These injuries are some of the most problematic anyone can suffer with. They are frequently missed as a diagnosis and that is even after the patient has seen multiple health professionals from doctors to physio’s, osteo’s, chiro’s, and podiatrists. These injuries are very common in the athletic population and especially the running athlete. Dancers are also commonly affected by these injuries, which is commonly due to high training demands that exceeds energy intake.

What are Bone Stress Injuries?

Bone stress injuries are basically those where bone damage exceeds bone formation. These injuries are on a spectrum of severity from bone stress reaction which is less severe, bone stress fracture (more severe) and complete fracture (most severe). A bone stress reaction is typically where there is local bone oedema (swelling) in response to loading. Shin splints could be thought of as this type of injury, which is why appropriate management is required for shin splints so they do not progress to a tibial stress fracture. Stress fractures are injuries where the bone has a crack located through it. These injuries are common in the foot bones, such as the metatarsals and navicular.

How does a Bone Stress Injury occur?

Our bones deform in response to loading, which leads to stress and strain throughout the bone. The degree of bone deformation depends on three factors.

1. The location the force is applied

2. The magnitude of the force applied

3. The ability of the bone to resist load

In response to normal loading, microdamage occurs leading to microfractures throughout the bone. These microfractures are normal and not pathological. Where the microfractures are located is where the bone undergoes targeted remodelling in order to make the bone stronger and more robust. When bone damage and bone formation are balanced, the bone adapts. However, when repeated loading occurs, there is an accumulation of bone damage where the formation of new healthy bone is exceeded by bone breakdown. As more and more bone turnover occurs, the bone becomes less stiff and more porous in nature. Therefore, is unable to absorb and accept the stress/strain it normally should.

The actual process of bone breakdown and targeted remodelling in response to load takes about 3-4 weeks! Most bone stress injuries therefore occur 3-4 weeks after the training load error occurred. The training load error could have been due to an increase in training volume or intensity.

The most important aspect of BSI apart from training load

What is probably the most important aspect of BSI is to do with our fuel and recovery. What it known to be one of the primary risk factors in these injuries is due to the fuel we are giving our body. This comes down to our nutrition and ensuring that we are not in an energy deficit. If the quality of our bones are poor due to poor mineralisation of the bone, then the ability to resist the mechanical load our bones are placed under is greatly reduced.

The most important minerals for good bone health are vitamin D and calcium. Calcium is required for bone mineralisation and vitamin D is needed for calcium absorption/resorption. One of the first symptoms of inadequate energy intake is amenorrhoea (absent menstrual period) or altered menstrual cycles in females and low testosterone in males, which can present as low libido or a lack of a morning erection.

For this reason, your osteopath will be holistic in their approach and ask questions concerning your diet and reproductive health. These questions really give us great insight if your risk of a BSI is high.

Low Risk Stress Fracture or High Risk Stress Fracture

BSI can be classified as being low risk or high risk. Those that are in the low risk group are those sustained to more compressive bone loading and have a great chance of healing with a good blood supply. While those considered high risk, are bones sustained to more tensile loading and have a poorer blood supply. The high risk stress fractures often need a surgical opinion.

Low Risk BSI

• Cuneiform

• Cuboid

• Calcaneal

• Distal Diaphysis of 2nd to 5th metatarsals

• PARS defect in lumbar spine

• Femoral shaft

High Risk BSI

• Sesamoids (in big toe)

• Talus (lateral process)

• Navicular

• Proximal diaphysis of 5th metatarsal

• Base of 2nd metatarsal

• Anterior tibia

• Femoral neck

At The Reform Lab Osteopathy we are passionate about these injuries and managing them appropriately inside the elite gym Project Reform. If you think you may have a BSI and want to get the care you need, please contact the clinic and we will get you some answers and a plan forward.