What is the difference between a bone bruise and a stress reaction in a runner? Well, that’s what we’re talking about today on the Doc On The Run Podcast.
Whenever I see a runner who tells me that they want to know if they can run but they were told they have a bone bruise, I get real confused and you should too. Now, a bruise is a very simple thing, right? You fall down and land on your knee and you get a bruise. You get a bruise because your kneecap crushes the skin against the ground and you get bleeding in the skin that you see as discoloration that we call a bruise. Well, you can’t see that in a bone, and when you get a bone bruise, you’re diagnosed with a bone bruise, I think you have to think of it in terms of that continuum that I talk about all the time in terms of stress fractures.
A stress response is inflammation in the bone that’s a part of the normal physiologic healing process. It looks bad on an MRI, but it’s not actually a problem. A stress reaction is where there’s too much inflammation, it actually starts to hurt because there’s so much inflammation in the bone, and if you don’t do something about it, it might actually turn into a real stress fracture. Now, this is kind of the situation that you have with a bone bruise. The difference in my mind is that either your doctor really doesn’t know what it is and just calling it a bone bruise or your doctor really does know what’s going on, but is calling it a bone bruise because you traumatized it in one single event. Let’s say you’re running a marathon. It’s really jam-packed at the start of the race, and you’re right next to the person in front of you. You’re running along and they suddenly step aside because there’s a pothole and your foot slams in the pothole and almost cracks one of your metatarsals.
It hurts. Maybe you don’t even finish the race. It’s not really broken. You can’t see a crack anywhere, but it’s inflamed. It hurts when you push on it the same as a stress reaction, but it really is a bone bruise. You’ve just torqued it so much that it almost broke and it’s kind of really angry and inflamed now. Well, that is really a bone bruise. What is concerning to me is when somebody has what they call a bone bruise in the ankle, if you roll your ankle over and the tailor’s that sits in the ankle actually smacks into the tibia on the side as it rolls over forcibly, that can actually crack the surface of the bone under the cartilage and lead to a really high risk debilitating thing called an osteochondral lesion or an osteochondral fracture where the bone under the cartilage cracks and then the blood supply dies off and it starts to get softer and mushy and then the cartilage caves in and you get all kinds of really bad problems with that.
It’s really hard to fix and really hard to run without injury. So if you have it in your ankle, I’d be real concerned that you might actually have one of these things brewing that just hasn’t been appropriately diagnosed. But in general, what I think of is the real difference between a bone bruise and a stress reaction as a runner is that the stress reaction happens because of repetitive trauma. You beat it up by running in the same way, on the same side of the road, in the wrong kind of shoes over and over and over with it, your foot hitting the ground exactly the same way that puts too much force on one specific bone and it kind of gets bruised over time. That’s a stress reaction. But a true bone bruise is where it happens in one single event. You jump on it, you land on it, you trip, you fall.
You do something where it just applies a lot of force in one moment and it starts to hurt right away as opposed to it hurting gradually as you ramp up for a race when you’ve been training and running a whole lot. That’s really the key difference. I think in general, it depends on how severe it is to determine when you’re going to get back to running and what you have to do in the interim. But you don’t always have to stop running, but you still just like a stress fracture, you have to decrease the force on that bone that’s been bruised enough that it doesn’t hurt when you’re doing the activities that you want to use to maintain your running fitness.
So the whole key is to get your stress apply to the bone down under your threshold for healing so you can continue to run, continue to train, continue to stay fit, whatever that means during that period that it’s actually healing. If you just continue to run and it actually hurts every step, you’re definitely going to make it worse. You don’t want to do that. But hopefully that helps you understand a little bit more about the differences between a bone bruise and a stress reaction.
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