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A bone stress injury (BSI) is typically an overuse injury associated with repetitive loading of bone by vigorous weight-bearing activity. There is a continuum of BSI ranging from ‘normal’ to ‘bone strain’ to ‘stress reaction’ to eventual development of a ‘stress fracture’. They are relatively common in athletes. They are also common among otherwise healthy people who have recently started new or intensive physical activity. The most common sites for a BSI are in the lower limb and include the tibia, metatarsals and femur.

In order to properly assess a patient with a BSI, a clinician must consider the risk factors for that individual. These risk factors can be broadly divided into extrinsic and intrinsic factors. Extrinsic factors usually relate to increased loads and include overtraining, improper footwear or running on hard surfaces. On the other hand, intrinsic factors such as genetics, nutritional deficiencies or menstrual and hormonal disorders may negatively impact bone density and thus, a BSI can occur even with lesser loads.


Once a diagnosis of BSI is confirmed, it is my belief that the best way to manage the condition is through multidisciplinary care. The following is a non-exhaustive list of the practitioners involved and their roles in the management of a BSI:

Sports & Exercise Medicine Physician

  • Implementation of an appropriate offloading plan, adaptable to the individual and site of injury.
  • Arrange further investigations to assess for intrinsic risk factors, including blood tests or bone density scans.


  • Vital for the rehabilitation component of BSI management.
  • Improve strength and movement patterns around the injury site.
  • Facilitate return to running and sport specific activity.

Orthopaedic Surgeon

  • Operative intervention is sometimes indicated in the event of a high-risk stress fracture.

Other allied health practitioners

  • Dietitians, psychologists, exercise physiologists and podiatrists may also be involved depending on the contributing factors and the individual.

Unravelling the all too common BSI can be a difficult task even for the experienced Sports Medicine practitioner. A multidisciplinary approach is needed in order to achieve the best outcome. If you have bony pain with exercise, don’t let it progress down the bone stress continuum, come and be seen by one of the Sports and Exercise Medicine specialists at Ballarat OSM.

Dr. Anthony Hipsley

Sports and Exercise Medicine Registrar

Ballarat OSM