Bone Stress Injuries and Bone Health for Endurance Athletes
Bone health is a foundational aspect of athletic performance, yet it’s often overlooked until injury strikes. For endurance athletes, especially runners, maintaining healthy bones is critical to sustaining training and avoiding setbacks. Dr. Steph Mundt, a physical therapist and running coach, shared key insights at our Skadi Athlete Summit, outlining practical strategies to manage and prevent bone stress injuries. Below, we explore these strategies and how endurance athletes can integrate them into their routines.
What Are Bone Stress Injuries?
Bone stress injuries occur when the strain on a bone exceeds its capacity to recover. These injuries exist on a spectrum, ranging from stress reactions to full stress fractures. While injuries affecting tendons or muscles may allow modified training, bone stress injuries require rest to avoid worsening the condition. Some high-risk sites for bone stress injuries, such as the femoral neck or sacrum, even have the potential to require surgical intervention if not managed appropriately.
For many athletes, bone stress injuries are a wake-up call, as they often occur due to deeper issues such as low energy availability, poor recovery practices, or insufficient strength training.
Key Factors Influencing Bone Health
Several factors affect bone health, many of which are modifiable. These include energy availability, training load, recovery practices, and strength training. Non-modifiable factors, like genetics and health history, also play a role and may increase risk.
The Role of Energy Availability
Consuming adequate energy and macronutrients is crucial in supporting strong bones. Energy availability refers to the balance between the energy an athlete consumes through food and the energy expended during training and daily activities. Without sufficient energy, the body makes trade-offs, often sacrificing bone health.
Low energy availability triggers hormonal changes that can weaken bones and increase the risk of injury over time. For athletes who menstruate, this might show up as irregular cycles or amenorrhea (absence of menstruation)—both significant red flags for potential bone health issues.
Action Step: Work with a sports dietitian to ensure you’re meeting the energy demands of your training. Carbohydrates, in particular, are critical for bone formation during exercise.
Strength Training for Bone Health
Strength training is an effective strategy to build and maintain bone mineral density. Targeted exercises help bones adapt by increasing their ability to handle mechanical load. Dr. Mundt emphasized heavy axial loading exercises, such as back squats, as well as plyometric exercises that enhance bone strength in areas like the hips and spine.
Recommended Approach:
Perform heavy lifts, such as squats or deadlifts, with weights appropriate to your ability (80–90% of your one-rep max) 2–3 times a week.
Incorporate short bouts of plyometrics (e.g., jump squats) 3–6 times per week, keeping sessions short and focused for optimal benefits.
How to Prevent Bone Stress Injuries
While not all bone stress injuries are avoidable, you can reduce your risk significantly by prioritizing certain habits and practices.
1. Prioritize Recovery
Proper recovery isn’t just about avoiding burnout; it’s essential for bone remodeling, the process by which bones repair and strengthen in response to training. Plan for at least one to two full rest days weekly and include low-impact “reset” weeks every 12 weeks to allow the body to adapt.
2. Individualize Training Plans
Training loads are personal and vary by athlete and season. What worked for you in one training cycle may not work in another. The key is to gradually build mileage and incorporate rest weeks. Avoid changing multiple variables in training—like increasing both volume and intensity—simultaneously.
3. Eat Enough—Especially Carbs
Low-carb diets are popular in some endurance circles, but they can impair bone health. Studies show that insufficient carbohydrate intake decreases bone formation and mineral density. A well-fueled body supports recovery and minimizes injury risk.
4. Focus on Strength
Strength training is especially valuable for athletes with a history of bone stress injuries. By progressively loading muscles and bones, strength work helps restore capacity and improve performance over time.
5. Know When to Rest
Pay attention to pain that feels localized, worsens with activity, or persists at night. For high-risk sites, like the femoral neck or sacrum, rest and imaging (like an MRI) are critical to avoid serious complications.
Recovery from Bone Stress Injuries
Recovery from a bone stress injury takes time, and the timeline varies based on the location and severity of the injury. High-risk sites or more severe injuries may require 3–6 months before a full return to running, while low-risk injuries can take as little as eight weeks.
Key Recovery Principles:
Offload as needed: Use crutches or a boot for high-risk injuries, but avoid total offloading for low-risk injuries to prevent muscle and bone density loss.
Gradual reloading: Return to activity should be progressive and intentional, starting with low-impact exercises before reintroducing running.
Strength work: Begin with exercises that load the injured bone as tolerated, progressing to heavier lifts over time.
For a deeper dive into recovery techniques and how psychology supports physical healing, explore The Ultimate Guide to Athlete Injury Recovery and Sport Psychology Techniques for Peak Performance.
Key Takeaways
Bone stress injuries can create a major setback, but they also present an opportunity to reevaluate your habits, training, and recovery practices.
Fuel first: Make adequate energy and carbohydrate intake a priority.
Train smart: Use progressive, individualized training plans that incorporate regular rest.
Strengthen wisely: Focus on heavy lifts and plyometric exercises to build bone density over time.
Pay attention to early signs: If you suspect a BSI, rest and seek medical evaluation promptly.
Endurance athletes push their bodies to incredible limits, and supporting bone health is essential for longevity and sustained performance. By incorporating these strategies, you can minimize your risk of bone stress injuries, recover effectively, and become a stronger, healthier athlete.
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