Bone Stress Injuries: Prevention and Recovery

A bone stress injury can affect any part of a bone — the bone lining or bone marrow (soft tissue inside bones) may swell, or the hard part of the bone may break.

These injuries have the same root cause. “They are overuse injuries — the bone doesn’t have enough time to recover from the stress applied to it. Stress causes progressive injury to the bone over time,” explains Haylee E. Borgstrom, MD, a Mass General Brigham sports medicine specialist.

Stress injuries to bones affect a wide range of active people, from professional, high school, and college athletes to weekend fitness enthusiasts. In fact, up to 20% of injuries treated in sports medicine clinics are stress fractures.

Bone stress risk factors

Most people with a bone stress injury notice pain that gets worse the more they use the affected bone, Dr. Borgstrom says. The bones most likely to suffer stress injury depend on your sport or activity, and the parts of the body that are used most. “Understanding common risk factors allows doctors to watch for potential problems and focus on prevention,” she adds.

These injuries are more common in people who participate in certain sports:

• Running, walking, and impact sports that involve the legs may cause injury to the hip, femur, shin, or foot.
• Softball, baseball, tennis, fencing, and volleyball, where the arms are overused, can stress the elbow.
• Golf and rowing, which need repetitive movement in the trunk of the body, may cause rib fractures.

The risk for injuries also depends on how you fuel your body and the way you use it, says Dr. Borgstrom. Behaviors that can contribute to a bone stress fracture include:

• Over-training, such as running many miles per week or increasing exercise too quickly
• Working out on hard surfaces like cement and asphalt that absorb less impact
• Muscle weakness and muscles that aren’t strong enough to support the load
• Weak bones related to medical conditions like osteoporosis, vitamin D deficiency, or eating disorders
• Poor nutrition or too few calories to provide enough energy

Protect against bone stress fracture

If you are an active person concerned about over-stressing your bones, you can take some simple steps to guard against injury. Dr. Borgstrom suggests:

• Proper nutrition: Fuel your body appropriately, with sufficient calories to sustain your activity.
• Cross-train: Try sports that work different parts of the body. Resistance training is a great way to build muscles that support and take stress off bones.
• Rest and recover: This can be as simple as working out every other day or more significant, like taking weeks off between sports seasons.
• Stop when it hurts: New pain or pain that gets progressively worse is your body telling you that you are exercising too much. “If something hurts, take a break from your regular activity and try something else, then see how you feel,” Dr. Borgstrom advises.

Evaluating and healing bone stress injuries

If you suspect an overuse injury is causing activity-related pain that doesn’t resolve with rest, Dr. Borgstrom recommends making an appointment with a sports medicine specialist.

Your doctor will:

• Assess underlying risk factors
• Conduct a physical exam
• Test muscle strength

Often, your doctor can diagnose you in the office without further testing. “An x-ray, MRI, and bloodwork may be required if recovery doesn’t progress as we expect it to with appropriate rest and recovery,” says Dr. Borgstrom.

Your doctor may suggest taking time off from the sport or activity that caused the injury, along with physical therapy or a home exercise program. Some injuries require a walking boot or crutches to take pressure off the bone and allow it to heal.

Swelling of the bone lining or bone marrow generally takes about 4 to 6 weeks to heal. A stress fracture could have you out of the game for several months. With proper care, most people heal from overuse injuries and gradually return to full activity.

“If it doesn’t heal over time or the fracture is in a high-risk area, you may need surgery to repair the bone,” Dr. Borgstrom says. In this case, pins or other hardware are placed inside the body across the fracture to support the bone while it heals.

“The goal is to allow the injury to heal so you can return to your sport,” Dr. Borgstrom says. “The earlier we get to these, the faster they heal.”