Bone Stress Injuries in Endurance Athletes: A Review of Risk Factors, Screening and Evaluation Pearls, Preventive Strategies, and Evidence-Based Management Approaches.

Bone stress injury is a common musculoskeletal condition presenting with insidious bony pain that is progressive and occurs with a number of intrinsic or extrinsic risk factors, particularly with a recent change in training. When elicited, the presence of bony tenderness remains the most important component of the physical exam, although reproduction at deeper sites is a challenge and requires a high index of suspicion and imaging for diagnosis. MRI should be utilized as the gold standard for diagnosis, grading, and return-to-sport timing prognosis when available, with plain radiographs used as first-line imaging. Careful management of training loads, appropriate periodization and rest, gradual progression, resistance training, and nutrition optimization are important for bone stress injury prevention. In bone stress injury treatment, identification of low-risk versus high-risk sites in conjunction with addressing modifiable risk factors and a two-phased approach of mechanical load control and pain-free progression will optimize recovery.