• eurico marques

Bone Stress Injuries Part 4 - Management of Low Risk BSI: The Road to Recovery.

Updated: Mar 31

#Physiotherapy #InjuryPrevention #Stress #Running

As discussed in the previous articles on Bone Stress Injuries, the aetiology is often complex and multiple factors need to be considered when discussing the management of low risk BSI’s. It should be noted that high-risk BSI’s differ slightly, and will be unpacked in a separate article.

The management of low risk BSI’s can be divided into two phases. Phase one of BSI management is load modification[1]. The complexity and the opportunities presented to the clinician in phase one means that it should be approached with great intent. In the clinical setting, once an athlete is diagnosed with a BSI the discussion around rest and activity modification can often be interpreted as “we need to just rest and allow your symptoms to settle” but in fact it offers the opportunity to manage the modifiable risk factors and create an athlete that is not only injury free, but also in greater physical and mental condition when compared to their pre-injury level.

Load may be the total of distance/reps x duration[1]. The primary goal of phase one is the elimination of pain during or after activity[1]. The presence of pain indicates that the site is being overloaded for the phase of healing[1]. The road to recovery is littered with multiple entry points on which to place the athlete. Through the assessment it should become apparent where the athlete is able to begin their loading and which modifications should be implemented.

It is imperative during the management phase to stay vigilant for signs of ongoing inflammation at the BSI site. The presence of resting and/or night pain is indicative of an ongoing inflammatory response and should be managed accordingly[1]. The inflammatory response needs to be respected as it is likely still to be present during the initial period on the road to recovery. The use of Non-Steroidal Anti-Inflammatory Drugs (NASIDS) should be used with caution as they may impair bone healing – particularly in areas prone to non-union (high risk sites)[1]. If analgesics are required, the use of paracetamol is most likely a better option. However, remaining in one’s scope of practice is important, and prescription of any analgesics should be under the guidance of a professional qualified to administer them.

Once the athlete has been placed on the Road to Recovery, phase one offers the opportunity for the clinician to identify potential contributing risk factors and implement steps to address these. This is often a great time to implement changes as athletes are highly motivated to address any risk factors and have the time due to reduced participation and activity[1]. The role of the coach and S&C professional is vital during this period. The coach and S&C are the people that the athlete has spent a large amount of time with, trusts and are able to increase compliance through active participation in the recovery period. In my experience, my most valuable asset in the recovery process is the team/club/school S&C. Aside from their professional input into addressing the potential risk factors, the S&C’s relationship with the athlete often supersedes that of the physio. I bring in the S&C as soon as possible, including during the assessment mentioned in previous articles.

When addressing potential risk factors, the sum of all bone loading needs to be considered[1]. For the most part, athletes often participate in other physical activities in a social context and will often exclude this information when asked what physical activities they participate in. A practical tip I could offer up would be to go through their week – day-by-day – and break down their sporting participation. Once an overview has been achieved each activity can be broken down to determine to load.

It should be noted that the identification and management of potential risk factors (fig. 2) needs to be approached with caution as it may be the first time that these factors are addressed. The contribution of different issues should not be underplayed even in the presence of athlete apprehension. I would advise referral to an appropriate professional should you and the athlete feel uncomfortable addressing any of these issues.

With regards to the physical assessment, running gait analysis is most likely not possible and thus a bit of detective work may be required. If possible, video analysis may provide insights into changing patterns over time[1]. In the environment I work in most a-level games/events are recorded and this allow us hindsight when reviewing athlete’s movement patterns. If this is not possible there are other components of load that can be reviewed. These include:

  1. Shoe wear patterns[1]

  2. Athletes subjective report of where loading takes place during the gait cycle

  3. Pain avoidance techniques used by the athlete before seeking assistance e.g. “I used to run on the outside of my foot to avoid any pain.

  4. Strength deficit assessments in pain free positions. As the athlete progresses on the Road to Recovery more strenuous tests can be included[1]

It is most likely that your assessment of contributing risk factors will take place over several weeks. Each session will add another piece of the puzzle as you begin to build a complete and holistic picture of the athlete, their risk factors and potential management options.

As the process of investigation continues, the maintenance of athlete physical conditioning (often this is linked with mental well-being as well) is paramount. However, it should be stressed that the importance of this needs to be weighed against the age, level of participation, long term health risks and socio-economic costs associated with placing an athlete on a modified exercise program. Clinically, each case needs to be taken on merit, but if I were to offer some general guidelines they would be:

  1. Young and high-risk athletes are to be managed with extra-care, as in my experience BSI’s in this population tend to be multifactorial and not simply load based. Often the management of the contributing risk factors supersedes the physical conditioning maintenance.

  2. The use of devices to aid physical loading modification (buoyancy devices and Alter-G treadmills discussed later) should be weighed up against their financial cost/reward relationship and not be included just to “make the client happy.” All interventions need to have relevance and clinical reasoning.

  3. All athletes – regardless of participation level – should be offered the same level of care as higher level athletes, but it should not be assumed that they desire the same level of care. Speaking to an athlete with regards to their motivations and personal preferences can sometimes reveal a different perspective than that of the professional.

Finally, the acceleration of tissue-level healing using therapeutic adjuncts (ultrasound, laser, needling etc.) requires further high-level research before they can be definitively identified as treatment options for athletes with BSI[1]. In the meantime, I would suggest using interventions that promote athlete empowerment and self-awareness (education) and respect tissue healing times (activity modification).

As we continue on the Road to Recovery, we will discuss phase two of managing low-risk BSI’s and setting up a return to running program. We will also discuss the management of high-risk BSI’s. Thank-you for hanging around in this series and I look forward to Part 5. Until then, happy running.

  1. Management and Prevention of Bone Stress Injuries in Long-Distance Runners. Warden, S J, Davis, I S and Fredericson, M. 2014, Journal of Orthopaedic & Sports Physical Therapy, pp. 749-765.


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