Bone Stress Injuries in
Adam S. Tenforde, MD
, Emily Kraus, MD
, Michael Fredericson, MD
Bone stress injuries (BSIs) in runners result from the failure of skeleton to withstand re-
petitive, submaximal forces from running. BSI can range in severity, with early injuries
showing radiographic findings of periosteal edema with varying degrees of marrow
edema and more advanced stress fractures showing evidence of a fracture line. Stress
fractures account for up to 20% of injuries seen in sports medicine clinic.
Studies suggest the annual incidence of BSI may be greater than 20% in runners
and that BSI is a common cause of injury in track and field athletes.
tion of a BSI is important in management, because delay in diagnosis or continued
running may result in a higher-grade BSI that requires longer healing time.
article discusses the incidence and distribution of BSI in runners. It reviews biological
and biomechanical risk factors for BSI, with a focus on risk factors that can be
Conflicts of interest: The authors have no conflicts of interest to disclose, and no funding was
received in the preparation of this review.
Department of Physical Medicine and Rehabilitation, Harvard Medical School, Spaulding
Rehabilitation Hospital, Spaulding National Running Center, 1575 Cambridge St., Cambridge,
MA 02138, USA;
Division of Physical Medicine and Rehabilitation, Department of Orthopae-
dic Surgery, Stanford University, 450 Broadway Street, MC 6120, Redwood City, CA 94063, USA;
Division of Physical Medicine and Rehabilitation, Department of Orthopaedic Surgery, Stan-
ford University, 450 Broadway Street, Pavilion A, 2nd Floor MC 6120, Redwood City, CA
* Corresponding author.
E-mail address: email@example.com
Stress fractures Runners Female athlete triad Track and field Cross-country
Bone stress injuries (BSIs) are a common form of injury in runners of both sexes.
Both biological and biomechanical risk factors may contribute to BSI.
History and physical examination are helpful to diagnose BSI, and MRI may be useful for
radiographic confirmation and grading BSI.
Prevention strategies include screening for risk factors during preparticipation evaluation,
promoting optimal nutrition, and encouraging appropriate bone loading activities,
including ball sports.
Phys Med Rehabil Clin N Am 27 (2016) 139–149
1047-9651/16/$ – see front matter Ó2016 Elsevier Inc. All rights reserved.
efficiently evaluated in the clinic setting. It discusses evaluation and management of
BSI by anatomic location and grade of injury by MRI. In addition, it reviews evidence
for prevention of BSI in runners.
Incidence and Distribution
The incidence of BSI varies by age and sex. In a study comparing high school sports,
female and male athletes participating in cross-country had the first and third highest
incidences of injuries at 10.62 and 5.42 per 100,000 athletic exposures, respectively.
In a separate investigation, adolescent runners of both sexes sustained stress frac-
tures at a similar rate of approximately 4% to 5% annually.
Elite collegiate runners
may sustain BSIs at a rate exceeding 20% per year.
Common sites for BSI include
the tibia, fibula, metatarsals, tarsals, calcaneus, and femur.
Risk factors for BSI can be divided into biological and biomechanical risk factors
(Table 1). Genetics are reported to modulate fracture risk.
Medications, including ste-
roids, anticonvulsants, antidepressants, and antacids, may impair bone health. Nutri-
tional deficiencies in calcium and vitamin D increase risk for BSI.
seem to be at greater risk for BSI than male athletes.
include the female athlete triad (hereafter referred to as the triad), defined as the inter-
relationship of energy availability, menstrual function, and bone mineral density
Each aspect occurs on a continuum of health with the most severe form of
the triad represented by low energy availability with an eating disorder, functional hy-
pothalamic amenorrhea, and osteoporosis.
A female runner may have 1 or more
components of the triad, and greater number of triad risk factors has been associated
with increased risk for BSI in female athletes.
In both sexes, prior fracture has been found to be a risk factor for development of
BSI in runners.
Lower whole body bone mineral content values increase risk for
BSI in female runners aged 18 to 26 years.
In adolescent female runners, the combi-
nation of menstrual irregularities with fracture history was associated with low bone
The largest study to date in male runners identified lower BMD as an inde-
pendent risk factor for increased time for healing from a BSI.
In addition, athletes with
Risk factors for BSI
Biological Factors Biomechanical Factors
Female sex Training patterns, including volume or
changes in intensity
Genetics Bone characteristics (thinner cortex, lower
bone mineral density)
Medications (including anticonvulsants, steroids,
Anatomic considerations (leg length
discrepancy, lean mass, foot type, smaller
calf cross-sectional area)
Female athlete triad (low energy availability,
menstrual dysfunction, and low bone mineral
Other dietary contributors (insufficient calcium
and vitamin D)
Tenforde et al
trabecular sites of fracture, including the sacrum, pelvis, and femoral neck, had lower
BMDs in the lumbar spine and proximal femur than runners with fractures in cortical
sites. In addition to bone density, bone geometric properties may predispose to
BSIs, including a thinner cortex of tibia in triathletes
and smaller tibial cross-
sectional area in runners.
Biomechanical factors can also contribute to BSI. Static alignment and anatomic is-
sues may contribute, including leg length discrepancy,
smaller calf girth,
or planus type foot.
Dynamic biomechanical loading patterns experi-
enced during running may also contribute to injury. These characteristics have been
evaluated primarily in female patients who sustain BSI in the tibia and include greater
average vertical loading,
higher peak acceleration,
and greater peak free
Higher peak hip adduction, knee internal rotation, knee abduction, tibial inter-
nal rotation, and rear foot eversion may also contribute.
Running volumes greater
than 32 km (20 miles) per week increase risk for BSI.
Clinicians should complete a full history and physical examination in runners who pre-
sent for evaluation of a BSI. A complete running history should be obtained (including
changes in running volume, shoe type and duration of use, frequency of racing, and
change in foot strike pattern strategy). In female runners, screening for triad risk fac-
tors is important, including dietary restriction behaviors, daily servings of foods rich in
calcium and vitamin D, menstrual dysfunction, history of fractures, and personal/fam-
ily history of low BMD.
Medications including hormones (oral contraceptive pills, es-
trogen, progesterone) and historical or current use of medications that influence bone
health, including steroids and antacids, should be recorded.
During physical examination, the characteristics of a BSI include focal bony tender-
ness and pain with direct and/or indirect percussion. Single-leg hop test may be
attempted to elicit pain depending on the clinical context. In more advanced cases,
local swelling or skin color changes may be noted.
Specific forms of BSI may require additional aspects of the physical examination. In
our clinical experience, and based on available research, we recommend clinicians
consider the following for specific examination findings based on location of pain.
In addition to focal tenderness, sacroiliac joint provocative maneuvers may elicit pain,
including thigh thrust; pelvic distraction; pelvic compression; and flexion, abduction,
and external rotation of hip (FABER maneuver). Evaluation for a leg length discrepancy
may be valuable to correct for biomechanical risk factors contributing to injury.
Pain may be provoked with hip internal rotation. In addition, evaluate for the presence of
femoral acetabular impingement with flexion adduction and internal rotation (FADIR
maneuver) because this has been associated with femoral neck BSI.
The clinical evaluation is similar to evaluation for a femoral neck BSI. This injury is
typically associated with iliopsoas tendinopathy and is a potentially high-risk injury
because it can progress to full fracture.
Fulcrum test may localize pain at the site of injury.
Bone Stress Injuries in Runners 141
Calcaneal squeeze test may elicit pain and help differentiate from other causes of heel
pain, including retrocalcaneal bursitis.
ANATOMY AND IMAGING
The anatomic locations for BSI can be divided into high-risk, moderate-risk, and low-
risk locations based on time to heal and risk for nonunion (Table 2). Table 2 is based
on a modified version of previously published high-risk
and low-risk classifica-
including a moderate-risk category that may be more challenging to address
given biological and biomechanical forces that can contribute to risk for impaired bone
MRI is commonly used to evaluate BSI because of the value in grading severity of
injury and use of nonionizing radiation. Multiple grading systems have been devel-
Two MRI imaging grades are shown in Table 3, including the initial pro-
posed criteria by Fredericson and colleagues
that have been most recently
updated by Nattiv and colleagues.
Activity Modification and Aerobic Activity
After the initial healing phase to achieve pain-free ambulation and no pain with provoc-
ative maneuvers on physical examination, most athletes initiate a nonimpact loading
activity to maintain fitness and strength, including deep water running. Athletes should
be counseled to maintain good caloric intake to meet the metabolic demands of
cross-training and not inadvertently restrict caloric intake, which may risk delayed
healing response. Use of an antigravity treadmill may allow for progressive impact
loading to maintain fitness while allowing healing of lower extremity BSIs.
lined a protocol used at Stanford University for athletes recovering from BSIs using
an antigravity treadmill that can modulate forces encountered in the lower extremities
to allow for progressive weight bearing.
Ensure Adequate Intake of Calcium and Vitamin D
All athletes with BSIs should be assessed to ensure adequate calcium and vitamin D
intake, preferably through diet. Target values published by the Institute of Medicine
based on age and sex in 2010 are as follows
600 IU of vitamin D daily is recommended for ages 9 to 70 years
800 IU of vitamin D daily is recommended for ages 71 years or older
1300 mg of calcium daily for ages 9 to 18 years
Anatomical location and risk of BSI
Medium Risk High Risk
Diaphysis of second to fourth
Pelvis (sacrum and pubic rami)*
Anterior tibial diaphysis
Talus (lateral process)
* The pelvis is a controversial anatomical location for determining risk for bone stress injury, but
recent research by Nattiv and colleagues
showed that time to full return to play is longer in trabec-
Tenforde et al
1000 mg of calcium daily for women aged 19 to 50 years and men aged 19 to 70
1200 mg of calcium daily for women aged 51 years and older and for men 71 years
Clinicians who suspect low energy availability should refer the runner for a complete
nutritional assessment with a registered dietitian. This assessment is best accom-
plished with a dietician who has sports nutrition background and takes into account
sports participation demands, caloric intake, and energy availability, in addition to other
important nutrients of bone health. Given the prevalence of vitamin D deficiency, we
recommend screening athletes who sustain a BSI by measuring 25-OH vitamin D level
and providing supplemental vitamin D if needed to ensure that the runner is not vitamin D
deficient. Further studies are needed to assess the relationship with BSIs and vitamin D.
Female Runners: Screening and Management of the Triad
In female runners, screening for the triad is critical for addressing risk factors for BSI
and identifying health risks in this population. The Female Athlete Triad Coalition state-
ment in 2014 outlined a risk factor assessment score that can be used to help in treat-
ment and return-to-play guidelines in female athletes.
The key component to
management of the triad is to ensure adequate energy availability, allow for ovulatory
menstrual cycles, and maintain bone mass.
In addition to preventing disruptions to
training from management of BSIs, female athletes may be motivated by research that
suggests that performance improves in athletes who maintain ovulatory function with
A full description of the evaluation and management of the fe-
male athlete triad is described elsewhere.
One important consideration is to ensure
that female runners understand that adequate energy availability (defined as the differ-
ence between energy intake and estimated energy expenditure standardized to fat-
free mass per day
) should be maintained both during the healing process and on
return to full running. Inadvertent low energy availability may occur if a female runner
does not consume adequate calories to meet the metabolic demands of aerobic
Evaluation of Bone Health in Male Runners
For male runners with diagnosed BSIs in trabecular sites, including the pelvis, sacrum,
and femoral neck, practitioners should consider work-up for impaired bone health,
including dual-energy X-ray absorptiometry (DXA) to measure BMD and initial endocrine
work-up. Athletes with higher-grade BSI assessed by MRI and lower BMD values may
MRI grading systems
MRI Grading Scales for BSIs
Nattiv et al,
2013 Fredericson et al,
1 Mild marrow or periosteal edema on T2;
Mild to moderate periosteal edema on
T2; normal marrow on T2 and T1
2 Moderate marrow or periosteal edema
plus positive T2
Moderate to severe periosteal edema on
T2; marrow edema on T2 but not T1
3 Severe marrow or periosteal edema on
T2 and T1
Moderate to severe periosteal edema on
T2; marrow edema on T2 and T1
4 Severe marrow or periosteal edema on
T2 and T1 plus fracture line on T2 or T1
Moderate to severe periosteal edema on
T2; marrow edema on T2 and T1;
fracture line present
Bone Stress Injuries in Runners 143
have a longer healing time before return to sports.
BMD values from DXA in athletes less
than 50 years of age should be interpreted using age, ethnicity, and male-sex reference
values (Z-scores). The AmericanCollege of Sports Medicine definesZ-score less than 1
as low bone mass in female athletes participating in weight-bearing sports,
criteria have not been defined for male athletes. The International Society for Clinical
Densitometry defines Z-scores less than 2 as low bone mass for age in both sexes.
RECOMMENDATIONS BY ANATOMIC SITE
Some of the most common locations for injury and management recommendations
are discussed here.
Femoral Neck and Lesser Trochanter
Femoral neck BSI are considered high risk because of complications that may occur
with nonunion, particularly on the tension side of the bone. Tension-side fractures
may be managed with bed rest, as long as widening of the cortical fracture is not
observed on serial imaging.
Fractures adjacent to the lesser trochanter may also
progress to femoral neck stress fractures if non–weight-bearing precautions are not
followed during initial management.
For compression side fractures and lesser
trochanteric fractures, we recommend use of crutches to maintain non–weight-
bearing status, with clinical evaluation and repeat imaging to ensure bony healing.
Runners can be advanced to cross-training exercises when pain free on examination
and cortical bridging on radiographs. Consultation with an orthopedic surgeon should
be sought early for tension-side injuries or failure to achieve interval bony healing on
repeat radiographs. Complete healing is typically expected by 2 to 3 months.
Anterior Tibial Cortex
Radiographs may include presence of the so-called dreaded black line, visualized as
horizontal radiolucency localized to the tension side of the tibia. Clinicians should
obtain repeat radiographs to ensure bony bridging and healing before progressing
to weight-bearing status. Nonsurgical outcomes in management have been described
; in the setting of nonunion, an intramedullary rod may be necessary.
Fractures involving the medial malleolus are important to identify given that this struc-
ture contributes to the ankle mortise. A published case series of athletes managed sur-
gically who had radiographic evidence of fracture line had good outcomes
we recommend an initial trial of immobilization unless there was significant displace-
ment of the fracture or involvement of the talocrural joint.
Base of Second Metatarsal
Fractures at the base of the second metatarsal are considered high risk, especially if
the fracture extends to the Lisfranc joint (metatarsal-cuneiform joint). A minimum of
4 weeks’ immobilization is recommended
and repeat radiographs and clinical
examination are advised to ensure that the runner is pain free before advancing weight
bearing. Morton toe (defined as second toe extending past the great toe) may be
observed on examination and be an associated biomechanical risk factor for this injury
because of increased force transmitted through the second ray of the foot. Custom
foot orthosis with metatarsal pad beneath the second metatarsal may address these
biomechanical forces to reduce risk for future injury.
Tenforde et al
Fifth Metatarsal Diaphysis Fractures
Also known as Jones fracture, this injury is considered high risk because of relative
avascularity of the bone distal to the tuberosity, which may result in nonunion.
review of nonoperative versus surgical management described current quality of evi-
dence as low, although the investigators concluded that better results were observed
Use of a CAM walker boot may offload this site most effectively to pro-
mote initial healing.
Surgical management, including intramedullary screw fixation
and bone grafting, has been shown to result in predictable healing and return to
play by as early as 12 weeks.
Examination findings may include presence of tenderness over the navicular tuberosity or
navicular-cuneiform joint. Maintaining strictnon–weight-bearing status initially to promote
healingmay result in the best clinical outcome.
Computed tomography may be a helpful
imaging modality when assessing for healing response in the setting of a chronic injury.
Saxena and colleagues
proposed a grading system for navicular BSI, and higher-
grade injuries treated with surgery may have more favorable outcomes, especially if there
is radiographic evidence of avascular necrosis, cystic changes, or sclerosis.
The sesamoids consist of a fibular and tibial sesamoid bone. Because of the loading
demands, BSI at this location may have delayed healing response. Use of cushioned
orthosis with accommodative insole to offload the sesamoid is helpful to reduce
biomechanical stress and promote healing. Note that bipartite sesamoid with sesa-
moiditis may radiographically appear as a split sesamoid. Plain radiographs of the
contralateral asymptomatic foot can sometimes show this normal anatomic variant.
Sacrum and Pelvis
Most injuries in the sacrum have radiographic evidence of high-grade BSI. Crutches
and other assistive devices to ensure pain-free mobility are important early in the clin-
ical course and can be discontinued with pain-free ambulation. Runners usually return
to full running activity around 12 weeks.
Tarsals Cuboid and Cuneiform
Given their location, both cuboid and cuneiform BSIs can be difficult to heal given the
biomechanical forces and loads encountered through the foot. Management includes
immobilization if needed to ensure pain-free ambulation, followed by progression to a
neutral shoe and physical therapy to address strength and other biomechanical defi-
cits that may have contributed to injury.
Injuries without evidence of displacement or cortical break tend to heal and allow
return to running within 8 to 12 weeks.
Injuries are typically located at the distal third posterior medial aspect of the tibia. Clin-
ical features suggestive of more severe injuries include focal pain, tenderness elicited
Bone Stress Injuries in Runners 145
with direct or indirect palpation, and associated MRI grading criteria can predict length
of recovery ranging from 3 to 12 weeks.
Easy to examine given the surface bony anatomy, these injuries tend to heal quickly
and allow prompt return to running when asymptomatic.
Heel pain in an athlete may be a clue to the presence of an injury involving the calca-
neus. The calcaneal squeeze test is helpful for eliciting bony pain. Given that the bone
has significant trabecular content, screening for female athlete triad risk factors is
particularly important. We recommend initial use of a walking boot and possibly use
of crutches to ensure pain-free mobility.
With exception of the base of the second metatarsal and fractures involving the meta-
physis of the fifth metatarsal, fractures involving the shaft of metatarsals 2 to 4 are
considered low risk and have good healing response. In lower grade BSI (injury
without presence of fracture line), use of a metatarsal pad and firm-sole shoe may
allow the athlete to ambulate without pain.
With the presence of a fracture line, repeat
radiographs at 4 weeks are recommended to document evidence of bony bridging
and cortical hypertrophy over the fracture site, along with a pain-free examination
before advancing to cross-training and starting a return-to-running progression.
Most injuries heal within 6 to 8 weeks to allow return to ground running.
Participation in Ball Sports During Adolescence
We have proposed prehabilitation strategies, including ball sports (basketball
and soccer) and related activities, during adolescence for 2 years to reduce BSI
These findings are based on prior research showing that military recruits and
runners who participated in ball sports during youth have reduced risk for stress
Adequate Calcium and Vitamin D Intake
Calcium and vitamin D intake may reduce risk for BSI. We recommend meeting daily
calcium and vitamin D intake levels published by the Institute of Medicine to optimize
The role of calcium and vitamin D in fracture prevention has previously
been described. Nieves and colleagues
showed that female runners consuming
800 mg of calcium daily have 6-fold increased risk for stress fractures compared
with those with intakes of 1500 mg daily. In this investigation, each cup of milk reduced
prospective fractures by 62%, highlighting other aspects of nutrition as contributing to
Lappe and colleagues
found a 20% reduction in female navy re-
cruits who were randomly assigned to supplemental calcium 2000 mg and vitamin
D 800 IU daily during 8-week basic training.
Preparticipation Physical Examination Screening
During preparticipation screening, all athletes should be asked about prior fracture
history and screened for triad risk factors. Female runners should be educated on
the importance of normal menstrual periods during training. Work-up for menstrual
dysfunction should be considered early to address this important aspect of female
Tenforde et al
BSI is a common form of overuse injury in runners of both sexes. Clinicians should
consider these injuries on the differential diagnosis for musculoskeletal complaints
in runners. Early and effective management of the injury can help facilitate return to
sport, and addressing underlying risk factors may prevent future injury. Early
screening for triad risk factors, optimizing nutrition, and encouraging participation in
higher-impact activities, including ball sports during adolescence, may reduce the
burden of these injuries in runners and promote overall bone health.
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