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No one wants to be the one to tell a runner they may have a bone stress injury (BSI), and even moreso, no runner ever wants to hear they might have a BSI.

Unfortunately, BSIs are pretty common among runners and they’re incredibly important not to miss. As written in an article by Warden, Davis & Fredericson in 2014: “...bone as the tissue of origin of a runner’s symptoms needs to be considered at all times during differential diagnosis to ensure prompt diagnosis and management.”

Let's chat about when you should suspect bone stress injury and, if you’re a clinician, refer a runner for imaging - and if you’re a runner, when to advocate for imaging for yourself. For the clinicians, let’s also talk about how to present this information without scaring the sh*t out of someone.

Typically patients will seek help due to pain, patients will be seeking help due to pain, though in the early stages they may report tightness or stiffness. Pain descriptions from a bone stress injury can vary widely, from sharp local pain to a diffuse ache. Typically, pain does not warm up with activity and worsens with continued activity over time. Oftentimes pain will be reproduced with bone-loading activities like running or hopping; however, this is not always the case particularly early on. BSIs in some areas, such as the femoral neck or pelvis, may present with variable pain patterns and inconsistent responses to loading.

Since pain descriptions and behavior can vary widely with BSIs, it's especially important to gather information about training progression, injury history and current risk factors to rule BSI up or down. 

First, does this athlete have a history of BSI? If yes, their risk for another increases significantly. Next, what does their training load and history look like? Changes in activity in the past 3-8 weeks should be noted and increase your index of suspicion, as BSI symptoms typically begin a few weeks after that change occurs. This change could be in total volume, intensity, frequency, terrain, stress, etc.

Other important risk factors for BSIs relate to relative energy deficiency in sport, or RED-S. Athletes in an energy deficit are at increased risk for BSI. If an athlete has a history of eating disorder, currently has or is choosing dietary restrictions, and/or is trying to lose weight, their risk of being in a state of energy deficiency is higher.


An athlete's hormonal status may also give clues to current energy availability and BSI risk - asking about menstrual status is important as amenorrhea (loss of 3 menstrual cycles consecutively) increases stress fracture risk. Keep in mind that birth control may muddy the waters a bit and make it more difficult to notice an effect of RED-S on the endocrine system. It's also possible for an athlete to have regular cycles while being in an energy deficit. In males, low testosterone related to RED-S increases stress fracture risk so asking about morning erections or changes in sex drive is important for BSI suspicion and diagnosis.

If you can't prove to yourself it's not bone, or if you're a runner seeking help and your clinician is unsure if bone is involved and risk factors are present, imaging is warranted. Having a good orthopedic or sports med doc in your contacts is so helpful here - communicate with them to let them know what you suspect and that you want to clear this out and it may help facilitate a faster diagnosis.

Healthcare providers, when communicating your concern to a patient, stay calm and reassuring. This is a very hard convo to have, but keep in mind it's even harder to hear. Let the athlete know that from what they've told you and how their symptoms present, there is a possibility of bone stress injury and you recommend imaging to either confirm or rule it out. Either way, the image will guide confident treatment - best case, the image is clear and we can move forward with more aggressive rehab and feel safe getting you back to running more quickly. In the other case, we know exactly what's going on and we can start a proper bone stress injury rehab program. 

Wooof. BSIs are tough. But we have a lot of room for improvement in more quickly diagnosing and managing these. Reach out if you have questions regarding stress fracture rehab or you're looking for a PT or coach to help with this injury!

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