What are the treatment options for a runner with symptoms of a tibia bone stress injury?

Treatment Options for Tibial Bone Stress Injury in Runners

The optimal treatment for a tibial bone stress injury in runners requires a graduated return-to-running program that begins only after the athlete is pain-free during daily activities for at least 10-14 days, with progressive loading guided by symptom response. 1

Initial Recovery Phase

• Rest from running until the athlete is pain-free with walking and daily activities for 10-14 consecutive days 1, 2
• Progress to 30-45 minutes of continuous pain-free walking before introducing any running-related loads 1, 3
• Ensure complete resolution of bony tenderness on palpation, which is crucial before advancing to more demanding exercises 2
• Assess lower extremity functional movements and strength before introducing running-related loads 2, 1
• Location of the injury should guide management - anterior tibial cortex injuries (high-risk) require more conservative management than posteromedial (low-risk) injuries 2

Strength Training Components

• Incorporate strengthening exercises targeting local muscles including calf and tibialis anterior 2, 1
• Add proximal strength training for hip and core muscles to improve biomechanics 2
• Address muscle flexibility, particularly in the calf and hamstring 2, 1
• Aim for 75-80% lower extremity strength symmetry before introducing running-related loads 2
• Use the single leg hop test to assess readiness for return to running 2, 1

Graduated Return-to-Running Protocol

Initial Running Progression

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

Surface Considerations

• Start running on a treadmill or more compliant surface 2, 1
• Avoid hard surfaces, hills, and uneven terrain during early recovery 2
• Progress to level surfaces before introducing hills 2, 1
• Vary terrain only once back to normal training 2, 1

Load Progression

• Increase distance before increasing speed - build to 50% of pre-injury distance before introducing speed work 2
• Follow the "10% rule" for weekly distance increases as a general guideline 2, 1
• Achieve specific distance milestones (30-45 minutes of continuous running) before introducing speed work 2
• Temporarily reduce running volume when increasing speed 2

Addressing Contributing Factors

• Evaluate and correct biomechanical abnormalities that may have contributed to the injury 2
• Consider gait retraining to reduce vertical loading rates 2
• Assess for and address nutritional factors and energy availability issues, especially in female runners 2, 4
• Evaluate footwear and consider appropriate changes or orthotic use if indicated 2, 5
• Modify training errors that may have contributed to the injury (excessive mileage increases, inadequate recovery) 2, 5

Special Considerations

• High-risk tibial stress injuries (anterior cortex) require radiological evidence of healing before return to running 2
• Female runners may require a more conservative progression due to higher tibial bone stresses across running speeds 1, 4
• Severity/grade of injury should guide progression rate - higher grade injuries require slower progression 2
• Recurrence rates for tibial stress injuries are high (up to sixfold in females and sevenfold in males), emphasizing the importance of addressing all contributing factors 2, 4

Common Pitfalls to Avoid

• Returning to running too soon (before pain-free walking for 10-14 days) 1, 3
• Increasing running speed before adequate distance is achieved 2
• Ignoring pain during or after running sessions 2
• Failing to address biomechanical issues and contributing factors 2
• Neglecting strength training of local and proximal muscles 2
• Running on inappropriate surfaces during early recovery 2