Understanding and Preventing Bone Stress Injuries in Runners

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Picture this– you have been religiously training the past six months to compete in the most important race of the year. You’ve been waking up at 5:00am and going to sleep at midnight just to balance training, work/school, social activities, meal prep, and the daily household chores. You’re holding it together at the moment, but ultimately feel like a superhero that’s one setback away from a mental/emotional/physical collapse.

But you are an ATHLETE. Nothing can break you– that wouldn’t be fair, right? You have been diligent in your training doing everything “correct.” That is, until one month prior to your big race, you feel this dull unrelenting pain at a pinpoint spot in your foot while running. It doesn’t “warm-up” as you run, it actually gets worse. 

You’ve met your match. Your kryptonite. A bone stress injury. 

Sound familiar? 

If this is you, know that you are not alone. I have been there (many times), but throughout my own experience with BSI, I have become passionate about helping others who are experiencing the same thing.

Throughout this blog, I hope to give you some helpful information that will keep you healthy and strong for all your upcoming races, such as:

  • What is a bone stress injury (BSI)?
  • What are the signs/symptoms to watch out for?
  • What are some predisposing factors to a BSI?
  • How as a runner can you avoid a BSI?

What is a Bone Stress Injury (BSI)?

A bone stress injury is the by-product of an imbalance between microdamage and repair of the bone. Microdamage is caused by repetitive load through the bone (running) that breaks down faster than the body can repair. The accumulation of microdamage can give rise to a stress reaction, stress fracture, and ultimately a complete fracture. 

Bone stress injuries in runners primarily occur in the femur, tibia, navicular, calcaneus, and metatarsals. All big fancy words that essentially mean the long bones in your legs, and the bones in your feet. Some sites of fracture are higher-risk than others due to their blood supply. The sites you should be particularly aware of if you identify some signs of a BSI are: neck of the femur, navicular, calcaneus, and the base of your fifth metatarsal. The sites of fracture with lower-risk include: tibia, metatarsal shafts, cuboid, and cuneiforms. All BSI’s are important however, and should each be treated with ample care! When seeking care, make sure to find a physical therapist who has experience working with athletes and runners with a bone stress injury- not all physical therapists are the same! 

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What Signs/Symptoms Should You Watch For?

A BSI can present as a dull ache, sharp pin-point pain, or if you’re one of the lucky ones– both. A hallmark sign is pain that does not “warm-up” as you continue to run. Bone stress injuries will stay persistent and progressively get worse with increasing load.

What are Predisposing Factors to a BSI

For all the female distance runners out there– please pay close attention! You ladies are built strong and can accomplish the impossible, but one thing you can not help is your predisposition to BSI’s. Females are at a 2x greater risk for developing a BSI with ⅓-⅔ of all distance runners having a history of BSI. Males, you are not out of the woods, so stay with me! In a study looking at collegiate track and field athletes, 35% of all BSI’s occurred in men. 

The greatest risk factor for a BSI is having a previous BSI. This increases your risk by five fold. If you don’t believe me, maybe my five stress fractures over the course of four years will bring that risk factor to life.

While there are many risk factors that are not preventable (i.e. your gender), there are some risk factors that are:

  • Training load
  • Intensity
  • Frequency
  • Type
  • Muscle imbalance
  • Energy availability 
  • Diet/nutrition
  • Vitamin deficiencies
  • Hormonal imbalance 
  • Sleep
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Monitoring training load is huge. Many of us (me included), have an outrageous goal in mind and hit the ground running– hard. Most often, too hard and too fast. There is an art to progressing your training appropriately and effectively for your body. BSI symptoms typically present themselves 4-6 weeks following the succession of a new training program, or ramp-up in your current training. Osteoblasts (cells that grow and repair bone) are just beginning to lay down at this time; therefore, when microtrauma (load) exceeds the body’s ability to re-build, BSI occurs. Next time you set a running-related new years resolution, check-in with your body in February– this is typically when most BSI’s arise (4-6 weeks out from those new years resolutions starting January 1).

Energy availability is a significant contributor to Bone Stress Injury. If you are not consuming enough energy via calories to support the amount of energy you are burning, your body will leech nutrition from other sources– your bones. 

Females–I’m talking to you again! RED-S is a combination of menstrual dysfunction, low energy availability (with or without disordered eating), and low bone mineral density. RED-S is a vital risk factor to consider with BSI, and if you believe you fall into this category, I encourage you to speak with your physician, physical therapist, and/or nutritionist about it. We are always here to listen and provide guidance!

Vitamin D and calcium are critical for bone health. In a study looking at female distance runners aged 18-26, they found that women who consumed less than 800 mg of calcium per day had a 6x higher rate of BSI risk than those who consumed 1500 mg per day. In a study conducted with male military recruits, the individuals with inadequate vitamin D had a greater risk for BSI. Moral of the story– as a runner, it is highly encouraged to meet or exceed the recommended dietary allowance for calcium and vitamin D. 

Last, but not least– SLEEP. Why is it that we prioritize work, training, chores, and neglect rest? Your body requires rest, simple as that. Research has shown that less than 6.5 hours of sleep increases your risk of a BSI. You’re not “weak” for getting adequate sleep, but let me tell you– your bones will be.

How Can Runners Avoid a BSI?

Are bone stress injuries scaring you yet? If they are, let me ease your mind. All of those predisposing factors I was talking about are preventable! In addition to what we talked about above (training load, nutrition, RED-S, sleep, etc.), strength and multidirectional/plyometric training is key. 

Yes, YOU runners should incorporate strength and plyometric training into your routine. 

According to Wolff’s law, bone adapts to the load placed upon it. Bone responds to increased magnitude and rate of loading, high-impact loading, and multidirectional loading. These types of activities promote greater bone mineral density gains than repetitive or non-weight bearing sports (running, biking, swimming). A longitudinal study was performed on adolescent male cyclists and swimmers in which they underwent a countermovement jumping program. Following the jumping program, their bone mineral density improved.  

How can we apply strength and plyometric/multi-directional training effectively into YOUR regime? Here are three exercises you can implement NOW:

1. Depth Jumps
2. Lateral jumps with explosive single-leg hop
3. Rear-foot elevated split-squats with dumbbells
Drop Jump Plyos Exercise
Lateral Hops Plyos Exercise
SL Lunge Exercise
(3-5 sets of 3-5 reps)
(3-5 sets of 3-5 reps)
 (2-6 sets of <6 reps)

Game Plan Activated!

Adding some heavy strength exercises and multi-directional high intensity plyometrics could be the missing link in your training as well as reduce the risk of a BSI leading into your big race. 

Let ME help YOU here at Runners’ Edge optimize your abilities and perform to your absolute best! What are you waiting for?

Want to learn more? Schedule a FREE discovery session today! 

By: Morgan Lash, PT, DPT, CSCS

  • Physical Therapist
  • Certified Strength and Conditioning Specialist 
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