From Risk to Rehab: Understanding Bony Stress Injuries in Youth Athletes

In our previous blog we explored the complexities surrounding athleticism in youth sport. Based on the National Strength and Conditioning Association definition of athleticism we proposed the development of athleticism in youth athletes could be optimised via the collective insight and agreement on a working definition of athleticism across all stakeholders and support for development of physical and psychological aspects of athleticism across a range of motor tasks and environments. In this blog we look more specifically at bony stress injuries in youth athletes and explore management and prevention options to optimise engagement in sport for our youth athletes.

High volumes of sport and more so repetitive running can carry the risk of developing overuse injuries in youth sport, including bony stress injuries (BSI). A BSI can be broadly defined as the inability to withstand repetitive mechanical loading, resulting in structural fatigue and localised bone tenderness and pain.  BSI occur along a continuum beginning with micro stress reactions, which overtime can progress to a stress fracture and further progression can lead to a complete fracture (See Warden et al., 2014 for further details on BSI). The purpose of this blog therefore is to discuss the management options for BSI in youth athletes.

High and Low Risk BSI

Treatment and recovery can vary depending on which bone is affected, where the injury is on the affected bone and the blood supply to that bony area. The location of the stress injury will determine whether it is at a low or high risk of progressing to a fracture.

High-risk BSI

Occur at specific bony areas that typically have poor blood supply

Result longer healing timeframes

Require prolonged immobilization

Low-risk BSI

Rehabilitation healing timeframes can vary depending whether it is a minor stress reaction or if it is a more advanced stress fracture

Usually resolve with modified training loads and strengthening exercises

Healing time-frames range between 6-8 weeks

Diagnostic Imaging is it necessary?

For low risk injury areas, imaging does not change the intervention strategy. X-rays do not always show a BSI, therefore, when imaging high risk injury areas, research suggest MRI is the most optimal choice when it comes to diagnostic imaging.


The first step to returning to sport is to ensure that the youth athlete is pain-free during daily life activities, such as walking. If the youth athlete is not pain-free while walking, crutches or a boot may be administered for temporary use. During these initial stages of rehabilitation, if walking is painful, the youth athlete can maintain basic fitness with aqua running and stationary bike sessions. The first step to returning to sport is to ensure that the youth athlete is pain-free during daily life activities for five days or more.

Factors Affecting Treatment Prognosis

Recovery can be delayed if an athlete progresses through their graduated loading rehabilitation program too quickly, ignoring pain as a result of their current training load. Additionally, factors such as diabetes, poor nutrition, endocrine disorders/dysfunctions, relative energy deficiency syndrome. Addressing the factors that have contributed to the BSI will have a positive effect on treatment prognosis. To have long-term positive treatment outcomes it is to assess the following:

Current training program design

Student athletes must modify training volumes, frequency and intensities of their land/pool training sessions as well as their gym strengthening sessions. Research recommends that acute training loads (increased within one week) should not exceed a 10% increase higher than their chronic training loads (load over four weeks).

Nutrition and General Bone Health

Nutrition should be monitored to avoid nutritional and energy deficits. Promoting healthy eating behaviours and detecting any nutritional, caloric, calcium or vitamin D intake deficiencies will prevent BSI.


It can be beneficial to address running biomechanics while simultaneously reducing the amount of loaded impact that the youth athlete is exposed to through their sport.

In summary, BSI can occur through high volumes of sport and highly repetitive sporting activities. BSI can occur as high and low risk BSI and in low risk BSI, the early management of pain during activities of daily living will be important to proceed with a return sport. Positive long term outcomes can be optimised through managing training loads (volume and intensity), promoting healthy eating behaviours  and addressing running and movement deficiencies.   

References for Further Reading

Arndt A, Westblad P, Ekenman I, Lundberg A. A comparison of external plantar loading and in vivo local metatarsal deformation wear- ing two different military boots. Gait Posture.

Barton, C.J., Bonanno, D.R., Carr, J., Neal, B.S., Malliaras, P., Franklyn-Miller, A. and Menz, H.B., 2016. Running retraining to treat lower limb injuries: a mixed-methods study of current evidence synthesised with expert opinion. British journal of sports medicine50(9), pp.513-526.

Bennell KL, Malcom SA, Thomas SA, et al. Risk factors for stress fractures in track and field athletes. A twelve-month prospective study. American Journal of Sports Medicine.

Warden, S.J., Davis, I.S. and Fredericson, M., 2014. Management and prevention of bone stress injuries in long-distance runners. journal of orthopaedic & sports physical therapy, 44(10), pp.749-765.

Leave a Reply

Fill in your details below or click an icon to log in: Logo

You are commenting using your account. Log Out /  Change )

Google photo

You are commenting using your Google account. Log Out /  Change )

Twitter picture

You are commenting using your Twitter account. Log Out /  Change )

Facebook photo

You are commenting using your Facebook account. Log Out /  Change )

Connecting to %s