What is the treatment for a runner with a tibia bone stress injury?

Treatment for Tibial Bone Stress Injury in Runners

The treatment for a runner with a tibial bone stress injury should include a period of rest until pain-free walking is achieved, followed by a graduated return to running program with progressive loading, while addressing biomechanical factors and incorporating appropriate strengthening exercises. 1, 2

Initial Recovery Phase

• Rest from running until the athlete has been pain-free with walking and activities of daily living for at least 10-14 days 2
• Ensure complete resolution of bony tenderness on palpation before advancing to more demanding exercises 1, 2
• Progress to 30-45 minutes of continuous pain-free walking before introducing running-related loads 1, 2
• For high-risk tibial BSIs (anterior tibial cortex), evidence of radiological healing should be confirmed before returning to running 1

Graduated Return to Running Program

Initial Running Protocol

• Begin with a walk-run interval program on alternate days to allow bone cells to regain mechanosensitivity 1, 2
• Start with 30-60 second running intervals interspersed with 60-second walking periods 1, 2
• Run at 30-50% of usual pace initially 1
• Monitor for pain during and after exercise - if pain occurs, rest until symptoms resolve, then resume at a lower level 1

Surface and Terrain Considerations

• Start running on a treadmill or moderate firmness surface 1
• Avoid hard surfaces, hills, and irregular/uneven terrain initially 1
• Limit multiple terrains in early stages of return 1
• Progress to varied terrain only once back to normal training 1

Load Progression

• Increase distance before increasing speed 1
• Follow the "10% rule" for weekly distance increases, though this should be individualized based on symptom response 1
• Progress to half pace strides only after achieving 30-45 minutes of continuous running 1
• Hold distance steady when increasing speed 1

Strength and Biomechanical Interventions

• Address lower extremity biomechanics through gait retraining 1
• Consider reducing stride length and increasing cadence to reduce vertical loading rates 1
• Incorporate strengthening exercises for:
  • Calf muscles 1
  • Hip muscles 1
  • Dorsiflexors and intrinsic foot muscles 1
  • Core muscles 1
• Include flexibility exercises, particularly for calf and hamstring muscles 1
• Consider orthotics for runners with excessive pronation or supination 1

Special Considerations

• Progression should be guided by:
  • Location of injury (high-risk vs. low-risk) 1
  • Grade/severity of injury 1
  • Previous running level 1
• High-risk tibial BSIs (anterior cortex) require longer recovery times and more gradual progression 1
• Use the single leg hop test to assess readiness for return to running 1
• Female runners may need more conservative progression due to higher risk of recurrence 1
• Address any underlying risk factors such as Relative Energy Deficiency in Sport (REDs) or low energy availability 1

Common Pitfalls to Avoid

• Returning to running too soon (before resolution of bony tenderness) 1, 2
• Progressing running volume or intensity too quickly 1
• Neglecting strength training during rehabilitation 1
• Failing to address biomechanical factors that contributed to the injury 1
• Running on hard or uneven surfaces too early in rehabilitation 1
• Ignoring pain during the return to running process 1