What Boise Runners Need To Know About Bone Stress Injuries
Bone stress injuries in runners are frustrating, misunderstood, and all too common.
They can creep up slowly, masked as harmless soreness… or strike suddenly when you’re in peak training. Either way, they’re responsible for sidelining countless runners every year.
In order to shine some light on this murky subject, I sat down with one of our physical therapists, Dr. Maria, to break down everything runners need to know about bone stress injuries. Instead of cramming it all into one overwhelming article, we’re splitting it into a 3-part series.
What to Expect in This 3-Part Series
Part 1: What Runners Need to Know About Bone Stress Injuries (You’re Here!)
In this post, we cover the basics: what bone stress injuries are (and how they differ from stress fractures), the key warning signs, and why simply resting isn’t enough to fix the problem.
Part 2: 5 Risk Factors You Can Actually Control to Prevent Bone Stress Injuries
No, you can’t change your bone structure—but you can control a lot of the risk factors that lead to these injuries. We dive into the training, nutrition, and biomechanical mistakes that set runners up for trouble (and how to avoid them).
Part 3: How to Treat Bone Stress Injuries—and Get Back to Running Stronger
This is where most runners go wrong. Recovery isn’t just about taking time off. In Part 3, we’ll walk you through the key steps to heal properly, maintain your fitness, and return to running without fear of re-injury.
If you’ve ever dealt with bone pain while running—or want to make sure you never do—this series is for you!
Let’s dive into Part 1 — What Runners Need to Know About Bone Stress Injuries:
What Exactly Is a Bone Stress Injury, and How Does It Differ From a Stress Fracture?
A bone stress injury encompasses both stress fractures and stress reactions. A stress reaction is a lower-grade bone stress injury than a stress fracture—it’s essentially the early stages before progressing toward a fracture.
On imaging, you would see swelling or edema in the bone. With a stress fracture, there’s an actual fracture line visible, but it’s not a complete fracture that splits the bone into two pieces. The most serious cases involve fractures that go through the cortical bone (the outer shell), which is much more concerning.
Where Do Runners Usually Develop Bone Stress Injuries?
Runners typically develop these injuries in the lower leg. We see a lot of metatarsal bone stress injuries in the long bones of the foot. They also occur in the hip at the femur and sometimes in the pelvis. The most common location would be the lower end of the tibia (the lower leg bone).
How Can a Runner Tell If They’re Just Sore From Training Versus Dealing With an Early-Stage Bone Stress Injury?
If a runner starts out on a run and finds that their symptoms improve after they’ve warmed up, this is typically a sign that it’s probably not a bone stress injury. While technically bones could “warm up,” I rarely see this clinically.
Tendon involvement, on the other hand, is notorious for warming up and feeling better with movement. Bone pain tends to persist or worsen with continued activity rather than improving.
What Are a Few Red Flags or Warning Signs That Runners Should Not Ignore?
Runners should be concerned about:
- Night pain associated with their injury
- Pain that persists and worsens despite rest
- Pain that only comes on with weight-bearing or when pressing on the bone itself
- Pain that doesn’t occur with gentle stretching or moving your foot or leg when seated
- Pain that worsens the longer you run
- Pain that causes you to limp
Are Bone Stress Injuries Really Just “Overuse Injuries”?
The majority of bone stress injuries in the running and endurance community are what we consider “bone stress injuries of insufficiency.” This means the body is experiencing an imbalance between how fast the bones are able to repair and rebuild relative to how quickly they’re breaking down.
These injuries occur when runners aren’t getting enough recovery or enough nutrients to support bone health. If you’re not consuming enough calories, the body will draw nutrients from somewhere else, and the bones often can’t keep up with this pattern.
Other contributing factors include stress, lack of sleep, and hormonal imbalances. Hormones are a significant piece of the puzzle and can provide important clues about energy expenditure problems. For example, when a female runner loses her menstrual cycle, this is her body’s warning sign that she’s not adequately fueling or maintaining hormonal balance.
What Happens If Someone Tries to Run Through a Bone Stress Injury Instead of Addressing It?
Running through a bone stress injury will only worsen it. It will not heal on its own if you continue to run on it. Bones should not be painful during physical activity. They need to be at zero out of 10 on a pain scale to safely perform any physical activity, especially running.
What Would You Say to a Runner Who’s Had Persistent Bone Pain but Keeps Putting Off Seeking Help?
Not addressing a bone stress injury, especially at a high-risk site, is extremely dangerous. High-risk sites tend to have a harder time healing and often progress to more serious injuries if not properly managed.
If you don’t unload them enough and continue to run while worsening your pain, a high-risk bone stress injury could lead to surgery and/or permanently end your running career. Early intervention is crucial for the best outcomes.
What Are The High-Risk Sites For A Bone Stress Injury, and What Makes Them High Risk?
Some bone stress injuries happen in areas that heal well with proper rest and care. Others are much more serious—these are called high-risk sites.
For runners, the most common high-risk locations include:
- The hip (femoral neck)
- The midfoot (navicular bone)
- The front of the shin (anterior tibia)
- The outer edge of the foot (base of the 5th metatarsal)
- The inner ankle (medial malleolus)
These areas are considered high risk for a few key reasons:
-Poor blood supply.
Without good circulation, bones in these areas take longer to heal—and sometimes don’t heal properly at all.
-High repetitive stress.
These bones absorb a lot of impact during running, making them more likely to worsen if not treated correctly.
-Risk of serious complications.
Because of their location, injuries in these locations can turn into complete fractures, require surgery, or cause long-term problems if ignored.
Low-risk sites, by contrast, usually heal faster and have fewer long-term consequences when managed early.
What’s One Myth About Bone Stress Injuries You Wish More Runners Understood?
One major misconception is that running alone is great for bone health. In reality, running does not do a particularly good job of stimulating bone formation. Runners can easily get into situations of under-fueling because of how much energy they expend while running, and many find it difficult to match their caloric intake to their expenditure.
When the body isn’t getting enough fuel, not only is the brain not getting enough glucose, but it also signals for the cessation of bone formation or osteoblastic activity within bone cells. For optimal bone health, runners need other interventions beyond just running, such as:
- Specific, purposeful plyometric training
- Regular strength training
- Adequate recovery
- Proper nutrition to support bone health
These additional activities, combined with proper fueling and recovery, are essential for maintaining healthy bones and preventing bone stress injuries.
Message To Boise Runners
Here in Boise, with access to everything from flat Greenbelt paths to steep foothill trails, runners face a wide variety of training stresses. Understanding bone stress injuries is key to keeping you healthy and ready for events like Race to Robie Creek—or simply enjoying your next long run pain-free.
If You Need Our Help
If you live in Boise, and you’re dealing with persistent bone pain and aren’t sure what steps to take, learn more about our bone stress injury rehab for Boise runners.
