How to return to running after a bone stress injury
Have you ever dealt with a bone stress injury and experienced difficulty with getting back to running? Have you ever experienced a second stress fracture en route to getting back to training? Getting back into the thick of running can be the most challenging and frustrating part of these injuries for runners. Below are some tips to follow if you’re dealing with a bone stress injury.
First, what is a bone stress injury?
A bone stress injury is an accumulation of bone microdamage which can result in either a bone stress reaction, stress fracture or a complete fracture. This occurs when there is too much strain on the bone with the repetitive nature of running, and your bone cells are unable to perform targeted remodeling and repair at the same rate of bone microdamage. Our bones naturally go through a remodeling process throughout life. Underfueling, sleep disorders, nutrient deficiencies, hormone health, genetics and medications can play a big role in this imbalance between cellular breakdown and repair.
How soon you can get back to running depends on the location and grade of the injury. High risk sites and higher grade injuries will take longer to get back to running. High risk sites include the femoral neck, anterior tibial cortex, medial malleolus, talus (lateral process), navicular, proximal diaphysis of the 5th metatarsal, base of the 2nd metatarsal, and great toe sesamoids. Low risk sites include the posteromedial tibia, fibula/lateral malleolus, femoral shaft, pelvis, calcaneus, and diaphysis of metatarsals 2-4. Grades 1-3 are categorized as stress reactions and grade 4 is a stress fracture with a visible fracture line. These grades are diagnosed with MRI, which is the gold standard for diagnosing bone stress injuries.
Most can engage in pain free cross training activities such as biking and swimming. Cross training is a great way to stay active through injury and can help maintain cardiovascular fitness. A pain free walking progression using daily step count can be started after a period of rest or unloading the injured side. Focusing on fueling is a must during this time if you and your healthcare provider suspect that part of the catalyst to your injury is due to unintentional or intentional low energy availability, genetics, and/or hormonal health. It will be important to make an appointment with a Sports Dietician and an Endocrinologist. This will not only help you get back to running and doing the things you love safely, but can also help to prevent bone stress injuries in the future.
Before a return to run program is started, a period of rest and/or non-weightbearing may be needed, followed by a progressive strengthening program. This can start with bodyweight exercises, to weighted exercises and then eventual progression to plyometrics. A strengthening program should be designed where there is progressive loading to muscles around the site of injury. If done in the right environment and with respect to healing times of each specific bone site, this will help to strengthen and remodel the bone’s fracture site. Bone gets stronger with progressive mechanical stress, intermittent rest/recovery and fueling our body appropriately. You should not provoke your pain during or after the exercise. With bone, we don’t want to push through >1/10 pain.
During the initial phases of a return to run program, the focus should not be on improving fitness quickly, reaching fatigue or achieving the “runner’s high”, but on improving the ability of the affected bone to tolerate repetitive loading. Running should be done at a “conversational” pace with a 5-10 minute warm up and cool-down. There should be more walking than running in the initial stages of a return to run program, and running should be performed every other day. Symptoms should not be provoked as you progress from a walk run program → continuous running → training → competing. If symptoms do return, it will be important to not push through the pain but to instead take a few days off from running until symptoms subside, and then to decrease the time running on your next few walk runs.
Once you are back to continuous fitness running, there will be 3-4 variables that you need to pay attention to. Duration is the amount of time spent running, frequency is the number of times you are running per week, intensity, and elevation. Work on increasing duration or frequency first but not at the same time since this may increase fatigue levels. This may mean progressing to running from non-consecutive days to consecutive days or building a long run into your routine. Don’t worry if you need to walk if you are feeling fatigued. Adding speedwork and elevation to the mix increases fatigue levels which can increase bone loads and should be added slowly, one at a time, and typically at the latter stages of your training. Again symptoms should not be provoked and if they are, take rest days until your symptoms diminish and you may need to reduce your duration or frequency. Don’t forget to add a deload week every 2-3 weeks to allow for recovery and reduce the risk of cumulative fatigue.
References:
Carlson, N. (2024). Ready to Run. Guidelines for Running after a Stress Fracture. https://runningmatekc.com
Hoenig, T., Ackerman, K. E., Beck, B. R., Bouxsein, M. L., Burr, D. B., Hollander, K., ... & Warden, S. J. (2022). Bone stress injuries. Nature Reviews Disease Primers, 8(1), 26.
Warden, S. J., Davis, I. S., & Fredericson, M. (2014). Management and prevention of bone stress injuries in long-distance runners.Journal of orthopaedic & sports physical therapy,44(10), 749-765.