Assessing Risk of Bone Stress Injuries

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Assessing Risk of Bone Stress Injuries

What are Bone Stress Injuries (BSI)?

A BSI is the result of a bone’s inability to tolerate repeated mechanical loads.  Microdamage is threshold dependent.  Once the threshold is exceeded, structural changes, periosteal/marrow edema, and/or pain can occur.  The damage may result in a fracture but also serves as a stimulus for targeted remodeling. 

Stress fractures have been estimated to account for more than 10% of all sport-related injuries.  BSIs are very common in runners with annual incidence of more than 20%.  Thus, early diagnosis of BSIs are most important.  Delayed diagnosis and continued loading of the bone can lead to higher grades of BSI.  More severe injuries will require longer healing time. Nye et al (2016) examined the methods to assess for the possibility of a bone stress injury.  They identified structures into high and low risk structures:                                       Bone Stress Structural Risks

The technique to assess the risk of bone stress injuries includes 3 components:                                                          Bone Stress AssessmentRisk FactorsSymptoms of Bone StressBone Stress Examination

If BSI score is equal to or greater than 4 and there is at least 1 examination finding, the technique to assess the risk of bone stress injuries includes 3 components: 

Bone Stress Treatment SequenceIf a high risk structure is involves and weight bearing is painful, an MRI should be obtained within 72 hours.  The patient should also avoid the use of NSAIDs because of the negative influence on bone healing.  The sooner a bone stress injury can be identified, the sooner the appropriate intervention can begin to facilitate healing.  Remodeling of cortical bone can require 3 – 4 months (Frost, 1969; Warden et al, 2014).

To reduce the likelihood of a recurring injury, the underlying cause of the BSI should be identified.  This could include factors that influence the load applied to the bone or the factors that influence the bones ability to resist the load applied.  Excessive bone loading can come from poor biomechanics, training frequency/duration, inadequate muscle strength/endurance, footwear, and training surfaces.  Whereas, factors that can contribute to the ability of bone to manage the load can include diet/nutrition, genetics, endocrine health, bone diseases, and medications.  Modification of any of these factors can help recovery and prevent future injuries.

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  • Frost HM. and Tetracycline-based histological analysis of bone remodeling. Calcif Tissue Res. 1969; 3: 211– 237.
  • Gulick DT. iOrtho+ Mobile App. DTG Enterprises LLC. 2020
  • Gulick, DT. OrthoNotes, 4th FA Davis Publishing, Philadelphia. 2018
  • Nye NS, Covey CJ, Sheldon L, Webber B, Pawlak M, Boden B, Beutler A. Improving diagnostic accuracy and efficiency of suspected bone stress injuries: Algorithm and clinical prediction rule. Sports Health. 2016;May-June;8(3):278-283
  • Warden SJ, Davis IS, Fredericson M. Management & prevention of bone stress injuries in long-distance runners.   2014;44(10):749-75 https://www.jospt.org/doi/10.2519/jospt.2014.5334

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