Address safety, settle excessive irritability and maintain useful movement.
What to do
Stop running/jumping that provokes bone pain
Maintain pain-free cross-training only if medically appropriate
Assess footwear, training error, nutrition and bone-health risk
Use protected weight bearing if walking is painful and clinician advises
Exercise dosage
Pain-free cycling/swimming if allowed: 10–30 minutes
No impact exercise while walking or daily activity remains painful
Progress when
Daily function is stable or improving.
No new red flags or progressive neurological deficit.
Exercise response returns to baseline by the following day.
Phase 2 — Mobility, Strength & Capacity
Restore the specific strength, mobility and control required by the condition.
What to do
Begin progressive strength and low-impact conditioning when daily walking is pain-free
Correct training-load and recovery contributors
Reintroduce impact only after clinical criteria and risk-site review
Exercise dosage
Calf/hip/trunk strength: 2–3 x 8–15, 2–3 days/week
Balance and low-impact conditioning
Progress when
Target movement and resistance are tolerated with good quality.
Functional capacity is improving without sustained symptom flare.
Progression is based on objective performance and patient goals.
Phase 3 — Functional Restoration & Return to Activity
Rebuild real-world, occupational or sporting capacity.
What to do
Graded walk-run programme with rest days
Progress distance before speed/hills
Monitor focal pain during and after loading
Exercise dosage
Walk-run intervals on alternate days, starting short
Increase one variable at a time; regress if focal bone pain returns
Progress when
Condition-specific return criteria are met.
Full task exposure is completed progressively.
No clinically meaningful deterioration during the following 24 hours.
Manual Therapy — Role & Application
Manual therapy does not heal bone stress injury and should not be applied over a suspected fracture.
Address only secondary mobility deficits after medical clearance.
Modalities — Use / Avoid
No modality substitutes for load reduction, bone-health assessment and graded return.
Avoid using analgesia to mask pain and continue impact.
Return / Discharge Criteria
Pain-free daily walking
No focal bony tenderness as judged clinically
Risk site and imaging/medical review addressed
Progressive running tolerated without recurrence
Common Clinical Mistakes
Using hop test to rule out fracture
Continuing impact through focal bone pain
Ignoring energy availability and bone-health risk
Returning by calendar alone
Clinical Pearls
Anterior tibial cortex is a higher-risk location than posteromedial tibia.
A normal early radiograph does not exclude bone stress injury.
Continue learning
Connect assessment with management
Use the related PNA learning pathways to explore examination techniques and structured rehabilitation. A test result should always be interpreted alongside the history, full examination and clinical presentation.
Use these sources as a starting point for clinical learning. A reference being listed here does not, by itself, establish that every recommendation on this page is strongly supported. Check the original publication, study design, population and limitations before applying findings to an individual patient.
Educational resource only. Tests and treatment plans must be adapted to the individual patient, irritability, comorbidities, surgical restrictions and local scope-of-practice requirements.
