Marathon Series: Return to Running
With the Melbourne Marathon for 2026 yesterday, here is the final piece in our series on bone stress injuries in running.
One of the more frustrating patterns we see with bone stress injuries isn’t the injury itself, it’s the recurrence. An athlete does the right thing, rests, comes back, and a few months later is dealing with the same problem again, sometimes in the same bone, sometimes in a different one. Almost always, that repeat visit traces back to one of two things: coming back too quickly, or never actually addressing why the first one happened.
The first step in management is working out what kind of stress injury you’re actually dealing with, because it changes everything downstream. Some sites — the shaft of the tibia, the fibula, most of the metatarsals — are considered lower risk and generally heal well with a period of modified activity. Others — the femoral neck, the sacrum, the navicular — carry a much higher risk of poor healing or progression to a full fracture, and often need a longer period of non-weight-bearing rest, sometimes with surgical input. Treating every stress injury the same way, regardless of site, is one of the more common ways recovery goes sideways.
Clearance to start running again isn’t just about pain settling down. For the higher risk sites in particular, it should mean the bony tenderness has genuinely resolved, walking is fully pain-free, and where relevant, imaging confirms the bone has actually healed rather than just quietened down symptomatically.
From there, the return itself needs to be graduated — starting with intervals of walking and running rather than jumping straight back into continuous mileage, and increasing speed or distance in stages rather than both at once.
There’s also a genuinely useful mechanical lever available during this phase: running cadence. Athletes who increase their step rate slightly tend to reduce hip adduction and lower their vertical loading rate, both of which translate into less strain on the bone per stride. It’s a relatively simple adjustment, and one worth building into the return to run program rather than treating as a separate project.
But the piece that gets skipped most often is the systemic check. If the injury was driven, even partly, by inadequate energy availability or an undiagnosed drop in bone density, then healing the bone itself hasn’t fixed the actual problem. Screening for that properly, and treating it if it’s there, is what separates a runner who gets back to full training and stays there, from one we see again in six months with the same story.
