– Written by Evan Jeanguyot, Qatar

“Form is a diagram of forces”

D’Arcy Wentworth Thompson, On Growth and Form (1917)

Return to running (RTR) and performance after lower-limb bone stress injury (BSI) is, at its core, an exercise in re-exposing the skeleton to load – progressively, intelligently, and with respect for the adaptive limits of bone. BSIs are particularly prevalent among runners. In National Collegiate Athletic Association (NCAA) Division 1 runners, the incidence of BSI’s has been reported to be as high as 20% across a single competitive season¹. More broadly, stress fractures alone account for 15-20% of all musculoskeletal injuries in runners, underscoring the substantial burden of BSI on the running community². Consequently, BSI’s represent a major disruption to attaining optimal performance for both training and competition.

A critical milestone following a BSI is the RTR phase. Despite its importance, the timing and method of RTR are inconsistently applied, with no clear consensus among clinicians or within the literature. This article addresses these questions by exploring the integration of RTR within rehabilitation frameworks for BSI. It outlines distinct, evidence-based criteria for reintegrating running, situating it within the broader goal of transitioning from acute injury management to performance optimisation.

While this review considers lower-limb bone stress injuries more broadly, it is important to note that much of the existing evidence is derived from tibial bone stress studies. Additionally, reported bone strain and stress values in this article arise from differing methodologies; direct in vivo measurement in which strain gauges are surgically affixed to bone surfaces to capture physiological loading, computational modelling approaches and animal loading studies.

RUNNING: BUILDER OR BREAKER OF BONE?

All BSIs in runners are caused by errors in workload³. So, what does running workload mean for bone? Running involves repetitive, high mechanical loading of the skeletal system, driven by external ground reaction forces and substantial internal muscle contractions. Mechanical fatigue ensues when the cumulative number and intensity of loading cycles exceed the bone’s capacity to tolerate and adapt. This leads to damage accumulation and progressive mechanical failure, even when strains remain within the normal physiological range⁴.

Bone adaptation is governed by the interplay of strain magnitude, rate, and distribution, with each parameter critically shaping the remodeling response of bone.  Higher strain rates such as those experienced during fast running or hopping can offer a powerful osteogenic stimulus, provided that the magnitude, volume, and recovery are appropriately managed⁵. Critically, the same high strain rates if applied monotonously and/or excessively without adequate recovery can accelerate fatigue accumulation and elevate bone stress risk. Thus, the paradox of running emerges: the very mechanical stimulus that builds bone can also break it. Balancing this interplay is key and these principles are central to shaping safe RTR frameworks.

So how does it go wrong? Consider that some of the highest peak tibial compressive strains recorded in humans have been observed during uphill and downhill zigzag running (−1226 and −968 με), yet these values remain well below the −2000 to −3000 με typically reported in animal fracture models⁶. This suggests that BSI in runners are less likely to arise from a single episode of extreme loading and are more likely from the cumulative effect of repeated submaximal strain⁶. Experimental bone loading to failure studies in humans have not been conducted; therefore, some extrapolation from animal studies is warranted, mindful of the obvious caveats. 

THE DISTINCT CHALLENGES OF REBUILDING BONE – TOO MUCH, TOO LITTLE AND JUST RIGHT – WHAT BONE LIKES AND WHAT IT DOESN’T

To rebuild bone, it is critical to understand how it responds to and interacts with mechanical loading. Bone cells have a short attention span and get bored quickly. Repeated identical loads offer diminishing osteogenic returns. Rubin and Lanyon⁷ demonstrated that as few as 36 loading cycles per day were as effective for bone formation as 1800 cycles, with the first four cycles within an 8-second window sufficient to prevent negative balanced remodeling. Quick hits pack a bigger punch than a slow grind. Once the mechanosensory pathways are saturated, additional repetitive loading yields minimal benefits. Hence, after a small dose of running, bone cells become ‘deaf’ to monotonous and unidirectional loading. For example, in training, two 5-week loading blocks separated by 5 weeks of rest has been shown to produce greater bone gains than 15 weeks of continuous loading⁸. 

Bone regains responsiveness to loading after 4-8 hours allowing subsequent bouts to stimulate adaptation⁹. In fact, splitting loading bouts across 4-6 sessions per day yields the highest bone formation rates compared to one continuous session¹⁰. Furthermore, even during a session, longer between-rep recovery periods of ~10-14 seconds appear superior to brief intervals (0.5s, 3.5s, and 7s) in sustaining osteogenic signaling^9,11. Hence, bone responds best to ‘quick hits’, not one extensive session – offer time between reps and split bone loadings across the day to maximize bone formation.

As noted, bone workload is the interaction between the magnitude of the load, how often it is applied (cycles), and how fast it is delivered (strain rate).

• This relationship follows an inverse power law, whereby even a 10% increase in bone strain can halve the number of tolerated loading cycles⁴. For example:
• A 1 m/s increase in running speed raises the peak tibial strain by approximately 9% (≈260 units of microstrain -με-) and strain volume by 155% (≈600 mm³)¹².
• Peak posterior tibial stress is 14% greater at 3.5 m/s than 2.5 m/s during level running¹³.
• Tibial strain rate demonstrates an almost 4-fold increase from walking to jogging, whereas the rise in compressive strain magnitude over the same transition is comparatively modest at only 1.6-fold⁶.

While jogging doesn’t hugely increase the total amount of force, it makes the forces act on the bone much more quickly which can have a bigger effect on bone cell adaptation. This considered, speed doesn’t just add more load it is the ultimate amplifier of bone load. Running speed exerts a disproportionately large effect on both bone strain rate and absolute strain magnitude. Even at moderate speeds (3.5–4.0 m/s), tibial compressive forces can reach ~9× bodyweight¹⁴. Matijevich et al.¹⁵ also reported peak tibial forces of 7.1–8.5× bodyweight (BW) across speeds of 2.6–4.0 m/s at slopes at −6% to +3%. Critically, and visible in Figure 1, peak tibial bending moments occur near mid-stance, when plantarflexor muscle activity dominates¹⁴. In contrast, ground reaction force (GRF) metrics such as vertical peak and loading rate typically approximate only ~2× BW at initial contact, capturing a small portion of the much larger internal loads transmitted closer to mid-stance¹⁶. Wearable sensor studies further demonstrate that GRF-based proxies such as tibial shock and tibial acceleration do not reliably predict internal tibial compression across varying speeds and slopes^16,17.

ASPETAR’S BSI PHASES OF REHABILITATION

Aspetar’s BSI Phases of Rehabilitation (see Figure 2) outline a systematic progression from early recovery to performance readiness. In the context of RTR, emphasis is placed on the late reload and accumulation phases where structured bone-centric loading and progressive running volume build the foundation for running reintroduction.

Think muscle forces, not impact.

The soleus is the dominant contributor to tibial compressive forces, generating up to 6.17× BW, roughly two-thirds of total tibial compression and ~4.6 times greater than that of the gastrocnemius¹⁴. Further, GRFs at initial contact generate 1.97× BW^13,14. These findings reinforce that mid-stance driven internal soleus muscle loading rather than early impact forces play the dominant role in loading the tibia. Hence, it is crucial to think soleus forces, not impact when evaluating bone loading at the tibia. A primary role of bone is to act as a rigid lever for muscle force transmission rather than as an absorber of impact. This means considering the muscle which attaches to the bone involved in a stress injury and appreciating its contribution to bone loads. 

Early Reload Phase – The Pre-Running Rehabilitation Block  

The reload phase seeks to seamlessly increase bone loading demands, where RTR is viewed as a continuum rather than a definitive leap in the rehabilitation process. For low-risk injuries such as tibial and metatarsal BSIs an “optimal loading” approach is advocated for. This means no pain and/or symptoms during or post session and the day following guide load progressions¹⁸.

Bone has a independent relationship with muscle, where muscle strength gains serve as the primary driver of bone load (by muscle pulling on it)¹⁹. Hence, high-load, low-frequency strength training seeks to restore muscle strength capacity and provide the mechanical stimuli necessary for bone remodeling. Lower limb strength training is complemented with introductory reactive strength, explosiveness and running mechanics drills (see Figure 3).

Loading of the contralateral uninjured limb can commence immediately to mitigate the negative effects of immobilization and subsequent disuse bone mass loss. Bilateral reductions in bone mineral density occur following tibial BSI with losses of up to 1% within 12 weeks of diagnosis²⁰. Importantly, these deficits can persist for six months or longer, indicating a potential mismatch between typical return-to-sport timelines and the slower trajectory of bone mass recovery.

Non-weight bearing activities such as swimming, cycling and deep-water running act as valuable tools for aerobic conditioning but offer little osteogenic stimulus. The use of anti-gravitational treadmills or level walking act as more suitable pre- RTR prescriptive strategies (see Table 1).

Late Reload Phase – Volume-Centric Focus, Intermittent Slow Running 

RTR is a pivotal milestone in recovery from BSI. Clinical criteria provide a structured checkpoint to assess an athlete’s readiness to tolerate the mechanical loads of running as well as monitor an athlete’s response to prescribed training sessions (see Figures 4 and 5). If an athlete experiences an exacerbation of symptoms, it is recommended that they cease activity until symptoms have settled. They should then return to the most recent stage at which no symptom exacerbation occurred and re-start from that session.

How to introduce and progress running?

A symptom guided, walk-run progression is often recommended, where running volume gradually replaces walking time²¹. One such protocol outlines a three-phase graduated RTR program: two weeks of progressive volume, two weeks of progressive speeds followed by consecutive run days for novel runners²². In contrast, Brown et al.²³, proposed a walk-jog-run protocol for military recruits with low-grade tibial BSI, progressing when pain remained <3/10 during or after activity. Given the wide variability among RTR programs, no single protocol can be applied in a one size fits all framework.

RTR frameworks should be adapted to the athlete’s level and pre-injury training history. In general, runners are advised to gradually return to their pre-injury workload over 3-6 weeks using introductory run progression principles (see Figure 6), commencing at 30-50% of their prior activity level²⁴. Interestingly, there is no evidence supporting the “10% rule”. Injury risk profiling suggests no difference in injury incidence with weekly volume changes of up to 30%²⁵. More recent data suggest that session specific increases in running distance ≥10% elevates injury risk, implying that within-session loading may be more important than cumulative weekly volumes²⁷.

Should running initially focus on volume or speed?

During the RTR process, each running bout should be regarded as a controlled bone-loading stimulus (see Table 2). Aerobic conditioning, therefore is better developed through cross-training modalities¹⁸.

Initial running prescriptions focus on volume (i.e. number of loading cycles). Load magnitude is controlled for via slower run speeds, flat surfaces and in the early re-load phase, body-weight support treadmill (where available). Once tolerance to volume is established and progressed, small increments in speed can be re-introduced recognizing its disproportionately large effects on bone strain. In parallel with running exposure, progression in reactive strength, explosiveness and running mechanics may further enhance strain-rate adaptation in a controlled prescription.

Monitoring bone load exposure is critical for a safe pathway to RTR. Key factors include:

• Session rate of perceived exertion (RPE) paired with running volume, duration and speed
• Surface type, footwear and gradient
• Individual BSI risk profile and anatomical site

Close monitoring is particularly important for high-risk BSI, where excessive loading may contribute to delayed union, non-union, complete fracture, or prolonged recovery²⁸. Each injury type presents unique considerations requiring a multifaceted and individualized approach which is beyond the scope of this article but fundamental to best practice.

Running Accumulation Phase – Return to Run is Only Halfway Done

Running isn’t the finish line; it’s merely a checkpoint. Achieving the RTR milestone is a significant accomplishment in the rehabilitation journey. However, running is not the finish line – it is a checkpoint in the rehabilitation journey. It simply means the athlete is tolerating initial running loads. In the accumulation phase, the sport specific demands of the athlete become increasingly relevant.

The athlete will have successfully completed a minimum of two-weeks rebuilding running volumes. Key considerations include:

• Target a progressive increase in linear run speeds up to ~75% of maximal sprint speed.
• Exposure to submaximal acceleration and decelerations
• For distance runners, terrain manipulation offers another tool for example running uphill (≥10%) increases internal tibial loading, whereas downhill running (≤-10%) can reduce it¹³.
• Bone-centric exercise such as 52cm drop jumps are equivalent in peak tibial internal strain to running at 17km/hr²⁹.

In this phase, progressions in running speed or bone-centric loading may necessitate temporary reductions in cyclic running volume to balance the cumulative bone workload already accrued³.

High-intensity interval training (HIIT) performed at maximal aerobic speed (MAS) and/or within 5-25% of the anaerobic speed reserve (ASR) offers a suitable starting point to re-introduce running conditioning³⁰. Training at MAS ensures the athlete is working at an intensity that maximally taxes aerobic capacity without drifting into unsustainable anaerobic zones. Structuring HIIT in short, repeatable bouts (30-90 seconds) also provides controlled bone exposure to higher strain rates while managing cumulative bone loading. In this way, HIIT serves as a bridge between steady-state running and the chaotic, variable demands of competition. From a bone perspective, HIIT better satisfies the key principles of osteogenic loading than long, steady runs. The short, high-intensity bouts deliver brief but potent strain stimuli that are high in rate and magnitude, while the interspersed recoveries may allow for enhanced mechanosensitivity between efforts. In contrast, continuous running produces repetitive, monotonous loading that may de-sensitize bone cells and favour fatigue accumulation rather than adaptation.

What about biomechanical and footwear interventions? Following a BSI, clinicians will commonly look to address running biomechanics as a key intervention strategy. Biomechanical factors have been extensively studied, particularly in runners with tibial BSI. A recent systematic review and meta-analysis comparing runners with tibial stress fractures to controls identified 25 kinematic and kinetic variables as well as 38 ground reaction force variables, yet the overall evidence remains inconclusive with conflicting findings and/or negligible effect sizes³¹.

For athletes with a history of recurrent BSI, one strategy to reduce skeletal loading is to increase running cadence. Willy et al.³² demonstrated this approach in an in-field retraining study where athletes used a wireless accelerometer to raise their preferred cadence by 7.5% over eight training sessions. On average, participants achieved an 8.6% increase in step rate, resulting in meaningful biomechanical changes: instantaneous vertical load rate decreased by 18%, average vertical loading rate by 19%, peak hip adduction by 2.9°, and eccentric knee joint work per stance phase by 26.9%³². Collectively, these reductions target factors which may alter tibial bone stress risk, highlighting the potential value of cadence manipulation as a re-injury prevention strategy in athletes returning from tibial BSI.

Modifying foot strike angle can also influence lower limb bone stressors. Transitioning from a rearfoot strike to forefoot has been shown to modify tibial loading, increasing bending moments and cumulative loading³³. As noted, ground reaction force surrogates and tibial acceleration measures are unable to map internal tibial bone loads and should be used with caution to indicate true bone loading progressions.

Footwear strategies can be used as a strategy to modulate plantarflexor forces and subsequently bone forces in early running reintroduction. Temporary use of a high-drop shoe, heel wedges, orthoses with a metatarsal bar and/or rocker shoes can be used to attenuate bone specific loads by attenuating plantarflexor forces and metatarsal bending moments. As tolerance improves, the athlete can progressively transition into sport-specific footwear (e.g., football, basketball shoes). 

Transition – Lay the base, prime with peaks, build them together

During the transition phase, the athlete must carefully balance the pursuit of performance gains with the management of cumulative bone loads. For field-based sports, this phase includes exposures to very high-speed running (m >25.2km/hr or 7m/s); high intensity accelerations and decelerations (>3m/s²) and linear running speeds up to 85% maximal sprint speed. In parallel, bone-centric HIIT blocks (3x per week) are tailored to the athlete’s sport specific demands.

Understanding which activities impose the greatest mechanical demands on bone helps shape and ultimately bulletproof an athlete’s transition to training and competition. Foundational in vivo research by Burr et al.⁶ demonstrated that peak tibial strain rates occur during sprinting, whereas the greatest compressive strains are observed during uphill and downhill zigzag running (~2000 με). More recently, in collegiate basketball players, sprinting and 45° lateral cuts have been shown to elicit the highest peak compressive tibial bone strains and strain rates³⁴ (see Figure 7).

Simulation & Resilience – Bone HIIT & Return to Performance

‘Bone HIIT’ provides a unique osteogenic stimulus, maximizing bone formation rates while minimising mechanosensory saturation (see Figure 8). Periodising these bone exposures as a distinct entity from routine training enhances adaptation and maintains skeletal robustness.

Bone HIIT combines high magnitude, high rate, multi-directional loading delivered in brief, novel, periodised bouts interspersed with recovery to restore the ability for bone tissue to remodel at least 3x/week. Some example exercises are seen in Figure 9. It is important to keep in mind the dominate role of muscle loads on bone. For example, when jumping, a primary focus is directed to the take-off phase rather than landing due to the muscle’s large contributions to load on bone.

Bone cell adaptations are proportional to the difference between applied load and routine load³. If routine loading is high, for example if an athlete has high chronic workloads, a greater or more novel stimulus is required to elicit adaptation. Periodisation of bone-centric exposures has been suggested as an effective strategy to restore the sensitivity of bone cells to mechanical load, enhance adaptation, and improve resistance to bone stress accumulation.

Evidence from youth sport further supports this. In prepubertal athletes, the most effective stimulus for bone adaptation is achieved through brief bouts of high-magnitude, rapid, multidirectional loading performed intermittently throughout the day, rather than through prolonged or repetitive exposure¹⁸.

This was highlighted in the PRO-BONE study: a 9-month jumping intervention program whereby 20 countermovement jumps were prescribed, 3x/day, 3x/week adding progressive load and volume, resulting in improved bone geometry and trabecular bone scores in male adolescent non-weight bearing athletes^35,36.

CONCLUSION

In essence, running presents a paradox for bone. Each stride delivers repetitive cyclical loading through ground reaction forces and high muscular contractions. This monotony makes running both friend and foe: a builder of bone when applied progressively and variably, yet an unforgiving breaker when bone workload errors accumulate. Recognizing and applying this paradox is fundamental to designing safe, effective, and performance-oriented RTR strategies for athletes recovering from BSI and beyond.

Evan Jeanguyot PT

Physiotherapist

Aspetar Orthopaedic and Sports Medicine Hospital

​Doha, Qatar

Contact: evan.jeanguyot@aspetar.com

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Header Image by Vitor Antunes (Cropped)