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Bone Stress Injuries Part 6 - Laces tied for the love of the sport


Part 1 - Clinical Diagnosis

Part 2 - Who is at Risk?

Part 3 - Classified!

Part 4 - Management of Low Risk BSI: The Road to Recovery

Part 5 - Return to Running (Pinning a tail on a Donkey)


#Physiotherapy #InjuryPrevention #Stress #Running

As the summer season in South Africa reaches its annual twilight, the running season is in full swing. A large contingent of runners has been waking up early to beautiful sunrises and getting the necessary mileage for the upcoming ultra-road running season. Unfortunately, certain portion of would-be enthusiasts remain on the side-lines through injury. High risk Bone Stress Injuries (BSIs) can often lead to prolonged periods of rehabilitation and load management. In this article on BSIs, we will discuss the management of high-risk BSI and conclude the series on stress injuries in runners.


High Risk BSIs

Whereas most BSIs can be managed conservatively and with little fan fair, there remains certain sites that are at risk of delayed diagnosis, prone to delayed union, and progression to complete fracture [1]. It is helpful for clinicians to be aware of these sites and maintain a high degree of vigilance when athletes complain of pain in these areas. Table 1 provides of list of these sites and their possible management approaches.

As demonstrated above, the management of these sites is more aggressive than low risk sites as the consequences of mismanagement are far-reaching for the athlete. There are four factors that would dictate the management approach with high risk BSIs and these include the site of the BSI, the presence of cortical defects on imaging, duration of symptoms and level of participation [1]. These factors should be discussed with the multidisciplinary team involved in athlete management as each member may need to contribute in creating a holistic care pathway.


As stated in the previous articles on the series, even members not traditionally associated with medical management of injuries (Strength and Conditioning coaches and coaching staff) have a role to play in the creation and implementation of appropriate strategies. I believe we create a greater sense of wellness for the athlete when they can see the light in what is for them often a difficult period. Allowing their coaches to be involved in the discussion allows them to understand that us as healthcare clinicians view their return to sport as important enough to be willing to include it from the start.


When compared to the management of low-risk sites, high risk BSIs require a greater degree of healing to minimise the probability of regression [1]. This means that imaging (when possible) becomes an important aspect of the recovery process. The presence of cortical bridging, the absence of symptoms when weight-bearing, and palpation are paramount before considering return to activity [1]. In the absence of imaging, the progressions discussed in Part 4 (here) are followed after a period of mandatory conservative management e.g. Non-weight-bearing for 6 weeks [1].


As athletes wait for the go-ahead to commence activity, clinicians should use that time to address any potential risk factors and develop creative ways of maintaining physical conditioning without impacting on the healing process [1]. Once an athlete can commence running the management principles follow those of low risk injuries – outlined in Part 5 (here) [1].


Closing Thoughts

We have reached the end of our series on Bone Stress Injuries. We have travelled far and wide to bring us to the point where we understand how they present and how to put our athletes back onto the path to recovery. All sports have inevitable highs and lows but the process and response in each moment allows us to develop both physically and mentally. Although this series is not going to put the brakes on the incidence of BSIs, I hope it can provide you with a blueprint to create an holistic management approach that keeps your athletes’ laces tied up and doing what they love – after all it’s the love of game that brought us full circle to a place where we can support others to do what they love.

  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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