The Natural History of Bone Stress Injuries in Athletes: How Physical Therapy in Denver Can Keep You Training Strong

Rise RSP
Sep 4
4 min read

Introduction

For athletes training at high volumes — whether it’s running, soccer, basketball, or skiing — few diagnoses are as frustrating as a bone stress injury (BSI). Unlike a quick ankle sprain, BSIs represent a spectrum of bone overload conditions that can take months to heal and derail entire seasons.

A recent review article, “The Natural History of Bone Stress Injuries in Athletes: From Inception to Resolution,” explored how BSIs develop, how long they last, and what factors influence recovery. For Denver athletes pushing limits in high-altitude training environments, this research has clear implications.

Most importantly, it underscores a message we emphasize daily: physical therapy plays a critical role in both preventing and managing bone stress injuries.

What Are Bone Stress Injuries?

Bone stress injuries occur when bones are subjected to repeated loading without enough time to recover and remodel. They exist on a continuum:

Stress Reaction: Early bone edema and microscopic changes — often painful but without a visible fracture line.
Stress Fracture: More advanced injury with a distinct fracture line detectable on imaging.

Athletes most at risk are those in high-impact sports or with sudden training increases — marathon runners, gymnasts, dancers, military recruits, and team sport athletes.

Common Risk Factors:

Extrinsic: Training errors, surface changes, poor footwear.
Intrinsic: Low energy availability (RED-S), vitamin D deficiency, menstrual irregularities, biomechanical imbalances, prior injury.

The “Natural History” of BSIs

The reviewed article emphasizes that bone stress injuries:

Develop Gradually: They rarely appear overnight. Instead, they follow weeks or months of cumulative microtrauma.
Have Predictable Healing Timelines:
- Low-risk sites (posterior tibia, fibula, metatarsals) may heal in 6–12 weeks.
- High-risk sites (navicular, femoral neck, anterior tibia) may require 4–9 months or longer.
Relapse Is Common: Without addressing the underlying cause, reinjury rates are high.

This natural history makes early detection, guided load management, and structured rehabilitation critical. That’s where physical therapy comes in.

How Physical Therapy Guides Recovery

1. Early Identification

Athletes often ignore early signs of BSIs, dismissing them as “shin splints” or “training soreness.” Physical therapists are trained to spot red flags:

Focal bone tenderness.
Pain that worsens with activity and lingers afterward.
Night pain in more advanced cases.

Through movement assessments and clinical tests, PTs can help determine when imaging (MRI, bone scan) is warranted.

2. Managing the Acute Stage

Once a stress injury is confirmed, the first step is offloading the injured bone. Depending on severity, this may include:

Activity modification or temporary cessation of high-impact training.
Assistive devices (crutches, walking boot) for more severe cases.

But this doesn’t mean “do nothing.” Physical therapy focuses on:

Maintaining cardiovascular fitness with non-impact cross-training (swimming, cycling, pool running).
Preserving strength in unaffected muscle groups.
Educating athletes on nutrition, rest, and recovery strategies essential for bone healing.

3. Restoring Strength & Correcting Imbalances

As pain decreases and healing progresses, PT shifts focus toward addressing the underlying risk factors:

Muscle Imbalances: Weak hip abductors, calf deficits, or poor core control can alter loading on bones.
Movement Patterns: PTs analyze running mechanics, cutting drills, or landing strategies to identify excessive stress points.
Flexibility & Mobility: Limited ankle dorsiflexion or hip extension can redistribute forces in harmful ways.

Example: A Denver marathoner with tibial stress reaction may need progressive calf strengthening and gait retraining to prevent excessive heel strike loading.

4. Return-to-Sport Progression

PTs structure a gradual return-to-play program:

Stage 1: Pain-free daily activity, walking without discomfort.
Stage 2: Controlled loading — anti-gravity treadmill, aquatic running.
Stage 3: Gradual reintroduction of impact (walk/jog intervals).
Stage 4: Sport-specific drills and progressive return to competition.

This structured progression prevents setbacks and ensures athletes return stronger than before.

Why Physical Therapy Matters for Denver Athletes

Training in Denver — with its altitude, variable terrain, and endurance-focused community — places unique stress on athletes’ bones. Elevation can alter recovery demands, while trails and hills increase loading variability.

Here’s why local athletes benefit from working with RISE Rehab and Sport Performance:

Expert Screening: We regularly see endurance athletes and understand altitude-related load challenges.
Individualized Programming: Training loads can be adjusted to account for trail running, skiing, and high-mileage road work.
Community Connection: We work directly with local running clubs, cycling teams, and collegiate athletes. Plus we are in the community doing the same activities as you!

In short: Denver athletes face unique demands — and local physical therapy providers are best equipped to meet them.

Prevention: The Real Opportunity

While PTs excel at managing injuries, the real win comes from prevention. Evidence shows that bone stress injuries are often predictable and preventable with the right strategies:

Preventive Physical Therapy Strategies:

Strength Training: Unilateral lower limb exercises (single-leg squats, calf raises, hip strengthening).
Load Monitoring: Educating athletes to increase weekly mileage or training volume by no more than 10%.
Running Mechanics: Cadence training, midfoot strike promotion, reducing excessive impact forces.
Nutrition Guidance: Collaboration with dietitians to address RED-S or vitamin/mineral deficiencies.
Recovery Optimization: Emphasis on sleep, periodization, and rest days.

A PT-led injury screening and prevention program in the offseason can drastically reduce stress fracture incidence.

The Role of Education

One of the most powerful roles of physical therapy is athlete education. Many athletes equate more training with more fitness, but PTs teach:

The importance of bone remodeling cycles.
Warning signs that shouldn’t be ignored.
The value of strength training as a performance enhancer, not just injury prevention.

Denver-based athletes benefit from PTs who combine clinical expertise with an understanding of the endurance community’s mindset.

Key Takeaways

Bone stress injuries represent a continuum from stress reactions to full stress fractures.
They follow a predictable natural history — with long recovery times if not managed correctly.
Physical therapy plays a vital role at every stage: early detection, acute management, rehab, and return-to-sport.
For athletes in Denver, RISE offers locally tailored prevention and recovery strategies, accounting for the demands of altitude, terrain, and training culture.
The biggest opportunity? Prevention through proactive PT screening and training programs.

Call to Action

If you’re an athlete training in Denver — whether for marathons, triathlons, skiing, or team sports — don’t wait for a bone stress injury to set you back.

At Rise Rehab and Sport Performance, our physical therapy team specializes in: