Bone stress injuries can be hard to understand, hard to suspect, and have unpredictable healing times.

They often occur from too much impact or rotational activity without enough time for proper bone recovery. 

In the volleyball world, hitters/opposites and middles tend to get lower leg and foot stress injuries from repetitive jumping. Lower-back stress injuries may be seen more in hitters/opposites and setters due to extra trunk rotation with spiking or making back sets. This is one type of injury less seen in liberos since they do not jump or hit overhead.


In describing bone stress injuries, think of bending a pen while bored.

  • When trying to bend a pen, the pen doesn’t bend much. This represents normal bone.
  • If you continue to play with the pen, it does start to bend more. This represents a stress reaction where the bone is softer and less able to resist continued load. A stress reaction will create swelling (bone edema) on a Magnetic Resonance Imaging (MRI) study. No true fracture line will be visible either on the MRI or plain X-ray study.
  • If you’re really bored, the continued bending the more weakened pen eventually will cause it to completely break on one side. This represents a stress fracture where a fracture line is seen on one cortex (outer lining of the bone) on either MRI or plain X-ray.
  • Even more attempts to bend the pen may result in breaking it in half. This represents a complete fracture where the fracture line is now easily visible on either MRI or plain X-ray.


Bone Stress Injuries: Stress Fracture of Left Femoral Neck. This MRI picture shows a fracture line involving only one cortex (outer lining) of the femur (thigh bone) with bone swelling (edema) also present.


If there’s that history of too much, too fast, or too soon, there is concern about a bone stress injury.

If there is an injury that just doesn’t seem to get better, there is concern about a bone stress injury.

Now, if an athlete can take the tip of their index finger and point directly to a single spot on a bone, there is definite worry about a bone stress injury.

If there is any worry about a bone stress injury, often x-rays and Magnetic Resonance Imaging (MRI) studies are used to make a formal diagnosis.


Part one of the bone stress injury challenge is to make the diagnosis.

Part two of the challenge is equally, if not more important and that is figuring out what might have caused the injury.

Bone stress injuries are usually caused by high loads on normal bone, or normal loads on weaker bones.

We will routinely see athletes who have been diagnosed with a bone stress injury and are looking for clues about causes and how best recover and reduce risk of future problems.

High loads can be from too much, too fast, too soon:

Weaker bones tend to come from:

Many young athletes are uncomfortable talking about food choices, caloric intake, and menstrual periods. However, these are important topics for bone health. Having a sensitive discussion that explain why these questions are being asked can help identify injury causes, reduce future risk, and improve future performance.


Knowing the exact location and type of bone stress injury can contribute to a most accurate treatment plan.

Knowing sleep and nutrition needs while having regular periods (for females) is key for current healing and future bone development.

The usual healing goal is to protect the injured area by keeping activity below levels that cause pain. This could mean no impact exercise (running, jumping, or leaping). In some cases, putting limited or no weight on the injured body part (by using a cast/boot, crutches, or a scooter) may be the best plan.

There are certain types of higher risk bone stress injuries that may even need surgical repair. Knowing your exact type of bone stress injury can limit risk of further complications by helping determine what you should and shouldn’t do in your recovery.


Healing a bone stress injury doesn’t always make someone become a couch potato. This is where the concepts of individualized modifications and cross training come into play. Again, remember the primary goal of limiting activity below levels that cause pain.

So, for lower body injuries, this often may include non-impact activities such as using exercise bike, elliptical machine work, or swimming/pool workouts. There are even specialized anti-gravity treadmills that may allow running during the recovery phase. Non-injured body parts can be used in carefully selected and supervised stretching and weight training exercises. An injured hitter with a lower leg or foot stress injury may be able to continue work on passing and serve-receive while waiting to return to jump activities. 

Working with a sports medicine specialist can design individualized recovery programs involving cross training that help reduce emotional stress and keep up levels of physical activity.

This article does not intend to diagnose or provide management tips for any particular bone stress injury, or for any injury or illness. With any suspected bone stress injury or other injury, please immediately contact your regular sports medicine specialist for evaluation and treatment. 
Dr. Chris Koutures is a dual board-certified pediatric and sports medicine specialist who practices at ActiveKidMD in Anaheim Hills, CA. He is a team physician for USA Volleyball (including participating in the 2008 Beijing Olympics), the U.S. Figure Skating Sports Medicine Network, Cal State Fullerton Intercollegiate Athletics, Chapman University Dance Department, and Orange Lutheran High School. He offers a comprehensive blend of general pediatric and sport medicine care with an individualized approach to each patient and family. Please visit or follow him on Facebook (, Instagram (, or Twitter (@dockoutures).


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