The Physical Performance Show

In episode 381 of The Physical Performance Show, host Brad Beer — sports and exercise physiotherapist — sits down with Pogo physiotherapist Tim Studley for the first instalment of a two-part mini-series on shin pain and tibial bone stress injuries, following on from their earlier three-part bone stress injury series. This episode is essential listening for runners, coaches, and clinicians alike, unpacking how to tell the difference between medial tibial stress syndrome (MTSS/shin splints) and a true tibial bone stress injury — two conditions that can feel identical but require completely different management. Brad and Tim walk through the physiology of bone loading, the palpation tests that separate a "safe to keep running" diagnosis from one requiring an MRI, and the loading tests used to stress-test the tibia safely in clinic. Show Sponsor: Pillar Performance continues to lead the way in sports nutrition through micro-nutrition innovation, now expanding into the Performance Health range. One of their newest releases, Collagen Repair, was developed with Gelita Laboratories (Germany) using a clinically trialled collagen peptide (Tendofort) to support tendon and ligament health in conditions like hamstring tendinopathy, Achilles tendonitis, shin splints, and patellofemoral pain. Head to pillarperformance.shop (or thefeed.com for North American listeners) and use code PHYSICALPERFORMANCE for 15% off your first purchase. Pogo Physio also offers online Telehealth Consultations for endurance athletes managing bone, tendon, or joint issues — book online at https://pogophysio.com.au. Listen in as we delve into the following: The prevalence of tibial bone stress injuries and why the shin is the most common bone stress site in runners Why bone stress injuries occur: workload errors, loading frequency vs. magnitude, and individualised risk factors The continuum from "happy bone" to stress reaction to frank stress fracture Why pain magnitude doesn't reliably predict injury severity The heterogeneity of bone innervation and why the periosteum is key to understanding pain Differentiating MTSS from tibial bone stress injury — and why the management is entirely different The 10cm palpation rule: a clinical prediction rule for when to suspect bone vs. soft tissue Why the anterior (front) shin is a higher-risk, non-union-prone injury site The loading-test ladder: double leg calf raise → single leg calf raise → single leg hop → side-to-side hop → forward hop The role of muscle-bone synergy: how calf strength and girth influence tibial bone stress risk Recovery timelines by injury grade, and why MRI matters for prognosis and athlete buy-in A real case study: a triathlete's navicular injury, deconditioning, and return to tibial bone stress injuries Quotes "You can go from hero to zero really quickly with bone."  "Higher levels of pain don't necessarily mean a worse injury."  "Muscle loads bone."  Timeline 00:00 – Introduction & sponsor: Pillar Performance 02:15 – Introduction to Tim and Brad's conversation 02:27 – Prevalence of tibial bone stress injuries 03:56 – Why bone stress injuries occur: workload and biomechanics 05:22 – Symptom patterns: bone stress injury vs. other shin pain 07:42 – Heterogeneity of bone innervation and pain variability 10:10 – Why pain severity doesn't predict injury severity 11:07 – MTSS vs. bone stress injury: two schools of thought 12:06 – Brad's clinical experience and personal injury history 13:59 – Cardinal signs and symptom progression in MTSS 15:23 – The three-legged stool: history, physical exam, imaging 16:19 – The 10cm palpation rule explained 19:43 – Applying the rule in practice 20:42 – Anterior shin pain: a higher-risk presentation 21:39 – Loading tests: from calf raises to forward hopping 24:07 – Individualising the loading-test progression 26:03 – Does the 10cm rule apply anteriorly? 26:55 – History as the biggest predictor of reinjury 27:53 – MRI, prognosis, and grading via the Fredericksons scale 29:15 – Reading hesitancy and movement quality in loading tests 31:10 – Why bone stress injuries aren't purely about vertical impact 33:03 – Calf girth and bone stress risk correlation 34:56 – Case study: a triathlete's navicular injury and recovery 35:58 – Episode close & sponsor mentions THE TEAM: Join The Physical Performance Show LEARNINGS membership through weekly podcasts here: https://www.patreon.com/TPPShow Our goal is to get you back to your Physical Best. Find out more about Telehealth Consultations and book online at pogophysio.com.au. Your Hosts: 🏃 Brad Beer - Instagram & X @Bradbeer and YouTube @PogophysioAu 🏃‍♂️‍➡️ Timothy Studley - Instagram @timothy_physio The Physical Performance Show can be found at: Facebook: facebook.com/thephysicalperformanceshowpodcast X: @tppshow1 Instagram: @physicalperformanceshow

In episode 379 of The Physical Performance Show, host Brad Beer and Pogo Physio physiotherapist Tim Studley continue their three-part expert series on bone stress injuries by shifting the focus from training errors to the biological factors that determine whether an athlete's skeleton can tolerate training demands. This episode explores the critical role of energy availability, bone health, recovery, and risk stratification in both preventing and diagnosing bone stress injuries. Brad shares practical screening strategies developed over two decades of clinical practice, explaining why identifying the underlying cause—not just treating the injury—is essential for long-term athletic performance and injury prevention. Show Sponsor: PILLAR Performance is leading a new frontier in sports nutrition through micronutrition innovation. Their new Collagen Repair formula, developed in collaboration with Gelita Laboratories, is designed to support tendon and ligament health while promoting collagen synthesis to help athletes stay healthy and perform at their best. For 15% off your first order, visit pillarperformance.shop (or thefeed.com for North American listeners) and use the discount code PHYSICALPERFORMANCE (one word, capitals) at checkout. In this episode, you'll hear Why biological factors may contribute more to bone stress injuries than training load alone The long-term consequences of early sport specialisation and why multi-sport participation builds a stronger skeleton Medical conditions and medications that can compromise bone health and increase injury risk Why low energy availability (RED-S) is one of the biggest contributors to bone stress injuries Practical screening questions clinicians should ask to identify athletes who may be under-fuelling The relationship between training volume, mood, gastrointestinal symptoms, sleep, life stress and bone health Female-specific indicators including menstrual irregularities and amenorrhoea Male-specific indicators including reduced libido and changes in morning erectile function Why blood tests, iron status, vitamin D and hormone profiles provide valuable clues to athlete health The importance of working with sports dietitians to optimise energy availability and performance Common locations of bone stress injuries throughout the lower limb and pelvis How injury location can provide clues to whether biomechanics or under-fuelling is the primary driver Understanding high-risk versus low-risk bone stress injury sites and why blood supply matters Practical assessment strategies including observation, palpation and functional loading tests When hop testing is appropriate—and when it should be avoided Clinical pearls for distinguishing bone stress injuries from other common running injuries Quotes / takeaways "Training loads the skeleton—but biology determines whether the skeleton can cope." "Eat more than you think you need." "The biggest driver of bone stress injuries is often invisible." "Above the knee, think fuelling. Below the knee, think biomechanics." "Treat the cause—not just the bone." Partners / links mentioned Show Sponsor: PILLAR Performance — 15% off your first order using code PHYSICALPERFORMANCE at checkout. North America: thefeed.com Timeline 00:00 – Introduction, sponsor and recap of the Bone Stress Injury mini-series 02:27 – Why biological risk factors deserve greater attention than ever before 03:51 – Early sport specialisation and athletic history as risk factors 04:50 – Medical conditions, medications and bone health 05:45 – Sleep, stress and the biological contributors to bone stress injuries 07:08 – Understanding low energy availability (RED-S) 08:32 – Practical screening questions for under-fuelling 09:02 – Female athlete indicators: menstrual health and amenorrhoea 10:29 – Male athlete indicators: libido and morning erectile function 11:51 – Blood tests, iron studies, vitamin D and hormone profiles 13:18 – Why even small daily energy deficits accumulate over time 14:16 – Working with sports dietitians and estimating energy requirements 15:40 – Brad's number one recommendation: "Eat more than you think you need" 16:08 – Common sites of bone stress injuries throughout the body 18:00 – Using injury location to distinguish biomechanics from under-fuelling 18:48 – High-risk versus low-risk bone stress injury locations 21:12 – The most commonly missed bone stress injuries in runners 22:37 – Clinical examination: observation, palpation and localisation of symptoms 24:19 – Differentiating shin splints from bone stress injuries through palpation 25:14 – Functional loading tests and when hop testing is appropriate 26:31 – Hop testing, femoral neck injuries and clinical safety considerations 27:24 – Differential diagnosis and key assessment principles 28:25 – Episode wrap-up and preview of Part 3 THE TEAM: Join The Physical Performance Show LEARNINGS membership through weekly podcasts here: https://www.patreon.com/TPPShow Our goal is to get you back to your Physical Best. Find out more about Telehealth Consultations and book online. Your Host: 🏃 Brad Beer – Instagram & X @Bradbeer and YouTube @PogophysioAu The Physical Performance Show can be found at: Facebook: facebook.com/thephysicalperformanceshowpodcast X: @tppshow1 Instagram: @physicalperformanceshow