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What is a bone stress injury (BSI)? 
Bone, like any other tissue in the body, responds to the amount of load that you subject it to. They become stronger and more robust with exercise, but injuries can occur if they are subjected to excessive load with inadequate recovery time. When this happens, the injury might present with different signs and symptoms based on the stage of injury
A bone stress injury is an overuse condition associated with repetitive loading of bone and inadequate recovery. There is an imbalance between load-induced microdamage and bone formation which typically results in varying levels of pain and reduced function depending on the extent of the injury.

Why do they occur?
Bone stress injuries commonly arise in sports that involve high impact forces, such as running. Typically, a runner has stepped up their mileage too much, too quickly and the body is unable to recover fully between training sessions. There are many risk factors but one study (3) that compared healthy adolescent athletes with those that sustained bone stress fractures found that those that sustained injuries:
–       Slept less (7.2hrs vs 8hrs)
–       Had greater life stress
–       58% did not weight train
–       Had a previous history of BSI
–       Had poorer nutrition
Other studies have found lower bone density, a history of menstrual disturbance, and leg length discrepancy (1,2) to be significant risk factors.

Stages of a BSI
The first stage is a stress reaction which can include swelling of the deep skin layer over the bone (termed periostitis) or bone bruising (bone marrow oedema). This typically presents with a diffuse ache over the bone which is aggravated by impact and relieved by rest. If the injury worsens then a stress fracture can occur which presents as a more localized, intense pain on weight-bearing and light impact. It may also be painful at rest.

The first step is to get an accurate diagnosis and rule out other potential conditions. Often a thorough case history and examination is sufficient however imaging, such as an MRI scan, may be required in order to clarify the extent of the pathology.
Early management is usually aimed at reducing pain and if necessary, a rest period may be required as well as the use of appliances to offload the injury site such as cushioned shoes or crutches if the condition is advanced.
Once the pain has settled then a progressive rehabilitation program is beneficial in order to build up surrounding muscle strength as well as stimulating healing of the injury site through progressive bone loading exercises before gradually returning back to your sport. This may require a gradual return to exercise such as a progressive running program, scheduled in such a way as to allow full recovery between sessions and a gradual increase in running duration over time so as not to provoke the old injury.
It is also important to identify all modifiable risk factors that may have contributed to the injury occurring in the first place in order to reduce the likelihood of recurrence in the future.

Example of possible rehabilitation exercises for a shin BSI:

Let us know if you have any questions. The team and I would be very happy to help.
Stay safe,
Peter – Clinical director, Osteopath and running coach at Acer House Practice
Check out Acer House Practice on Facebook and Instagram for further tips and exercise video’s or contact Peter directly via email

1 Kelsey, J.L. et al, 2007. Risk Factors for Stress Fracture among Young Female Cross-Country Runners Medicine & Science in Sports & Exercise: 39 (9), p 1457-1463
2 Bennell, K.L. et al, 1996. Risk Factors for Stress Fractures in Track and Field Athletes. The American Journal of Sports Medicine, 24(6), pp.810–818.
3 Nussbaum, E.D. et al, 2019. Identifying Factors That Contribute to Adolescent Bony Stress Injury in Secondary School Athletes: A Comparative Analysis With a Healthy Athletic Control Group. Sports Health: A Multidisciplinary Approach, 11(4), pp.375–379.