Etiology — what causes it

Cumulative microdamage exceeding bone's adaptive capacity. Contributors include training error, energy availability deficit (REDS), prior bone stress injury, female athlete triad, biomechanical factors, and footwear changes.

Epidemiology — who gets it

Common in runners, military recruits, and athletes after volume spikes. Tibia (compression side) is the most common site; femoral neck, navicular, and metatarsals are higher-risk locations requiring careful management.

Clinical signs

Focal bony tenderness, pain with weight-bearing, positive hop test on the affected limb, possibly positive fulcrum test. Imaging staging — MRI is the modern standard for early diagnosis (Kaeding-Miller and Fredericson classifications).

Symptoms

Localized bony pain, often progressive over weeks. May start as activity-related discomfort, progress to pain during activity, then pain at rest. Night pain is a concerning sign.

Best evidence for chiropractic treatment

Staged return to running based on symptom resolution and imaging healing. Energy availability assessment (RED-S screening) and nutritional counseling. Cross-training (cycling, pool running) to maintain fitness during deload. High-risk locations (femoral neck tension side, navicular, anterior tibial cortex) often warrant longer protection and orthopedic consultation.

Subtypes

  • Low-risk (medial tibia, fibula, distal radius). Symptom-guided return.
  • High-risk (femoral neck tension side, navicular, anterior tibial cortex, 5th metatarsal proximal). Imaging-guided, often surgical consultation, prolonged protection.

When to seek emergency care

Some symptoms need urgent medical attention — not a chiropractic visit. Call 911 or go to the nearest emergency department for: progressive limb weakness, loss of bowel or bladder control, saddle anesthesia (numbness in the groin/inner thighs), severe unrelenting pain unrelieved by position, signs of fracture after significant trauma, chest pain, stroke-like symptoms (face drooping, arm weakness, speech changes), or any rapidly worsening or unusual symptom.

Bottom line

Bone stress injuries need staged return based on symptoms and location. High-risk sites need careful management — ignoring them risks complete fracture.