Overuse and bone stress injuries
Stress reactions and stress fractures are signals: the load was too much, or the body's capacity to absorb that load was reduced. Specialist assessment looks at both sides of that equation and builds a return-to-load plan that addresses the underlying drivers.
Stress reactions and stress fractures are signals: the load was too much, or the body's capacity to absorb that load was reduced, or both. Treating only the bone misses half the picture. Specialist sport and exercise medicine assessment looks at both sides of the equation and builds a return-to-load plan that addresses the underlying drivers.
Common bone stress problems we see
What bone stress injuries are
Stress reactions and stress fractures, and why they happen.
Read more Risk sitesHigh-risk and low-risk sites
Why some sites need more caution than others.
Read more CausesUnderlying drivers
Training load, energy availability, bone health and biomechanics.
Read more RecoveryReturning to load
A graduated return-to-load plan that addresses the causes.
Read more
What bone stress injuries are
Bone is constantly remodelling in response to load. When mechanical demand exceeds the bone's capacity to remodel, microdamage accumulates: first as a stress reaction (bone marrow oedema on MRI without a fracture line), then as a stress fracture (a true fracture line). The transition matters because management differs.
Common sites in runners include the tibia, fibula, metatarsals, navicular, femoral neck, and pelvis. In rowers, the rib. In cricket fast bowlers, the lumbar pars. In dancers, the metatarsals and tibia.
High-risk versus low-risk sites
Bone stress injuries are classified by site:
- High-risk sites: femoral neck (tension side), tibial mid-shaft anterior cortex, navicular, fifth metatarsal base, talus, sesamoid. These sites have higher non-union rates and may need surgical opinion.
- Low-risk sites: posteromedial tibia, fibula, second to fourth metatarsal shafts, pelvis. Generally manageable non-surgically with structured load reduction and graduated return.
Imaging (MRI) is usually needed for confirmation. X-ray often misses early stress reactions.
Underlying drivers
Bone stress injury rarely has one cause. The workup considers:
- Training load: how recent and how rapid was the increase
- Energy availability: RED-S is a major contributor in athletes (see female athlete health)
- Bone health: vitamin D, calcium, hormonal status, prior bone density
- Biomechanics: running technique, footwear, and surface
- Sleep and recovery: both contribute to bone remodelling capacity
- Medications: some medications affect bone health
Recurrent stress fractures particularly warrant a thorough review of these drivers, often including DEXA, bloods, and a sports dietitian referral.
Returning to load
The return-to-load plan respects the bone's remodelling timeline (typically weeks to a few months) and addresses the drivers identified above. Cross-training to maintain fitness, graded weight-bearing progression, and a structured running return are common elements. Specialist input helps with the timing decisions, the imaging follow-up where needed, and the integration of the load plan with the wider workup.
Common questions
How long until I can run again?
It depends on the grade and the site: lower-grade injuries recover faster than higher-grade ones. Either way, we are generally talking weeks to months, not hours to days.
Will I have to stop training entirely?
Yes, commonly there will be a period of strict offloading, but we discuss cross-training options where appropriate.
Should I have a DEXA scan?
For some patients, yes, particularly with recurrent injuries, low bone density, a history suggestive of low energy availability, or other risk factors.
