What is a bony stress injury?
A bony stress injury is an overuse injury which causes inflammation within a bone. This usually occurs when there is an increase in training load (including walking, running, marching, etc) with inadequate recovery following activity. These injuries often occur in endurance athletes, military personnel and field sport athletes. Bony stress injuries occur on a spectrum from bony stress reactions to stress fractures being the most severe. Majority of these injuries occur in the foot, shin, lower back and thigh/hip.Risk Factors for bony stress injuries:
The biggest risk factor for a bony stress injury is a spike in load, especially when combined with a previous history of a bony stress injury, poor dietary intake, changes in hormones (I.e. changes in menstrual cycle for females) and prolonged use of steroids. Bony Stress injuries are also closely linked with Relative Energy Deficits in Sport (RED-S). Other factors that can increase the load on your bones include training surfaces, footwear, training factors (such as duration, frequency and intensity) and inadequate muscle strength.Symptoms
The symptoms of bony stress injuries can vary depending on the severity of the injury. Generally, patients will suffer from a dull aching pain in the area which worsens with activities that load the affected bone. This pain does not “warm up” as you continue the activity. In more severe cases the pain will remain even after the activity is complete. The bone is often tender to the touch and as the condition progress you can also experiencing aching in the morning and when at rest.Diagnosis
Your physiotherapist will take a thorough history to assess for risk factors, possible increases in load and will rule out other conditions that may cause similar symptoms. This will then be followed by a thorough physical assessment where your physiotherapist will identify bio-mechanical factors that can be contributing to your symptoms (also known as “work ons” at Complete Balance) and formulate an individualised rehabilitation plan. If a bony stress injury is suspected your physiotherapist will often refer for further imaging.Management
At Complete Balance, your physiotherapist will guide you through your individualised rehabilitation to address your goals and return to sport/activity. Physiotherapy management includes:- Hands on treatment for pain relief
- Address work ons
- Prescription of an initial de-load period to allow for bone healing
- Progressive reload to allow for return to full function – this will include an exercise program (home or gym based) and a run/walk program if applicable to your goals
- Assist in the management of risk factors
- Discuss pain relieving strategies
- Assist with ongoing load management
Hoenig, T., Eissele, J., Strahl, A., Popp, K. L., Stürznickel, J., Ackerman, K. E., Hollander, K., Warden, S. J., Frosch, K.-H., Tenforde, A. S., & Amling, M. (2023). Return to sport following low-risk and high-risk bone stress injuries: a systematic review and meta-analysis. British Journal of Sports Medicine, 57(7), 427–432. https://doi.org/10.1136/bjsports-2022-106328
Warden, S. J., Davis, I. S., & Fredericson, M. (2014). Management and Prevention of Bone Stress Injuries in Long-Distance Runners. Journal of Orthopaedic & Sports Physical Therapy, 44(10), 749–765. https://doi.org/10.2519/jospt.2014.5334
