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Stress Fractures in Distance Runners

Running Injury being treated by Rebecca Root at Balanced Osteopathy

Bone stress injuries are a spectrum of injuries ranging from periostitis (inflammation of the periosteum), to stress fracture, to a full bone break. Let's take the example of shin splints, aka Medial Tibial Stress Syndrome (MTSS for short) - most runners that present to our clinic with 'shin splints' are often surprised to learn that it is in fact a bone injury, and the real risk of poor management and increasing pain is that the issue can progress to a stress fracture.


Often your clinician can make a diagnosis of stress fracture from your description of the pain, the history and an examination. Occasionally this may need confirmation with imaging such as MRI, for example when a high risk area such as hip or pelvis are involved, or for our runners some choose to do this to confirm the diagnosis if there is a major event coming up that they may have to miss in the event of a fracture. It is important to note that often stress fractures in the early stages will not be present on an x-ray.

Typical presentation of stress fracture is a history of pain during activity that has progressively become more painful and may now be there also at rest e.g. sitting on the sofa relaxing you maybe feel a throbbing pain. It often correlates with an increase in training volume/intensity. You may also find that you have been limping slightly after runs or after walking around for a distance.

Risk factors

Risk factors for bone stress reactions or stress fractures include:

-A change in training such as increased distance, volume or cross training with insufficient time for the body to adapt. Change in footwear or surface (2. Kiel & Kaiser 2019)

-Inadequate energy intake (overall calories in). In females when there is menstrual disruption (absent or infrequent periods) associated with caloric restriction there is further risk increase (3. Richard et al 2018)

-Malabsorption or poor intake of vitamin D (gastrointestinal disorders or excluded food groups from the diet are therefore relevant)

-Metabolic bone disorders

Treatment and management

Quick diagnosis is essential, as often a bone stress reaction can be curtailed with a few weeks of reduced mileage (sometimes full rest from running), whereas recovery for stress fracture may take 6-8 weeks of full rest and a further 6-8 weeks of gradual return to activity to get you back to your baseline - this is something that your osteopath can help you with. Recovery may take longer with more complicated stress fractures or if there is time required in a boot or on crutches.

If it is likely the stress fracture came about due to biomechanical issues combined with any of the above named risk factors, your osteopath will focus rehabilitation and treatment to resolving these issues to offload the injury site in your running gait.

If you are concerned about an injury or worried that you might have a stress fracture, it's important to get diagnosed quickly to prevent further injury and a longer recovery. You can book to see any of our osteopaths at Balanced Osteopathy here.

1. Image courtesy of



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