Back Pain Doctor
Bone Stress Injury (Stress Reaction & Stress Fracture)
Written by Dr Joshua Hatch, Musculoskeletal GP, RACGP Fellow, Diploma in Musculoskeletal Medicine (FSEM UK).
Bone stress injury often begins quietly: a sore spot on the shin, foot or hip that appears after a jump in training and gets worse with impact. Assessment focuses on a focal tender spot on the bone, the training and recovery history, footwear and surface, food intake and menstrual or hormonal history, and whether the site is one of the higher-risk locations such as the femoral neck, front of the shin, navicular or base of the fifth metatarsal. MRI is the reference test and allows grading.
First-line care is usually load management guided by symptoms, protected weight-bearing where the site or grade calls for it, attention to energy intake (see relative energy deficiency in sport), vitamin D and bone health, and a structured, stepwise return to sport. Higher-risk sites or slow healing may need orthopaedic input, and surgery is sometimes considered. Low energy availability is checked for as a driver of recurrence.
The GP role is early recognition, imaging and blood tests, screening for contributing factors and coordinating physiotherapy, sports medicine and dietitian input. Because some sites can progress to a complete fracture, persistent groin, front-of-shin or midfoot pain should be assessed, and running through it is unsafe. This page is educational information only. Bone pain with impact that does not settle within a week or two of reducing load should be seen by a GP, and sudden severe pain or inability to take weight needs same-day care.
Common symptoms
- A specific tender spot on a bone that hurts with impact
- Pain that builds with running or jumping and eases with rest
- Pain that follows a sudden rise in training or a change in footwear
- Pain at the groin, front of the shin or top of the foot that does not settle
Commonly seen in
Evidence for twelve treatment options in bone stress injury (stress reaction & stress fracture)
This is not a fixed ladder or a package of treatments. Every option is assessed independently against this diagnosis, including treatments with limited direct research that may still be reasonable for a clearly defined tissue target. The evidence level, likely benefit, risks, cost and alternatives are weighed at consultation.
Foundation: diagnosis, education and rehabilitation
The part of care with the broadest relevance. For many people it is enough on its own; other options are judged against it, not automatically added after it.
Diagnosis, education and progressive rehabilitation Working out what is driving the pain, explaining what your imaging does and does not mean, and building a graded loading plan you can actually follow. The priority
What it involves
Assessment to identify the likely pain source, an explanation of what the diagnosis means, adjustment of the loads that aggravate it, and a progressive strength and conditioning plan, with weight management where that is clinically relevant.
What the evidence shows
The sources reviewed for this page were the 2025 international Delphi consensus on bone stress injuries (Hoenig, Br J Sports Med; article text without the full statement tables), the 2021 meta-analysis of MRI grade and return to sport (Hoenig, Am J Sports Med) and a 2023 classification commentary (Warden). Australian guidance was not retrieved. The consensus panel recommended structured physical therapy and a stepwise return to sport guided by pain-free activity, bone-loading tests and palpation over the injury, taking account of site, severity and level of sport; it also agreed on load management, adequate energy intake and, for some lower-limb injuries, standard fracture care with immobilisation and partial weight-bearing. It noted that formal return-to-sport guidelines are lacking (Hoenig 2025). Mean return times in a 16-study meta-analysis were 41.7, 70.1, 84.3 and 98.5 days for MRI grades 1 to 4, with more than 90 per cent returning (Hoenig 2021).
Pairing reviewed 2026-10-24.
Where it fits
The starting point: confirm the grade and site, reduce load to what the bone tolerates, correct contributors such as energy intake and vitamin D, then progress loading in steps. Time frames are averages, not promises.
Muscle and symptom-modifying options
Useful only when the examination identifies the tissue they target or when short-term pain control creates a useful rehabilitation window.
Wet needling and trigger point injection (trigger point injection) A fine needle into a tender band of muscle, with a small volume of dilute glucose solution injected through it. Does not treat the condition
What it involves
The needle is placed into the tender muscle band and a small volume of 5% glucose with a very dilute local anaesthetic (0.02-0.08%) is injected. Often done in the same visit as your assessment, and usable where the tender area sits deeper. Dry needling (the same technique with nothing injected) is not offered here.
What the evidence shows
The sources reviewed for this page were the 2025 international Delphi consensus on bone stress injuries (Hoenig, Br J Sports Med; article text without the full statement tables), the 2021 meta-analysis of MRI grade and return to sport (Hoenig, Am J Sports Med) and a 2023 classification commentary (Warden). Australian guidance was not retrieved. Needling is not among the treatments in the consensus and does not address bone.
Pairing reviewed 2026-10-24.
Where it fits
Not offered for bone stress injury. Healing depends on load management and the factors that caused the injury, and higher-risk sites need orthopaedic input.
Ultrasound-guided injections Guidance means the needle can be seen reaching the target. What goes into the needle depends on the diagnosis. Does not treat the condition
What it involves
The injection is performed under ultrasound so the needle can be watched into the target structure. What is injected is decided by the diagnosis, and corticosteroid is used sparingly, for the reasons set out below.
What the evidence shows
The sources reviewed for this page were the 2025 international Delphi consensus on bone stress injuries (Hoenig, Br J Sports Med; article text without the full statement tables), the 2021 meta-analysis of MRI grade and return to sport (Hoenig, Am J Sports Med) and a 2023 classification commentary (Warden). Australian guidance was not retrieved. Injection into soft tissue is not among the consensus treatments, and corticosteroid in an unhealed bone injury is not supported by the sources reviewed.
Pairing reviewed 2026-10-24.
Where it fits
Not offered for bone stress injury. Healing depends on load management and the factors that caused the injury, and higher-risk sites need orthopaedic input.
V-ACTOR vibration therapy (vibration therapy) Low-frequency vibration applied over tender muscle. Not a shockwave, despite sharing the machine. Does not treat the condition
What it involves
A vibration handpiece is moved over the tender muscle and fascia for a few minutes. It runs from the same STORZ MASTERPULS icon console as radial shockwave but is a separate handpiece delivering a different, gentler form of energy. No needles, no anaesthetic, no downtime.
What the evidence shows
The sources reviewed for this page were the 2025 international Delphi consensus on bone stress injuries (Hoenig, Br J Sports Med; article text without the full statement tables), the 2021 meta-analysis of MRI grade and return to sport (Hoenig, Am J Sports Med) and a 2023 classification commentary (Warden). Australian guidance was not retrieved. Vibration-based devices do not reach bone and are not part of the consensus.
Pairing reviewed 2026-10-24.
Where it fits
Not offered for bone stress injury. Healing depends on load management and the factors that caused the injury, and higher-risk sites need orthopaedic input.
Energy-based treatment options
Radial pressure wave, focused shockwave and EMTT have different targets and different evidence. They are assessed separately rather than treated as one category.
Radial or focused shockwave? Read the overviewRadial shockwave (radial pressure wave) Broad treatment across tender muscle and fascia, close to the surface. Does not reach bone
What it involves
A handpiece is moved over the tender tissue while ballistic pressure pulses are delivered, using a transmitter head chosen for the tissue, including heads shaped for fascia and for the muscle either side of the spine. The pulse is strongest at the skin and weakens with depth, so this is mainly a myofascial treatment, though it can reach deeper in some areas. No anaesthetic, no downtime, usually a course of sessions about a week apart.
What the evidence shows
The sources reviewed for this page were the 2025 international Delphi consensus on bone stress injuries (Hoenig, Br J Sports Med; article text without the full statement tables), the 2021 meta-analysis of MRI grade and return to sport (Hoenig, Am J Sports Med) and a 2023 classification commentary (Warden). Australian guidance was not retrieved. Radial pressure waves are absorbed in superficial tissue. The consensus panel did not reach agreement on extracorporeal shockwave as a bone stimulation method (Hoenig 2025).
Pairing reviewed 2026-10-24.
Where it fits
Not offered for bone stress injury. Healing depends on load management and the factors that caused the injury, and higher-risk sites need orthopaedic input.
Focused shockwave (ESWT) A true shock wave converging at depth: for tendon, joint, ligament and bone. No consensus
What it involves
A focused system generates an acoustic shock wave that converges at a focal point set at a defined depth, concentrating the energy where the target is. This is the form used for tendon, joint, ligament and bone. Typically four to six sessions about a week apart, no anaesthetic and no formal downtime.
What the evidence shows
The sources reviewed for this page were the 2025 international Delphi consensus on bone stress injuries (Hoenig, Br J Sports Med; article text without the full statement tables), the 2021 meta-analysis of MRI grade and return to sport (Hoenig, Am J Sports Med) and a 2023 classification commentary (Warden). Australian guidance was not retrieved. The consensus panel did not reach agreement on extracorporeal shockwave, low-intensity pulsed ultrasound or electromagnetic stimulation as treatment for bone stress injury (Hoenig 2025). Case-series evidence in resistant stress fractures is described on the foot and ankle stress fracture page and was not re-reviewed here.
Pairing reviewed 2026-10-24.
Where it fits
Not part of the standard care of a bone stress injury. Discussed only for an injury that has not healed on a proper offloading programme, on the understanding that the evidence is limited.
EMTT (magnetotransduction therapy) High-energy magnetic pulses applied over the area. Usually painless, no contact. No consensus
What it involves
You sit with the applicator positioned over the area for a short session. It is usually painless and needs no gel or skin contact. It is usually given as a course, commonly alongside shockwave.
What the evidence shows
The sources reviewed for this page were the 2025 international Delphi consensus on bone stress injuries (Hoenig, Br J Sports Med; article text without the full statement tables), the 2021 meta-analysis of MRI grade and return to sport (Hoenig, Am J Sports Med) and a 2023 classification commentary (Warden). Australian guidance was not retrieved. Electromagnetic stimulation did not reach consensus as a bone stress injury treatment (Hoenig 2025), and no trial in bone stress injury was identified in the sources reviewed.
Pairing reviewed 2026-10-24.
Where it fits
Not offered as treatment for the injury itself. At most an adjunct alongside offloading and bone health, after the evidence gap is explained.
Biologic and joint injection options
Each injection is assessed independently for the named diagnosis. Cost, uncertainty, likely benefit, risks and alternatives are part of the decision.
Platelet-rich plasma (PRP) Your own blood, concentrated and injected under ultrasound guidance. No consensus
What it involves
Blood is taken from your arm, spun to concentrate the platelets, and injected into the target under ultrasound guidance in the same appointment.
What the evidence shows
The sources reviewed for this page were the 2025 international Delphi consensus on bone stress injuries (Hoenig, Br J Sports Med; article text without the full statement tables), the 2021 meta-analysis of MRI grade and return to sport (Hoenig, Am J Sports Med) and a 2023 classification commentary (Warden). Australian guidance was not retrieved. Platelet-rich and bone marrow aspirate injections did not reach consensus as bone stress injury treatment (Hoenig 2025). Higher-risk sites that fail to heal go to orthopaedic assessment.
Pairing reviewed 2026-10-24.
Where it fits
Not offered for bone stress injury. Healing depends on load management and the factors that caused the injury, and higher-risk sites need orthopaedic input.
Prolotherapy (dextrose) A course of dextrose injections into and around the structure and its attachments. No consensus
What it involves
Hypertonic dextrose is injected at the tender ligament and tendon attachments, and into the joint where relevant, usually as a series of treatments a few weeks apart.
What the evidence shows
The sources reviewed for this page were the 2025 international Delphi consensus on bone stress injuries (Hoenig, Br J Sports Med; article text without the full statement tables), the 2021 meta-analysis of MRI grade and return to sport (Hoenig, Am J Sports Med) and a 2023 classification commentary (Warden). Australian guidance was not retrieved. Prolotherapy is not mentioned in the consensus, and biological adjuncts did not reach consensus (Hoenig 2025).
Pairing reviewed 2026-10-24.
Where it fits
Not offered for bone stress injury. Healing depends on load management and the factors that caused the injury, and higher-risk sites need orthopaedic input.
Viscosupplementation (hyaluronic acid) A gel-like injection into an arthritic joint. Widely used, and genuinely contested. Wrong problem
What it involves
One or a short series of hyaluronic acid injections into the joint under ultrasound guidance.
What the evidence shows
The sources reviewed for this page were the 2025 international Delphi consensus on bone stress injuries (Hoenig, Br J Sports Med; article text without the full statement tables), the 2021 meta-analysis of MRI grade and return to sport (Hoenig, Am J Sports Med) and a 2023 classification commentary (Warden). Australian guidance was not retrieved. Hyaluronic acid is used in arthritic joints, not in bone.
Pairing reviewed 2026-10-24.
Where it fits
Not used for bone pain.
Nerve-targeted options
Relevant when examination identifies a superficial neuropathic pattern or a compressed peripheral nerve, not simply because pain is present.
Lyftogt perineural therapy (perineural injection therapy) A series of small dilute dextrose injections just under the skin, over tender superficial nerves. Does not treat the condition
What it involves
Small injections of low-concentration dextrose, usually 5%, placed just beneath the skin along tender superficial nerves. Given as a series of short sessions.
What the evidence shows
The sources reviewed for this page were the 2025 international Delphi consensus on bone stress injuries (Hoenig, Br J Sports Med; article text without the full statement tables), the 2021 meta-analysis of MRI grade and return to sport (Hoenig, Am J Sports Med) and a 2023 classification commentary (Warden). Australian guidance was not retrieved. Perineural injection does not treat bone injury and is not part of the consensus.
Pairing reviewed 2026-10-24.
Where it fits
Not offered for bone stress injury. Healing depends on load management and the factors that caused the injury, and higher-risk sites need orthopaedic input.
Ultrasound-guided nerve hydrodissection Fluid placed around a nerve to free it from the surrounding tissue. Does not treat the condition
What it involves
Under ultrasound, fluid is placed in the plane around the nerve to separate it from the tissue that is tethering or compressing it.
What the evidence shows
The sources reviewed for this page were the 2025 international Delphi consensus on bone stress injuries (Hoenig, Br J Sports Med; article text without the full statement tables), the 2021 meta-analysis of MRI grade and return to sport (Hoenig, Am J Sports Med) and a 2023 classification commentary (Warden). Australian guidance was not retrieved. Hydrodissection addresses nerve entrapment, not bone injury.
Pairing reviewed 2026-10-24.
Where it fits
Not offered for bone stress injury. Healing depends on load management and the factors that caused the injury, and higher-risk sites need orthopaedic input.
This is general information only and suitability is assessed individually. Treatments with limited or condition-dependent evidence may still be discussed, but only with clear explanation of the uncertainty, the expected benefit, risks, cost and alternatives. Red flags, progressive neurological symptoms or suspected serious pathology require a different pathway.
Every treatment above is described in full on the non-surgical treatments page, including what each one is used for and what the evidence supports. Ratings apply to the named diagnosis; an adjacent muscle, tendon, joint or nerve problem is assessed as a separate target. The method behind the ratings, and the treatments not offered, are set out on the evidence page.
Corticosteroid injection is reviewed separately for each diagnosis.
Cortisone reliably reduces pain in the short term, and that can be genuinely useful when pain is stopping you sleeping or moving enough to rehabilitate. Beyond that window the picture changes. A systematic review of 41 randomised trials and 2,672 participants found that corticosteroid injection reduced pain in the short term but that the effect reversed at intermediate and long term; in pooled analysis for lateral epicondylalgia the short-term effect was large (SMD 1.44, 95% CI 1.17 to 1.71) while no intervention was favoured at 26 weeks (-0.40, -0.67 to -0.14) and at 52 weeks (-0.31, -0.61 to -0.01) (Coombes, Lancet 2010). In a randomised trial in lateral epicondylalgia, 83 per cent of the corticosteroid group had completely recovered or much improved at one year against 96 per cent given a placebo injection, and recurrence ran at 54 per cent against 12 per cent; adding physiotherapy made no significant difference at one year (Coombes, JAMA 2013). In joints, repeated corticosteroid injections have been associated with cartilage loss. It does not repair anything.
So treatment plans are not built around it. Where an injection is the right call, the specific diagnosis and target are reviewed, what is being injected and why is discussed, the number is kept low, and it is paired with the loading work that changes the longer-term course.
When it might still be considered
- Pain severe enough to block rehabilitation
- A clear inflammatory or bursal target on imaging
- A specific short-term goal: a trip, a procedure, a return to work
- Diagnostic use, where the response shows where the pain is coming from
When a cortisone injection is worth doing, and when it is not
Other general conditions
Pain in the same area can come from more than one source, and the label matters less than what the examination and history point to. These are the other guides for this region.
Related articles
Shorter articles that answer the questions patients ask most often about this.
Frequently asked questions
What is the difference between a stress reaction and a stress fracture?
How long until I can return to sport?
Why did it happen, and does anything speed healing?
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