Bone Stress Injuries in Runners: What Every Runner Needs to Know (Part 1)
By Resolve Physical Therapy & Performance – Cherry Hill, NJ
If you're a runner in Cherry Hill or the South Jersey area, chances are you've dealt with your fair share of aches and pains. But one of the most overlooked—and most frustrating—injuries is the bone stress injury (BSI). It doesn’t start with a pop or a fall. It builds quietly over time, until one day that shin, foot, or hip pain won’t go away.
This is Part 1 of our two-part series on bone stress injuries in runners. We're breaking down what they are, how they develop, where they tend to occur, and what to do about them before they become serious.
What Is a Bone Stress Injury?
A bone stress injury happens when repetitive stress is placed on a bone faster than the body can repair it. Over time, this imbalance weakens the bone and can lead to a full-blown stress fracture if not caught early.
The 4 Stages of Bone Stress Injury
Grade 1: Stress Reaction
Inflammation in the bone, no visible crack. Often missed on imaging.Grade 2: Periosteal Edema
Swelling in the outer bone layer. Pain increases with impact.Grade 3: Bone Marrow Edema
Inflammation inside the bone. Pain becomes more persistent.Grade 4: Stress Fracture
A visible crack in the bone that requires extended rest and recovery.
Catching a BSI in the early stages (Grades 1–2) means a faster return to running and less risk of long-term issues.
Why Do Runners Get Bone Stress Injuries?
BSIs usually occur when training load outweighs recovery capacity. The most common causes include:
Rapid increases in mileage or intensity
Low energy availability or poor nutrition (including RED-S)
Hormonal imbalances or irregular menstrual cycles
Biomechanical inefficiencies or poor running form
Running in worn-out shoes or on hard surfaces
Inadequate sleep or stress management
We often see BSIs in runners training for the Broad Street Run, Philly Half Marathon, or local Cherry Hill 5Ks who ramp up too quickly.
How Common Are Bone Stress Injuries in Runners?
Bone stress injuries account for up to 20% of running injuries.
They’re especially common in:
Female runners
Athletes with a history of stress fractures
Those returning from time off
Young athletes with high training volumes
The earlier you catch a BSI, the better your outcome.
Top 5 Most Common Sites for BSIs in Runners
Tibia (shinbone) – Often mistaken for shin splints early on
Metatarsals (foot bones) – Especially 2nd and 3rd metatarsals
Femoral neck (hip) – High risk area that requires careful management
Pelvis or sacrum – Less common, but hard to detect without imaging
Fibula – Lateral shin pain that mimics muscle strain
If you have localized pain that worsens with impact, get it checked out.
Symptoms of a Bone Stress Injury
Localized pain (feels like a bruise on the bone)
Pain that worsens during running or jumping
Pain that improves with rest but returns quickly
Point tenderness over the bone
Occasional swelling or mild aching at rest
These injuries don’t always cause bruising or swelling, which is why they often go undiagnosed until later stages.
Imaging: What Works and What Doesn’t
X-Ray
Often the first test ordered, but early BSIs usually don’t show up on X-rays.
MRI
The gold standard. MRIs detect inflammation, bone marrow changes, and early-stage injuries long before X-rays can.
CT Scan
Useful for later-stage injuries or confirming fractures, but not great for early detection.
At Resolve PT in Cherry Hill, we work with trusted local providers to help our runners get quick access to MRIs when needed.
What To Do If You Suspect a BSI
If you feel localized pain that’s worsening with every run—stop and get assessed by a physician!!!
Ignoring a bone stress injury can turn a manageable stress reaction into a stress fracture that sidelines you for months.
Immediate Care Tips:
Stop high-impact activity (no running or jumping)
Use cross-training only if cleared (biking, swimming, elliptical)
Avoid anti-inflammatories unless advised—these may interfere with healing
Apply ice for short-term pain relief
Schedule a sports physical therapy evaluation
At Resolve Physical Therapy & Performance, we specialize in helping runners in Cherry Hill, Voorhees, Marlton, and Haddonfield navigate injuries like BSIs with precision and a plan.
What’s Next?
In Part 2 of this series, we’ll break down:
How to rehab from a bone stress injury
How to return to running safely
Nutrition tips to support bone healing
How to prevent future bone stress injuries
Need Help Now?
If you’re dealing with running pain that won’t go away, don’t wait. Our team at Resolve Physical Therapy & Performance in Cherry Hill helps active adults and runners return to the activities they love—safely and with a plan.
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