Prevalence and factors associated with bone stress injury in middle school runners

Adam S. Tenforde, Stephanie DeLuca, Alexander C. Wu, Kathryn E. Ackerman, Margo Lewis, Mitchell J. Rauh, Bryan Heiderscheit, Brian J. Krabak, Emily Kraus, William Roberts, Karen L. Troy, Michelle T. Barrack

Research output: Contribution to journalArticlepeer-review

16 Scopus citations


Background: Bone stress injury (BSI) in youth runners is clinically important during times of skeletal growth and is not well studied. Objective: To evaluate the prevalence, anatomical distribution, and factors associated with running-related BSI in boy and girl middle school runners. Design: Retrospective cross-sectional study. Setting: Online survey distributed to middle school runners. Methods: Survey evaluated BSI history, age, grade, height, weight, eating behaviors, menstrual function, exercise training, and other health characteristics. Main Outcome Measurements: Prevalence and characteristics associated with history of BSI, stratified by cortical-rich (eg, tibia) and trabecular-rich (pelvis and femoral neck) locations. Participants: 2107 runners (n = 1250 boys, n = 857 girls), age 13.2 ± 0.9 years. Results: One hundred five (4.7%) runners reported a history of 132 BSIs, with higher prevalence in girls than boys (6.7% vs 3.8%, p =.004). The most common location was the tibia (n = 51). Most trabecular-rich BSIs (n = 16, 94% total) were sustained by girls (pelvis: n = 6; femoral neck: n = 6; sacrum: n = 4). In girls, consuming <3 daily meals (odds ratio [OR] = 18.5, 95% confidence interval [CI] = 7.3, 47.4), eating disorder (9.8, 95% CI = 2.0, 47.0), family history of osteoporosis (OR = 6.9, 95% CI = 2.6, 18.0), and age (OR = 1.6, 95% CI = 1.0, 2.6) were associated with BSI. In boys, family history of osteoporosis (OR = 3.2, 95% CI = 1.2, 8.4), prior non-BSI fracture (OR = 3.2, 95% CI = 1.6, 6.7), and running mileage (OR = 1.1, 95% CI = 1.0, 1.1) were associated with BSI. Participating in soccer or basketball ≥2 years was associated with lower odds of BSI for both sexes. Conclusion: Whereas family history of osteoporosis and prior fracture (non-BSI) were most strongly related to BSI in the youth runners, behaviors contributing to an energy deficit, such as eating disorder and consuming <3 meals daily, also emerged as independent factors associated with BSI. Although cross-sectional design limits determining causality, our findings suggest promoting optimal skeletal health through nutrition and participation in other sports including soccer and basketball may address factors associated with BSI in this population.

Original languageEnglish (US)
Pages (from-to)1056-1067
Number of pages12
JournalPM and R
Issue number9
StatePublished - Sep 2022

Bibliographical note

Funding Information:
Dr. Heiderscheit is the owner of Science of Running Medicine, LLC, outside the submitted work. Dr. Tenforde has no disclosures related to this work. He serves as senior editor for . He gives professional talks such as grand rounds and medical conference plenary lectures and receives honoraria from conference organizers. He has participated in research funded by The Arnold P. Gold Foundation (physician and patient care disparities), Football Player Health Study at Harvard (health in American‐Style Football players), and American Medical Society for Sports Medicine (bone density research). PM&R Journal

Publisher Copyright:
© 2021 American Academy of Physical Medicine and Rehabilitation.


  • Adolescent
  • Bone Density
  • Child
  • Cross-Sectional Studies
  • Female
  • Humans
  • Male
  • Osteoporosis
  • Prevalence
  • Retrospective Studies
  • Running/injuries
  • Schools

PubMed: MeSH publication types

  • Journal Article
  • Retracted Publication


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