How to Treat Bone Stress Injuries and Get Back to Running Stronger
Treating bone stress injuries in runners requires expertise, patience, and a strategic approach to recovery.
Welcome to the final installment of our bone stress injury series for runners. In parts one and two, we explored the risk factors and prevention strategies. Now, we’re focusing on what happens after a BSI diagnosis and how to navigate the recovery process effectively.
Our lead physical therapist, Maria, shares her expertise on treatment approaches, rehabilitation protocols, and strategies that have helped countless Boise runners not only recover from bone stress injuries but return to running stronger than before. As Boise’s only specialized running clinic, we’ve developed evidence-based protocols that balance necessary rest with strategic activity to optimize healing.
Q: Once a runner comes in with a suspected BSI, how do you typically confirm the diagnosis?
A: When a runner comes in with a suspected BSI, there are a few things that we look for to confirm our suspicion of a bone stress injury.
The first thing is the location of pain, which gives us good insight into which structure is involved. From there, we examine the behavior of the pain. Is it painful at rest? Is it painful with weight-bearing? Is it painful at night when sleeping? Is it painful to press on? These questions help us understand the behavior and location of the pain. Usually, through conversation and questioning, we can form a good idea that it may be a bone stress injury before even beginning the physical exam.
If I’m seeing a runner for the first time, I automatically ask many questions about when they started running, their consistency with running, and how they feel—not just on race day, but in everyday life on a week-to-week and month-to-month basis. I look at how they ebb and flow throughout the seasons, what their training schedule has been like, and if there were any spikes in training prior to the onset of injury.
I also ask about bone mineral density, history of osteoporosis or osteopenia, history of relative energy deficiency in sport (RED-S), disordered eating, and how they cope with injury and recovery. All these factors can lead to tissue overload. It basically comes down to whether there’s an imbalance between recovery and the stimulus of running, cross-training, or whatever activity they’re doing.
Once I have these pieces of the puzzle, I examine the exact tissue that’s painful to determine whether it’s pain with muscular contraction, pain over a tendon, or if it’s in a bony area. Pressing on bones should not be painful.
Q: What does the recovery process look like—what’s the balance between rest and keeping active?
A: The recovery process can look different for many people. First and foremost, the foundational elements for any runner include consistency with sleep, adequate fueling, and sufficient time between loading sessions, runs, and exercise.
The specifics may vary depending on the caliber of runner, their expertise, and experience, but certain elements remain consistent across the board. If you’re not sleeping enough or consuming enough calories to sustain and help your body recover from running, there will be an imbalance that leads to injury.
I often talk with runners about managing stress and using tools like RPE (rate of perceived exertion) to stay attuned to their fatigue level. This awareness helps them determine when it’s safe to engage in their training schedule or when they should consider modifications to allow their body grace and recovery, rather than just following what’s written on their calendar.
Q: Why isn’t complete rest always the best answer for healing a bone stress injury?
A: Complete rest isn’t always the best answer for recovering from a bone stress injury because when that individual is allowed to start loading again, you want them to be as strong and fit as possible for that process.
We know runners are at increased risk for a subsequent bone stress injury during the recovery phase from their prior injury, particularly during that first year. This is partly due to the reasons why they got a bone stress injury in the first place—insufficiency with fueling and recovery, etc. It’s also because they likely went through a phase of non-weight bearing (for a high-risk bone stress injury) or some type of de-loading (for a low-risk bone stress injury).
Q: What types of cross-training do you usually recommend to runners during their recovery?
A: The cross-training recommendations differ based on whether someone has a high-risk or low-risk bone stress injury. High-risk sites usually require some form of non-weight bearing for many weeks to a couple of months, depending on the severity or grade of the bone stress injury following imaging.
For a low-risk bone stress injury that tolerates weight bearing without pain, individuals can do much more. They can often participate in activities like cycling, walking, and strength training to keep their bodies as healthy as possible. The caveat is that they must remain pain-free during these activities without irritating or exacerbating their condition.
Q: When can strength training safely be added back in, and why is it so important during recovery?
A: Strength training can be safely reintroduced following a bone stress injury when an individual can comfortably spend time on their feet throughout daily activities at home and work without increasing pain. When they can safely load their limb, hip, pelvis, or wherever the injury is located without exacerbating pain and feel confident doing so, strength training becomes important.
It’s crucial to maintain as much strength training in a pain-free manner as possible to stimulate the muscles. This approach prevents prolonged time off from strength training because the body quickly loses muscle mass with sedentary behavior and lack of strength training stimulus.
Q: What does a safe, gradual return-to-running plan typically involve after a BSI?
A: A gradual return-to-running plan typically involves some form of run/walk programming. We like to think of these sessions as “bone loading sessions” rather than runs, which gives runners a good mindset about the strategy and purpose of the programming.
It usually starts with something like a 60-second jog followed by three to seven minutes of walking, especially for higher-risk bone stress injuries. This is done on non-consecutive days while monitoring for symptom exacerbation during the activity and within the next 24 hours. We also offset these sessions from cross-training days to maintain balance and avoid doing too much on the same day when initiating the return to running.
Q: How do you help runners mentally deal with the frustration and fear of being sidelined?
A: There is definitely a mental component to dealing with the frustration and fear around bone stress injuries. They’re not well known or understood by most people until you’ve experienced one—it’s not something that’s on most runners’ radar.
I find that sharing statistics and being honest about the severity of the situation is the best approach. Giving information about healing and recovery time gives individuals something to anchor their focus on. I emphasize that their body is the boss—not the orthopedic surgeon, not the runner, not myself as the rehab specialist. It truly comes down to their body’s recovery and healing process.
I use a stair-step approach and give them the mental construct of plateaus in their programming. This allows their body to demonstrate that they’re handling the load well, which builds their confidence.
Q: For runners who’ve recovered, what habits or practices should they stick with long-term to stay healthy?
A: The best habits and practices for runners to stay healthy and avoid future bone stress injuries start with listening to their body. Pay attention to the niggles that inevitably pop up with running and notice patterns that may be emerging. Get these assessed sooner rather than later if something becomes repetitively problematic.
Consistent sleep habits are crucial—going to bed at the same time and getting adequate rest. Develop the habit of fueling within 30 minutes after exercise, which is a good guideline for most individuals. Prepare and plan for fueling as a foundational piece of training. This preparation should happen before exercise so you’re ready to complete the task at hand—which is not just to provide the stimulus of running but to actually recover from that stimulus. That’s where you make your gains.
Another good habit is incorporating a deload week every three to four weeks when building or progressing through a training season. This prevents perfectly linear training throughout a season and gives your body some reprieve. Also, plan for off-seasons throughout the year.
Finding goals for the year and planning ahead is a good practice. Building and strategizing recovery practices throughout the year, just as you would plan for races, is crucial to staying as healthy as possible.
Your Path to Running Again Starts Here
Bone stress injuries require specialized care and a methodical approach to recovery. With the right guidance, you can heal properly and develop habits that will help prevent future injuries.
Living in the Boise area and concerned you might be dealing with a bone stress injury? Our specialized team understands the unique challenges runners face and provides customized treatment plans that address both the injury and its underlying causes.
Don’t let uncertainty or fear of a long recovery keep you from getting the help you need. If you’re in the Boise area, learn more about our bone stress injury treatment for Boise runners. The sooner you address a potential bone stress injury, the more efficient your recovery can be.
At our Boise clinic, we’re committed to helping runners of all levels return to the trails and roads safely. Connect with us today to begin your journey back to pain-free running.
