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Bone stress injuries (BSI) are typically overuse injuries associated with repetitive loading of bone by vigorous weight-bearing activity (such as running/ jogging/ marching) and inadequate recovery.

In the final instalment on an introduction to bone stress injuries Dr Rick Seah, Consultant in Sport & Exercise Medicine looks at the management options for bone stress injuries.

General principles

This is a complex area as specific management is often dependent on various factors. These include the area of the body in which it occurs (e.g. upper limb versuslower limb); the risk of developing complications such as non-union and the individualcharacteristics of the patient and the sport/ physical activity they typically engage in.

General principles are discussed, with the proviso that some BSI cases areparticularly complex and require more detailed input.

Offload or consider stopping the precipitating activity, especially high-impact exercise in lower limb BSI.

Consider cross training while a stress fracture heals (Examples include swimming, cycling, pool-running). This will allow a patient to maintain some degree of fitness although ‘match fitness’ in high-level athletes will inevitably suffer.

A pneumatic brace or cam walker (e.g. Aircast boot or similar) may be required for lower limb stress fractures. Consider the use of crutches and immobilisation in a cast for severe stress fractures or those at high risk of non-union.

Physiotherapy input and a graduated strengthening programme is frequently indicated. Consider and address other aspects such as flexibility, proprioception and stability which may also be affected.

Address hydration and dietary needs. This can be a complex area, particularly in patients who have a history of poor nutrition or chronic inadequate calorific intake. The involvement of a dietician or nutritionist can be very useful.

Blood tests will reveal patients who are deficient in calcium and/or vitamin D. Consider calcium and vitamin D supplementation for these patients, particularly if there is a likelihood of poor underlying bone health.

Blood tests may also reveal systemic causes associated with poor bone health- e.g. thyroid disease and various other inflammatory conditions such as rheumatoid arthritis.

There may be a role for bone density scanning (also known as a DEXA scan or bone densitometry) in patients who are suspected of having osteopaenia. Enquire about age, past medical history, family history of osteoporosis and smoking status.

The Fracture Risk Assessment Tool (FRAX) can be used to assess if a DEXA scan is appropriate and also calculates a patient’s probability of fracture in the next decade.

Hormonal treatment (in the form of the oral contraceptive pill or hormone replacement therapy) may be appropriate for female patients with BSI who are identified as having severe menstrual dysfunction and risks factors for developing osteoporosis. Such cases are rarely straightforward and it is helpful to discuss such cases with rheumatology/ endocrinology/ gynaecology colleagues who have a particular interest in metabolic bone disease.


In most cases, there is significant resolution by 8 weeks if the BSI is straightforward. This is debatable- figures quoted in studies vary from 4-16 weeks, sometimes longer.

Repeat imaging may be indicated to ensure bone healing, particularly if there is a risk of displacement or non-union.

Unless the precipitating causes are identified and addressed, BSI may recur.Encourage a graded return to previous level of sport or physical activity.

Address any modifiable risk factors and highlight to all patients the importance of building in recovery periods.


  • Arendt EA, Griffiths HJ. The use of MR imaging in the assessment and clinical management of stress reactions of bone in high-performance athletes. Clinics in sports medicine. 1997 Apr 1;16(2):291-306.
  • Behrens SB, Deren ME, Matson A, Fadale PD, Monchik KO. Stress fractures of the pelvis and legs in athletes: a review. Sports Health. 2013 Mar;5(2):165-74.
  •  Brukner P. Brukner & Khan's clinical sports medicine. North Ryde: McGraw-Hill; 2012.
  •  Clough TM. Femoral neck stress fracture: the importance of clinical suspicion and early review. British journal of sports medicine. 2002 Aug 1;36(4):308-9.
  •  Hardy R, Cooper MS. Bone loss in inflammatory disorders. Journal of Endocrinology. 2009 Jun 1;201(3):309-20.
  •  Moreira CA, Bilezikian JP. Stress fractures: concepts and therapeutics. The Journal of Clinical Endocrinology & Metabolism. 2016 Oct 12:jc-2016.
  •  Mountjoy, Margo, et al. "Authors’ 2015 additions to the IOC consensus statement: Relative Energy Deficiency in Sport (RED-S)." (2015): 417-420.
  •  Pegrum J, Crisp T, Padhiar N. Diagnosis and management of bone stress injuries of the lower limb in athletes. BMJ. 2012 Apr 24;344(7854):e2511.
  •  Pepper M, Akuthota V, McCarty EC. The pathophysiology of stress fractures. Clinics in sports medicine. 2006 Jan 31;25(1):1-6.
  •  Schandelmaier S, Kaushal A, Lytvyn L, Heels-Ansdell D, Siemieniuk RA, Agoritsas T, Guyatt GH, Vandvik PO, Couban R, Mollon B, Busse JW. Low intensity pulsed ultrasound for bone healing: systematic review of randomized controlled trials. bmj. 2017 Feb 22;356:j656.
  •  Taunton JE, Ryan MB, Clement DB, McKenzie DC, Lloyd-Smith DR, Zumbo BD. A retrospective case-control analysis of 2002 running injuries. British journal of sports medicine. 2002 Apr 1;36(2):95-101.