Bone stress injury in young athletes
A bone stress injury occurs when repeated loading exceeds the bone's ability to recover and adapt. In young athletes, growth, increases in training, recovery, and energy and nutrient availability are particularly important factors.
Localized pain in a specific area that mainly occurs during or after running and jumping and improves with rest. There may be focal tenderness over the bone.
Bone stress injuries usually develop gradually through repeated loading such as running, jumping, and changes of direction. Rapid increases in training volume or intensity can increase stress on bone.
Contributing factors in young athletes
- •Rapid increase in training load
- •High volumes of running and jumping
- •Insufficient recovery
- •Periods of growth
- •Insufficient energy or nutrient intake
- •Previous bone stress injury
- •Insufficient variation in training load
Prevention involves balancing training load and recovery while ensuring adequate energy and nutrition during both training and growth.
- •Increase training load gradually
- •Plan recovery days
- •Vary running, jumping, and other impact loading
- •Ensure adequate energy and nutrient intake
- •Act early on persistent focal bone pain
- •Monitor athletes with previous bone stress injuries carefully
Stop or reduce impact activities that provoke pain. Avoid repeatedly testing the injury with hopping or running.
Load management
Reduce impact loading and maintain only activities that are symptom-controlled.
Goals
Reduce focal bone pain.
Progression criteria
Daily activities and low-load exercise are pain-free.
Gradual loading
Load is gradually increased through strengthening followed by progressive reintroduction of impact.
Goals
Restore normal load tolerance.
Progression criteria
Progressive loading is tolerated without recurrence of focal bone pain.
- No focal bone pain during daily activities
- Strength training is tolerated
- Gradual running is tolerated
- Jumping and changes of direction are tolerated
- Football training can be completed without pain
The information in the Injury Center is for educational purposes and does not replace professional medical advice. Always consult a qualified healthcare professional for diagnosis and treatment.
Bone stress injury in young athletes
A bone stress injury occurs when repeated loading exceeds the bone's ability to recover and adapt. In young athletes, growth, increases in training, recovery, and energy and nutrient availability are particularly important factors.
Mild — Ofta flera veckor, men varierar beroende på lokalisation och omfattning.
Symptoms
Localized pain in a specific area that mainly occurs during or after running and jumping and improves with rest. There may be focal tenderness over the bone.
Acute Treatment
Stop or reduce impact activities that provoke pain. Avoid repeatedly testing the injury with hopping or running.
Rehabilitation
Reduce impact loading and maintain only activities that are symptom-controlled.
Goals
Reduce focal bone pain.
Progression criteria
Daily activities and low-load exercise are pain-free.
Load is gradually increased through strengthening followed by progressive reintroduction of impact.
Goals
Restore normal load tolerance.
Progression criteria
Progressive loading is tolerated without recurrence of focal bone pain.
Return to Play
- ☐ No focal bone pain during daily activities
- ☐ Strength training is tolerated
- ☐ Gradual running is tolerated
- ☐ Jumping and changes of direction are tolerated
- ☐ Football training can be completed without pain
Moderate — Ofta 6–12 veckor eller längre beroende på lokalisation, omfattning och biologiska faktorer.
Symptoms
Focal bone pain that recurs during activity and affects running or jumping. Pain may persist after training and tenderness over the bone is often clear.
Acute Treatment
Impact training should be reduced or stopped and medical assessment should be considered. Continuing to load through clear focal bone pain may worsen a bone stress injury.
Rehabilitation
The location and severity of the injury are assessed and load is modified.
Goals
Prevent progression and create conditions for healing.
Progression criteria
Daily loading is pain-free and medical assessment allows progression.
Strength is maintained while loading is gradually rebuilt.
Goals
Restore full load tolerance.
Progression criteria
Strength and progressively increasing load are tolerated without bone pain.
Running, jumping, and football-specific loading are gradually reintroduced.
Goals
Tolerate the impact and running demands of competition.
Progression criteria
Full football training is tolerated without pain or a post-training reaction.
Return to Play
- ☐ Medical assessment has been completed when bone stress injury is suspected
- ☐ No focal bone pain during daily activities
- ☐ Strength and function are restored
- ☐ Running and jumping are tolerated
- ☐ Full training is tolerated without a post-training reaction
Severe — Kan kräva flera månader beroende på lokalisation och omfattning. Vissa lokalisationer har högre risk för komplikationer och kräver längre uppföljning.
Symptoms
Pain with walking or at rest, night pain, significant swelling, marked focal tenderness, or inability to bear weight may indicate a more extensive bone stress injury or stress fracture.
Acute Treatment
Stop impact activity and seek medical assessment. Some locations may require protected weight-bearing or other treatment. Do not test the injury by hopping or running.
Rehabilitation
The location and risk level determine the need for unloading, imaging, and follow-up.
Goals
Ensure healing and prevent progression.
Progression criteria
Medical assessment confirms that loading can be increased.
Loading progresses gradually from daily activities to strengthening, running, and sport.
Goals
Restore full load tolerance without recurrence of bone pain.
Progression criteria
Full football-specific loading is tolerated and medical assessment allows competition.
Return to Play
- ☐ Medical assessment has been completed
- ☐ The injury has healed according to the medical plan
- ☐ No focal pain during daily loading
- ☐ Running, jumping, and changes of direction are tolerated
- ☐ Full training is tolerated
- ☐ Medical clearance for relevant stress fractures or high-risk locations
When to Seek Medical Care
Persistent focal bone pain related to loading should be assessed, particularly in young athletes with rapidly increasing training loads.
- Pain recurring at exactly the same location
- Pain worsening with running or jumping
- Pain during walking
- Pain at rest or at night
- Marked focal bone tenderness or swelling
- Previous bone stress injury
- Concurrent signs of low energy availability
References
- International Delphi consensus on bone stress injuries in athletes — British Journal of Sports Medicine (https://doi.org/10.1136/bjsports-2024-108616)
- 2023 IOC consensus statement on RED-S — International Olympic Committee (https://doi.org/10.1136/bjsports-2023-106994)