• eurico marques

Bone Stress Injuries Part 1 - Clinical Diagnosis

Updated: Mar 31

#Physiotherapy #InjuryPrevention #Stress #Running

As the road running world gears up for the racing season, athletes spill onto the roads in the early morning. The excitement of a new season and the sudden increase in mileage brings with it the risk of Bone Stress Injuries (BSI), particularly in long-distance runners. BSI continues to pose a unique challenge in their diagnosis, management and prevention due to their multifactorial nature and presentation on a continuum rather than an easily distinguishable and isolated injury.


The prevalence of BSI has been shown to be between 4.9% and 21.1% in competitive cross-country and track-and-field athletes. The re-occurrence rate is of concern with 50% of these athletes reporting history of BSI on more than one occasion and 10.3% to 12.6% showing a reoccurrence with 1 to 2 years of follow-up. Half of the reported BSIs in long-distance runners occur in the tibial diaphysis with the tarsals, metatarsals, femur, fibula and calcaneus also at risk of injury[1–3].

Clinical Diagnosis

Being on the front line of the sporting world often places Strength & Conditioning coaches or Sports Scientists in the role of first responder. They are often the first member of the technical team to hear of the aches and pains that the athletes report. They need to be able to discern between the “give it a couple of days” to “Oh, you should probably get that checked out.” As BSIs present on a continuum and have similarities with overuse injuries, their early identification is a challenge even for the most experienced professional[5]. The more the clinician or coach knows of the athlete’s training history the better they can associate them with the subjective complaints and possibly identify the stress reaction.

Subjective assessment

With most athletes only reporting difficulties once their pain begins to affect their participation, we are more likely to be dealing with athletes down the continuum, heading towards a stress fracture. The subjective history is key in establishing the risk profile of an athlete in terms of BSIs[5]. I have listed the key pieces of the subjective puzzle that should raise the level of suspicion for the clinician:

  1. Consistent and predictable history that centres around their pain

  2. Starts with mild, diffuse ache that occurs in relation to an amount of running and is associated with a specific aspect of the running gait cycle.

  3. Pain does not tend to improve with a mild warm-up and only ceases when running is stopped.

  4. Increased pain and localization as training continues.

  5. Pain may start earlier in training and persist for longer after running is stopped. As the pathology progresses it can begin to be present during activities of daily living such as walking.

  6. Eventually, the pain may lead to the athlete needing to stop training altogether and may present with night and resting pain due to the inflammatory nature of the pathology[5].

Objective Assessment

The most obvious sign of a BSI is localised bony tenderness on palpation. As the injury progresses on the continuum, so the site of pain tends to focus, with athletes pointing to the exact area of maximal tenderness when stress fractures have developed. Certain areas have clear anatomical boundaries and thus can be assessed through palpation. Tenderness appears to be very localised with adjacent structures often pain free. There may be redness, swelling and warmth on more progressed injuries as the inflammatory response is heightened. Callus formation may be palpated on long standing BSIs[5].

Palpation doesn’t offer much for deeper anatomical sites with bone loading tests the preferred method of examination in such instances. Any bone loading test should be seen as only part of the puzzle as their sensitivity and specificity continues to be a topic of disagreement amongst clinicians and researchers[5]. Some tests that can be included for the deeper areas include hopping, the fulcrum test for the femoral shaft, or the one-legged hyperextension for the pars interarticularis[5].


In order to confirm BSIs athletes should undergo imaging when there is a high level of suspicion. MRI continues to be the gold standard due to its lack of exposure to radiation, high contrast resolution and high sensitivity and specificity[6,7]. Plain radiographs continue to be the first option in most settings due to their low cost and wide availability. However, radiographs have limitations as they are planar in nature and have low spatial resolution. This means that their sensitivity is compromised, and this shouldn’t be used in isolation. Computed tomography (CT) may be used in the cases where the fracture localization will affect treatment but it should be noted that they also lack sensitivity[6,7].

Closing thoughts

Early diagnosis and management are important to ensuring prompt and favourable outcomes for the athlete. A great deal of information can be gathered by a thorough subjective and simple objective assessment. Once a BSI is suspected there should be appropriate referral to a physiotherapist to confirm any suspicions and then, if needed, onto a sports physician in order to ensure that the athlete is given the best opportunity to return to sport without long term sequelae.

  1. Tenforde, A. S., Fredericson, M., Sayres, L. C., Cutti, P. & Sainani, K. L. Identifying Sex-Specific Risk Factors for Low Bone Mineral Density in Adolescent Runners. Am. J. Sports Med. 43, 1494–1504 (2015).

  2. Brukner, P., Bradshaw, C., Kahn, K., White, S. & Crossley, K. Stress Fractures: A Review of 180 Cases. Clin. J. Sport Med. 6, 85–89 (1996).

  3. Bennell, K. et al. Risk Factors for Stress Fractures in Female Track-and-Field Athletes: A Retrospective Analysis. Clin. J. Sport Med. 5, 229–35 (1995).

  4. Stress Fractures: what are they and how to prevent them. Available at: http://www.physioworks.co.il/stress-fractures-what-they-are-and-how-to-prevent-them/. (Accessed: 5th February 2019)

  5. Warden, S. J., Davis, I. S. & Fredericson, M. Management and Prevention of Bone Stress Injuries in Long-Distance Runners. J. Orthop. Sport. Phys. Ther. 44, 749–765 (2014).

  6. Gaeta, M. et al. CT and MR Imaging Findings in Athletes with Early Tibial Stress Injuries: Comparison with Bone Scintigraphy Findings and Emphasis on Cortical Abnormalities. Radiology 235, 553–561 (2005).

  7. Kiuru, M. J., Pihlajamaki, H. K., Hietanen, H. J. & Ahovuo, J. A. MR imaging, bone scintigraphy, and radiography in bone stress injuries of the pelvis and the lower extremity. Acta radiol. 43, 207–212 (2002).

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