Stress Fractures vs Soft Tissue Injuries: How Can You Tell the Difference?
A new running injury appears.
Maybe it's pain in your shin, foot or hip. At first, you assume it's a tight muscle or irritated tendon. But after a few runs, it isn't settling.
So how do you know whether you're dealing with a soft tissue injury or a bone stress injury?
Unfortunately, there isn't one simple test that can tell you.
However, there are certain features that can make us more or less suspicious of a bone stress injury, particularly in runners.
What Is a Bone Stress Injury?
Bone isn't an inactive structure. It's constantly adapting and remodelling in response to the loads we place on it.
Running provides repeated mechanical stress to our bones. With appropriate training and recovery, the body adapts to this stress and becomes better prepared to tolerate it.
Problems can develop when repeated loading exceeds the bone's current capacity to recover and remodel.
This can result in a bone stress injury (BSI).
Rather than thinking of a stress fracture as something that suddenly appears, it can be useful to think of bone stress injuries as existing on a continuum.
This can progress from an early stress reaction within the bone towards a more significant stress injury and, eventually, a stress fracture.
Identifying the problem early is therefore important.
Where Do Runners Get Bone Stress Injuries?
Bone stress injuries can occur in several areas, but common locations in runners include the:
Tibia or shin bone
Metatarsals of the foot
Fibula
Femur
Pelvis
Sacrum
Not all bone stress injuries carry the same level of risk.
Certain locations require greater caution because continued loading can increase the risk of complications. This is one reason why persistent or suspicious bone pain shouldn't simply be treated as another running niggle.
Stress Fracture or Soft Tissue Injury?
One of the difficulties with bone stress injuries is that their symptoms can overlap with muscle, tendon and other soft tissue problems.
For example, pain around the shin could potentially relate to the calf muscles, medial tibial stress syndrome or a tibial bone stress injury.
Pain around the foot might come from a tendon, joint or metatarsal bone.
Rather than relying on one symptom, we look at the overall pattern.
1. Is the Pain Very Localised?
One feature that can increase suspicion of a bone stress injury is focal tenderness.
Someone with a stress injury may be able to identify a relatively small, specific area that is particularly painful when pressure is applied.
Soft tissue injuries can also be localised, so this isn't diagnostic by itself.
However, a very distinct area of bony tenderness is something worth paying attention to.
This can also help distinguish certain presentations of shin pain. Medial tibial stress syndrome, commonly referred to as shin splints, typically produces more diffuse tenderness along a larger portion of the inside of the tibia, whereas a more focal area of bony pain may increase suspicion of a tibial bone stress injury.
2. What Happens When You Run?
Early in a bone stress injury, pain may initially appear towards the end of a run or after a certain amount of loading.
As the problem progresses, symptoms may start earlier and earlier.
Perhaps you originally noticed discomfort after 10 km.
A week later, it starts after 5 km.
Eventually, you notice it almost immediately.
This progressive reduction in your ability to tolerate impact can be an important part of the history.
Soft tissue injuries can behave similarly, but the trend is something we want to understand rather than simply asking whether running hurts.
3. Does It Hurt During Everyday Activities?
As a bone stress injury becomes more irritable, symptoms may no longer be limited to running.
Pain may begin to occur with:
Running → walking → everyday activity → potentially rest
Pain during normal walking, particularly when this wasn't initially present, is more concerning than discomfort that only appears during higher-load activity.
Rest or night pain may also warrant further assessment, although these symptoms aren't specific to bone stress injuries.
4. Does Hopping Hurt?
Hopping places considerably more impact through the lower limb than normal standing.
Clinically, hopping may therefore be used as one piece of information when assessing a suspected bone stress injury.
If repeated hopping produces significant, localised bone pain, that may increase suspicion.
However, this is important:
A hop test cannot diagnose or rule out a stress fracture.
Other injuries can hurt when hopping, and someone with a bone stress injury may not necessarily have a strongly positive hop test.
So repeatedly hopping on a painful leg at home to "check for a stress fracture" isn't something I'd recommend.
5. What Changed in Your Training?
This is one of the most important questions.
Bone stress injuries often occur following a change in the amount or type of loading someone is exposed to.
This might include:
A sudden increase in weekly mileage
Increasing long-run distance
Adding more running days
Introducing faster running
Increasing hill training
Returning to running after time off
Increasing overall time on feet
Adding another impact-based sport
Increasing training for an upcoming race
This doesn't mean running itself is damaging your bones.
Quite the opposite. Appropriate mechanical loading is important for maintaining and developing healthy bone.
The problem occurs when training demand exceeds the body's current capacity to adapt and recover.
Training Isn't the Only Factor
When assessing a suspected bone stress injury, we shouldn't only look at someone's Strava history.
Bone health is influenced by several factors.
Nutrition, energy availability, previous bone stress injuries and other aspects of someone's medical history can all influence risk.
This is particularly important when an athlete's energy intake isn't sufficient to support both everyday physiological function and the demands of their training.
This concept forms part of what is known as Relative Energy Deficiency in Sport (RED-S).
This can affect athletes of any sex and is one reason recurrent bone stress injuries deserve a broader assessment rather than simply being blamed on poor running technique or shoes.
What About Tendon and Muscle Injuries?
Soft tissue injuries can produce many overlapping symptoms.
Tendon pain, for example, may also be:
Localised
Painful during running
Sensitive to loading
Worse after increasing training
Painful first thing in the morning
Muscle injuries may produce pain with contraction, stretching or specific movements.
This overlap is exactly why symptoms alone aren't always enough to confidently distinguish bone from soft tissue.
The location of symptoms, training history, palpation, strength testing, functional testing and overall clinical presentation all help build the picture.
Do You Need a Scan?
Not every running injury requires imaging.
However, if a bone stress injury is suspected, imaging may be appropriate depending on the location and clinical presentation.
One important point is that an early bone stress injury may not appear on a standard X-ray.
MRI is generally much more useful for detecting early bone stress changes and can also provide information about the severity of the injury.
The decision to image should therefore be based on the clinical picture rather than simply waiting until pain becomes severe.
Should You Keep Running?
If there's a genuine suspicion of a bone stress injury, this isn't something I'd recommend simply "running through" to see what happens.
Continuing to repeatedly load an injured bone can potentially allow the injury to progress further along the bone stress continuum.
That doesn't necessarily mean months of complete rest.
Management depends on the bone involved, severity of the injury and the individual athlete.
Once appropriate healing has occurred, load can usually be gradually reintroduced before progressing towards running and eventually returning to normal training.
The Key Difference: Look at the Pattern
There isn't a single symptom that tells us:
Bone = this.
Muscle or tendon = that.
Instead, we put several pieces together.
A runner with increasingly localised bony tenderness, worsening pain with impact, decreasing running tolerance and eventually pain during walking following a significant increase in training would make me more suspicious of a bone stress injury.
Someone with a clearly load-dependent soft tissue presentation may point us in another direction.
But when the clinical picture isn't clear, it's better to investigate appropriately than to guess.
When Should a Runner Get Their Injury Assessed?
Consider getting assessed if you have:
Persistent localised bone pain
Pain that is progressively worsening with running
Pain beginning earlier during each run
Pain with walking or normal daily activities
Significant pain with impact
Symptoms that aren't improving despite reducing training
Recurrent bone stress injuries
A recent substantial change in your training
Early identification can potentially prevent an early bone stress reaction from progressing into a more significant injury.
At Dunmore Osteopathy in Chatswood, I work with runners experiencing lower-limb pain and running-related injuries.
Assessment involves looking beyond simply where it hurts. Your symptoms, training history, recent changes in load, strength and physical capacity can all help determine the most appropriate next step.
And if your presentation raises suspicion of a bone stress injury, appropriate medical referral and imaging can be arranged rather than treating it as another soft tissue running injury.
When it comes to persistent running pain, the question isn't always "Can I run through this?"
Sometimes the more important question is:
"What tissue am I actually dealing with?"
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