"High risk injuries need a more cautious treatment strategy"
-Hoenig 2021

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Bone stress injuries (BSIs) start well before an athlete enters at your clinic.

Because bone is uniquely innervated, patients typically do not begin to feel the symptoms of a BSI until long after the injury has occurred.

By the time they seek help, they are already at a disadvantage, making it crucial to manage these injuries effectively to ensure long-term success.

There's no time to waste.

You may think I'm being dramatic, but high-risk BSIs represent one of the most challenging injuries that runners face.

They have a prolonged recovery and a higher likelihood of requiring surgery or preventing an athlete from running altogether in the future.

There's two big reasons for this increased risk.

Specific Biomechanics

Specific portions of bones are designed to deal with compressive or tensile forces.
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The geometry of a bone and its microscopic makeup adapt to the specific stresses it deals with.

Bone adapts to withstand multiple types of forces simultaneously.
Its diversity gives it strength when dealing with the impact of running.

Injuries on the medial side of a bone typically heal more easily due to their compressive nature, while the lateral side, built for tensile loads, presents a greater challenge.

Bone is designed to withstand compressive forces, so when an injury occurs at a tensile location, it's harder for the body to recover without outside help.

Poor blood flow

Specific locations are better supplied with nutrients than others.

The femoral neck (and head) is supplied by the circumflex artery, which wraps around the neck. If a runner develops a displaced fracture, it can sever the artery, putting the proximal femur at risk of dying.

Locations like the navicular and proximal 5th metatarsal have "watershed" areas with little blood supply, limiting healing without a surgical intervention.

Whether it's the biomechanics or blood flow of a specific location, high-risk BSIs must be managed more conservatively than other running injuries.

Absolutely no pain

The top priority in a high-risk location is to prevent the runner from putting stress on the area until an MRI can confirm or rule out a BSI.

This information might be new for your patient, so it’s important to remain firm in your advice.

Pain can indicate structural failure, which means we must avoid it at all costs! The patient will likely be on crutches for several weeks to allow the injury to stabilize and begin healing.

No cross-training, no exercises, just rest.

You may need multiple images

MRI is the gold standard for diagnosing a BSI and helping establish estimated timelines for returning to running. Some patients will require a second MRI to confirm healing before moving forward in rehab.

Patients may still need additional diagnostic testing, particularly of the anterior tibia, navicular, and 5th metatarsal, to better define the injury and determine whether they are surgical candidates.

Imaging findings and initial recommendations are summarized from the recent Aspetar publication on BSIs👇.

Get your patients diagnosed ASAP!

Then keep them from going crazy during their six weeks of crutches so they can actually get back to running.

One more thing

Once a patient is diagnosed with a high-risk BSI, their social media feeds become inundated with stories of professional athletes experiencing similar injuries.

It's important to remind patients that just because an athlete is a professional doesn't mean they get the best short or long-term treatment advice.

Professional athletes make money from competing.

Endurance athletes have a limited number of years in which they can compete for cash, so the decisions they make about their health often prioritize short-term performance over long-term well-being.

Get an accurate diagnosis, make progress, and try your best to stay patient.