Bone Stress Injuries And The Warning Signs With Runners

Early Warning Signs Every Runner Should Know

One of the biggest misconceptions among runners is that pain is simply part of training. While muscle soreness after hard sessions is common, persistent localised bone pain is not.

Look out for these typical warning signs:

• Pain that develops during running

Pain often begins after several kilometres and disappears once the run finishes. As the injury progresses, symptoms appear earlier and become increasingly predictable.

• Pain that "warms up"

A common misconception is that pain improving after the first few minutes of running means it is safe to continue.

Bone stress injuries can temporarily feel better as surrounding tissues warm up, only to become more painful later in the run or afterwards. This temporary improvement should never be interpreted as a sign that the bone has recovered.

• Localised pain

Unlike muscle soreness, bone stress injuries usually produce pain that can be identified with one or two fingertips over a very specific area.

Diffuse aching across a broad region is less typical.

• Pain after running

Your symptoms frequently persist for several hours after training and may still be present the following morning.

• Pain with hopping

Single-leg hopping increases force through the affected bone and commonly reproduces symptoms.

• Pain during walking

Once pain develops during normal walking, your injury has usually progressed beyond the earliest stage.

• Night pain or resting pain

Pain while resting or that disturbs sleep should never be ignored!

 

Book Online Now to Fix Your Body

 

Risk Factors for bone stress injuries

Bone stress injuries rarely result from one issue alone. Most runners present with several interacting risk factors.

• Training load

Rapid increases in running volume remain one of the strongest predictors.

• Previous bone stress injury

A previous stress fracture substantially increases the risk of another injury, particularly if the original contributing factors were never addressed.

• Relative Energy Deficiency in Sport (RED-S)

One of the most overlooked contributors is low energy availability.

When athletes consistently consume fewer calories than they expend, the body begins conserving energy by reducing hormone production and slowing bone formation.

Although historically associated with female athletes, RED-S also affects male runners and endurance athletes. Reduced testosterone, impaired recovery, recurrent injuries and declining performance may all occur in men experiencing chronic low energy availability. Our Dieticians at Melbourne Sports Physiotherapy can help you with this.

• Nutrition

Healthy bones require more than calcium alone.

Adequate intake of:

• Total daily energy

• Protein

• Calcium

• Vitamin D

• Carbohydrates to support training demands

all contribute to bone health and recovery.

• Low bone density

Reduced bone mineral density increases susceptibility to stress injuries and can be investigated with a Bone Density Scan when your bone injuries recur or occur with relatively low training loads.

• Biomechanics

There is no ‘good’ or ‘bad’ running style that has an effect on sustaining a bone stress injury.

Instead, we assess how an individual's movement patterns interact with training load.

Contributing factors may include:

• Reduced calf strength

• Hip weakness

• Poor single-leg control

• Limited ankle mobility

• Excessive fatigue

• Inappropriate footwear for training demands

•  

Book Online Now to Fix Your Body

 

Diagnosing a bone stress injury

At Melbourne Sports Physiotherapy, we will ask for following things during your initial appointment:

• Training history

• Recent changes in running volume

• Footwear

• Nutrition

• Sleep

• Previous injuries

• Medical history

• Pain behaviour

• Physical examination findings

Imaging may include an X-ray, MRI or a CT scan. The earlier the diagnosis, the quicker the treatment can start.

 

Treatment

Treatment depends on:

• Injury severity

• Bone involved

• Risk classification

• Running goals

• Individual risk factors

Management often includes cross-training such as cycling and aqua jogging to reduce the impact on your bone.

Rehabilitation typically involves:

• Progressive strength training

• Running load modification

• Calf strengthening

• Hip strengthening

• Running technique assessment where indicated

• Nutritional advice or referral to an accredited sports dietitian

• Structured return-to-running progression

Simply resting until pain settles without addressing the underlying causes significantly increases the likelihood of recurrence.

 

Book Online Now to Fix Your Body

 

When can you return to running?

A successful return-to-running program should be gradual and criteria-based rather than time-based.

Most runners begin with walk-run intervals before progressively increasing continuous running, weekly volume and eventually speed sessions.

If you experience pain during or after running, your bone may not yet be tolerating the current training load.

 

Why do bone stress injuries recur?

Recurrence is common when the original contributing factors remain unresolved.

These may include:

• Returning too quickly

• Inadequate strength

• Poor recovery

• Persistent low energy availability

• Repeating previous training errors

• Ignoring early warning signs

Successful rehabilitation focuses on correcting these factors rather than simply allowing symptoms to settle.

 

Can you prevent bone stress injuries?

There is a risk for everyone, but keeping these guidelines in mind, will reduce your risk:

• Progress training gradually

• Schedule recovery days

• Complete regular strength training

• Maintain adequate energy intake

• Optimise calcium and vitamin D intake where appropriate

• Monitor persistent localised pain

• Avoid sudden changes in footwear or training surfaces

• Seek assessment early when symptoms develop

Being consistent in your training and recovery remains one of the strongest protective factors.

 

Book Online Now to Fix Your Body

 

When should you see us?

Arrange an assessment if you experience:

• Localised bone pain lasting more than a few days

• Pain that becomes progressively worse with running

• Pain during walking

• Pain with hopping

• Night pain

• Recurrent pain in the same location

• Pain that repeatedly returns after rest

The quicker you see someone or do something about it, the less risk of progressing your stress reaction into a stress fracture.

 

Book Online Now to Fix Your Body

 

Key takeaways

Bone stress injuries are not simply overuse injuries that improve with a few days of rest. They develop when the demands placed on the skeleton exceed the bone's ability to recover and adapt.

You should never ignore persistent localised pain; symptoms that progressively worsen with running, pain during walking or pain that repeatedly returns after exercise. Early diagnosis, appropriate load management and addressing contributing factors such as strength, nutrition and recovery provide the best opportunity for a safe return to running.

If you are experiencing ongoing bone pain during or after running, an assessment with a physiotherapist at Melbourne Sports Physiotherapy can help determine whether a bone stress injury is present and guide an evidence-based rehabilitation plan before the injury becomes more serious.

 

Book online today to feel great & move well again!

Super Simple with Instant Confirmation & No Login Required!

For consultation fees and more information, please visit our Fees and FAQs page or call us on 03 9498 0205.

Some types of consultations may require pre-payment or a deposit. 100% Money Back Guarantee (T&Cs apply).