 10 on a pain scale, doesn’t go away after running, or is constantly bothering you over a period of months, it’s probably time to figure out what’s going. The most important thing to determine right off the bat is what kind of injury we are dealing with. Is it a bone stress injury, or a tendon injury? While this can be tricky to figure out, there are a few things you can do to try and determine the answer. The first is to ask yourself if your pain gets worse as you run. Generally, tendon injuries will “warm-up” and either become less severe the further you run, or go away completely. Bone stress injuries tend to get worse the longer you run. The second thing to ask yourself is, “does impact cause the greatest amount of pain.” In bone stress injuries, pain will usually be the worse right as your foot lands during your stride, as this creates the greatest amount of ground reaction force in the bones. Tendon injuries will usually be more painful through the whole gait cycle and may worsen during the push-off phase. Lastly, if you suspect you may have a bone stress injury, a good test is to start hopping on both legs, and if that’s pain-free, try hopping on just the affected leg. The huge amount of force being put through the bones on the leg should elicit your symptoms if you have a bone stress injury (don’t do it for too long though!). If you have all these symptoms of a bone stress injury, the next step is to get some imaging done, either an MRI or CT scan are considered the gold standard as of now. 


So how do we treat these injuries? If you and your PT suspect you have a bone stress injury, the first thing to do is stop running. Start hopping on the bike for your cardiovascular fitness, as this minimizes the damaging impact of running and also will be a huge help to increase the amount of blood flow to the affected area. It’s important to note that just taking time off, then returning is NOT enough for bone. You also will need to start a progressive loading program. This means that you need to perform strengthening exercises to the muscles around the affected bone. These muscles pull directly on the bone, which stimulates the bone to regenerate at a faster rate and improve bone density, making your bone stronger (remember to perform all these exercises in a 3-dimensional way to maximize input!). It’s also important to note that bone responds best in short bouts performed multiple times throughout the day. So rather than performing 3 sets of an exercise in one session, it’s best to perform 3 sets of exercises spaced out throughout the day. The intensity of these exercises must then gradually be increased to keep providing a continuous beneficial stress to the bone. At the same time, a progression from biking to walking to running to jumping to distance running must occur to safely build tolerance of the affected bone. Lastly, it’s important to note that not all bone stress injuries are created equal. Based on the severity, and the location of the injury, your time to return to running can take anywhere from 8 weeks to 22 weeks.


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