Overcoming Stress Fractures from Running

One of the most common running-related injuries many athletes hear about—but don’t fully understand—is a bone stress injury (BSI), often referred to as a stress fracture or stress reaction.

Bone stress injuries make up approximately 16–20% of all running injuries, and they happen when repetitive loading on the body outpaces your ability to recover.

In my career as a running physical therapist, this is one injury that we want to catch early. Continued exercise on a bone stress injury can result in delayed healing and long recovery times.

What Is a Bone Stress Injury?

Running involves repeated impact—and that’s not inherently bad! We need stress (a.k.a. load) to grow stronger, build bone density, and improve our performance. But when training loads exceed what your body can handle, that tipping point can lead to injury.

This is especially true when it comes to bone. Unlike muscle or tendon issues that can often be managed while continuing to run, bone stress injuries typically require a 6+ week break from running to allow healing.

Wondering how to safely increase training loads? I break that down in [this blog post] (insert link).

Warning Signs of a Bone Stress Injury

If you're a runner, here are the symptoms that should raise red flags:

• 🚶‍♀️ Pain with all weight-bearing activities – walking, running, jumping

• 🌙 Pain at night or aching at rest

• 📍 Point tenderness – especially over the shin, foot, or hip

• ⚠️ No relief with warm-ups or stretching

Common injury locations include the pelvis, femur, tibia, and foot bones.

What Increases Your Risk of a Stress Fracture?

1. Training Load Errors

   • Too much, too soon—mileage spikes, increased intensity, or back-to-back hard efforts

2. Running Mechanics & Gear

   • Poor running form, worn-out shoes, or muscle imbalances

3. Nutrition Deficiencies

   • Inadequate calcium, vitamin D, and iron intake compromise bone strength

4. Hormonal or Genetic Factors

   • Especially for females with irregular cycles or low estrogen

5. Low BMI (<19)

   • Insufficient body mass can reduce shock absorption

6. Early Sport Specialization

   • High-volume training in young athletes with little cross-training

7. Medications

   • Long-term corticosteroid use may weaken bones

Managing Bone Stress Injuries: A Team Effort

Recovery starts with accurate diagnosis—usually confirmed via MRI or bone scan—and a multi-disciplinary approach:

• 🩺 Sports Medicine Provider to monitor healing progress

• 🥗 Registered Dietitian to address nutrition and energy availability

• 🧑‍⚕️ Physical Therapist (preferably one who specializes in running) to guide loading and return-to-run progression

The Role of Nutrition in Bone Health

Nutrition plays a huge role not just in recovery—but in prevention of BSIs. Here’s what to prioritize:

• Calcium: 1,000–1,300 mg/day (dairy, leafy greens, fortified foods)

• Vitamin D: Essential for calcium absorption—get levels checked if you live in a low-sunlight area

• Iron: Crucial for red blood cell production and oxygen delivery (meat, beans, spinach, sardines)

Returning to Running After a Stress Fracture

Even during the no-running phase, it’s important to stay active. I regularly work with runners on no-run precautions to keep them moving safely.

Once you're cleared to return to running, don’t just jump back in—work with a running-specialized PT who understands how to rebuild training load without re-injury.

If you're experiencing pain that matches the signs of a bone stress injury—or you're returning from one—don't go it alone. Reach out to a provider who understands the demands of running.

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Sources

Warden SJ, Davis IS, Fredericson M. "Management and Prevention of Bone Stress Injuries in Recreational Runners." Journal of Orthopaedic and Sports Physical Therapy 2014

Kraus E, Tenforde A, Nattiv A. "Bone stress injuries in male distance runners: higher modified Female Athlete Triad Cumulative Risk Assessment scores predict increased rates of injury." Journal of Orthopaedic and Sports Physical Therapy 2019.