Running-related Bone Stress Injuries Not to be Missed - Part 1

Running‑related Bone Stress Injuries Not to be Missed — Part 1

When most people think of bony injuries they imagine an acute fracture with sudden, severe pain. In runners, however, bones can suffer a spectrum of overload called a bone stress injury — from bone marrow swelling through to a complete fracture. The longer these are present, the worse the outcome and the longer the recovery. Some sites carry a much higher risk of progression to full fracture because of poor blood supply or high mechanical forces; missing these leads to delayed diagnosis and poor outcomes.

Key sites to watch for

• Femoral neck — runners may report what feels like a tight hip flexor, but unilateral hip flexor pain is often a femoral neck stress injury. A tension‑side femoral neck fracture can displace and require surgery, with long‑term consequences. High risk.

• Sacrum — often mislabelled as low back or buttock muscle pain; may respond poorly to massage and stretching. High risk, especially vertical ala fractures in female runners.

• Pubic ramus — can present like a groin strain or adductor tendinopathy (osteitis pubis).

• Tibial shaft — more severe than “shin splints”; pain that does not settle with warm‑up suggests bone involvement. High risk — prolonged rehab often required.

• Fibula — can be mistaken for a high ankle sprain or lateral shin pain.

Red flags and management essentials Suspect a bone stress injury when there is focal bony tenderness, a recent rapid increase in training load, or risk factors such as low energy availability. Management depends on severity: from reduced running load to full non‑weight bearing. Importantly, many early stress injuries will not show on plain X‑ray — MRI or CT are often needed. If you suspect a bony stress injury, seek assessment promptly to avoid progression.