Understanding Bone Stress Injuries: Symptoms, Causes, and Treatment

Bone stress injuries (BSIs) are an increasingly common concern among high-performance athletes, particularly runners, gymnasts, and dancers. Often misunderstood or dismissed as “overuse injuries,” they are in fact early signs of bone fatigue—and if missed, they can progress to stress fractures or even long-term bone damage.

This article explores the causes, symptoms, and treatment options for bone stress injuries, with a focus on the role of RED-S (Relative Energy Deficiency in Sport) as an underlying contributor.

What Are Bone Stress Injuries?

A bone stress injury occurs when a bone is subjected to repetitive loading without sufficient time for recovery. Unlike an acute fracture caused by a single traumatic event, a BSI develops gradually, starting with bone strain and potentially progressing to a stress fracture if left untreated.

This is especially prevalent in sports that involve:

• High-impact repetitive movements (e.g. running, jumping)

• Extreme ranges of motion and loading (e.g. dance, gymnastics)

• Low body weight demands or aesthetic pressure

Who Is Most at Risk?

Bone stress injuries are most common in:

• Distance runners (especially track and marathon athletes)

• Ballet dancers and contemporary dancers

• Artistic gymnasts and acrobats

• Young female athletes with restrictive diets or menstrual dysfunction

The most affected sites include:

• Tibia (shin bone)

• Metatarsals (foot bones)

• Femoral neck

• Pelvis

• Lumbar spine (especially in gymnasts)

RED-S: A Key Contributor

Relative Energy Deficiency in Sport (RED-S) is a critical, often overlooked factor in BSIs. RED-S occurs when the body’s energy intake is insufficient to support both training demands and physiological functions. This leads to hormonal disruption, poor bone health, and impaired healing.

In athletes with RED-S, the following are common:

• Menstrual irregularities or amenorrhoea in females

• Low testosterone in males

• Decreased bone mineral density (BMD)

• Frequent injury recurrence

RED-S is particularly prevalent in sports that emphasise leanness, aesthetics, or weight categories. At MSK Doctors, we take RED-S seriously as a medical condition, not a performance trade-off.

Symptoms of a Bone Stress Injury

Bone stress injuries often present with localised pain that:

• Increases with activity and improves with rest

• May worsen over time and start during daily movements

• Is accompanied by tenderness to touch

• Is not visible on early X-rays but may appear on MRI or bone scan

At MSK Doctors, we utilise onMRI™ technology to detect early signs of bone stress—often before a full stress fracture develops.

Diagnosis and Monitoring

Accurate and early diagnosis is key. Our approach includes:

• Clinical examination focused on loading patterns

• onMRI™ scanning for early bone marrow oedema or micro-injury

• Bone density testing if RED-S or osteopenia is suspected

• Force plate analysis and motion testing to evaluate abnormal biomechanics contributing to repetitive load

Treatment Options at MSK Doctors

We provide non-invasive, evidence-based care aimed at bone healing and long-term injury prevention. Treatment may include:

1. Activity Modification

Temporary reduction or cross-training to offload the injured bone. We help athletes maintain fitness with low-impact alternatives.

2. Nutritional and RED-S Management

We partner with dietitians and sports endocrinologists to restore energy availability and hormonal health.

3. Bone Regeneration Therapy

For slow-healing or high-risk areas, we offer magnetic field therapy, photobiomodulation, and PEMF-based treatments in our Regen PhD Pod.

4. Biomechanical Rehabilitation

Using MAI-Motion™, we analyse movement asymmetries and develop personalised rehab programmes that prevent recurrence.

Long-Term Impact and Return to Sport

Returning too early can cause recurring stress fractures and compromise an athletic career. Our phased return-to-sport protocol includes:

• Functional strength testing

• Landing mechanics assessment

• Nutritional stability

• Bone re-scanning for structural integrity

Our team supports the athlete’s journey from diagnosis to full return, with a multidisciplinary strategy built on preservation, regeneration, and performance.

FAQs About Bone Stress Injuries

1. How can I tell if it’s just shin splints or a stress fracture?

Shin splints affect a larger area and improve with warm-up. Stress injuries cause pinpoint pain that worsens with impact and may persist during rest in later stages.

2. Can RED-S affect male athletes too?

Yes. RED-S is not limited to women. Males may experience low testosterone, reduced bone density, fatigue, and poor performance when under-fuelling.

3. Are X-rays useful for bone stress injuries?

Not in the early stages. X-rays may miss subtle injuries. We recommend MRI or bone scans, particularly onMRI™, which can detect pre-fracture changes.

4. How long does a bone stress injury take to heal?

Depending on the grade, it can take 4–12 weeks or longer. Proper nutrition, rest, and regeneration therapies accelerate healing and reduce complications.

5. Will I need to stop training completely?

Not necessarily. Our goal is intelligent load management, using cross-training to maintain cardiovascular fitness while protecting the injured site.

6. Can this affect my bone health long-term?

Yes—especially if RED-S is not addressed. Early management and bone health screening are essential to prevent chronic issues like osteopenia or osteoporosis.

When to Seek Help

If you’re an athlete experiencing persistent bone pain—especially if your performance is declining or your menstrual cycle has changed—it’s time to get assessed. Bone stress injuries and RED-S are serious medical issues, not just training side effects.

At MSK Doctors, we specialise in elite athlete care, motion diagnostics, and regenerative medicine, all under one roof. Our tailored care pathway ensures you're not just treated—but optimised for a stronger return.

No referral needed. Book your consultation today.