The Physical Performance Show

In episode 387 of The Physical Performance Show, host Tim Studley picks up part two of his conversation with fellow Pogo Physio physiotherapist Lewis Craig, continuing last week's deep dive into surf life saving and Ironman racing. This episode shifts focus from injury patterns to managing niggles, optimising performance, and the habits that separate top-tier surf ironman athletes from the rest.

Tim and Lewis discuss the collaborative decision-making involved in managing a recurring niggle, the key training and screening recommendations every surf life saving athlete should have in place, the lessons Lewis has learned working with elite athletes in the sport, and his top tips for improving performance — from sand-specific training to fuelling properly for a demanding training load.

SHOW SPONSORS:

💯 Today's episode is brought to you by Pillar Performance and Pogo Physio's telehealth consultations. If you are an endurance runner battling with bone, tendon, joint related concerns, our online Telehealth consultations are an ideal platform to help get you back to your physical best - book online at https://pogophysio.com.au.

💯 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 https://pillarperformance.shop (or https://thefeed.com for North American listeners) and use the discount code PHYSICALPERFORMANCE (one word, capitals) at checkout.

IN THIS EPISODE YOU'LL HEAR:

A recap: this episode picks up where Part 1 (episode 386) left off, continuing the discussion on surf life saving and Ironman racing

Managing recurring niggles: why the decision to rest or continue training should be a collaborative one between physio, athlete and coach

How timing within the season affects the risk-benefit of resting versus maintaining training load

Why a first-time niggle warrants a more cautious, rest-forward approach compared to a chronic, familiar issue

Practical ways to modify training around a niggle — for example, adjusting swim technique (removing paddles, adding kick, more dry-land warm-up) rather than stopping entirely

The physiotherapist's role in performance: keeping athletes pain-free and injury-free so coaches can focus on skill and aerobic development

Baseline recommendations for surf life saving athletes: two gym sessions per week, individual screening, consistent dry-land warm-ups, and tracking training load

How swimmers can track training intensity despite the difficulty of measuring heart rate in the pool, including simple session RPE-based load tracking

Why tracking training load matters most when returning from injury or time out of the sport

The performance and injury-reduction upside of athlete and team awareness around REDs and energy availability

The value of a collaborative support team: coach, physio, dietician, sports psychologist and massage therapist working together

Lessons learned from working with elite surf life saving athletes, including individual variation in pain tolerance, treatment preferences and communication style

Common themes among top athletes: professionalism, a genuine quest for knowledge about their bodies and training, and long-term training consistency

Lewis's top three tips for improving performance: sand-specific training with a focus on calf and lower-limb capacity, prioritising shoulder health from a young age, and taking fuelling seriously

The best piece of performance advice Lewis has been given: you can only benefit from the training you can recover from

Closing thoughts on the sport deserving more attention, and interest in having surf life saving athletes themselves on the show in future

QUOTES / TAKEAWAYS:

"It should always probably be a collaborative decision between the physio treating the athlete, the athlete themselves, and the coach."

"Can I take one or two, three days now to maybe potentially avoid a bigger block or weeks of interrupted niggling soreness?"

"You can only benefit from the training you can recover from."

"Eat more than you think you need."

"There's a professionalism, there's a quest for knowledge, and then there's a consistency thing."

"It's trying not to confuse doing more with being best."

TIME STAMPS:

00:17 – Episode introduction and breakthrough experience

00:23 – Episode 387 introduction: Part 2 with Lewis Craig on surf life saving

02:22 – Managing a recurring niggle: how to approach the decision to rest or train through

03:20 – Timing within the season and its effect on rest decisions

04:20 – Why a first-time niggle warrants a more cautious approach

04:50 – Modifying training instead of stopping: examples from swimming

05:47 – The physio's role in performance: keeping athletes pain-free so coaches can coach

06:46 – Baseline recommendations: two gym sessions per week

07:41 – Screening to identify individual injury risk factors

08:06 – The value of consistent dry-land warm-ups

09:06 – Tracking training load and intensity in swimming

10:35 – Session RPE and simple load-tracking methods

11:06 – Why tracking load matters most when returning from injury

11:36 – Awareness of REDs and low energy availability

12:05 – Recap: gym, screening, warm-ups, training load, energy awareness, support team

12:32 – Lessons learned from working with elite surf life saving athletes

13:30 – Individual variation in athlete preferences and pain tolerance

13:59 – Common themes among top athletes: professionalism and consistency

15:24 – Lewis's top three tips for improving performance

16:22 – Recap: sand-specific training, shoulder health, fuelling

16:52 – The importance of eating enough to support training load

17:17 – The best performance advice: recovering from training, not just doing more

18:15 – Closing thoughts and interest in future athlete guests

18:45 – Episode close and thanks to Lewis Craig

19:17 – Recap of the two-part surf life saving discussion

19:36 – Pogo Physio Telehealth Consultations and closing details

Join the 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 HOSTS:

🏃‍♂️‍➡️ Timothy Studley - Physiotherapist: Instagram @timothy_physio

💪 Lewis Craig - Physiotherapist and Clinical Lead, Pogo Physio: Instagram @_lewiscraig_

The Physical Performance Show can be found at: Facebook: facebook.com/thephysicalperformanceshowpodcast X: @tppshow1 Instagram: @physicalperformanceshow

Please direct any questions, comments, and feedback to the above social media handles.

In episode 386 of The Physical Performance Show, host Tim Studley sits down with fellow Pogo Physio physiotherapist Lewis Craig to explore the world of surf life saving and Ironman racing — a sport many listeners may be unfamiliar with, but one that shares a huge amount in common with traditional triathlon and endurance sport.

Tim and Lewis unpack what a typical training week looks like for a semi-professional surf ironman/ironwoman athlete, the most common injuries seen across swimming, ski paddling, board paddling and soft sand running, the disproportionate impact running-based injuries can have on an athlete's ability to race, and why energy availability, sleep and recovery are just as critical in this sport as they are in any other high-volume endurance discipline.

SHOW SPONSORS:

💯 Today's episode is brought to you by Pillar Performance and Pogo Physio's telehealth consultations. If you are an endurance runner battling with bone, tendon, joint related concerns, our online Telehealth consultations are an ideal platform to help get you back to your physical best - book online at https://pogophysio.com.au.

💯 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 https://pillarperformance.shop (or https://thefeed.com for North American listeners) and use the discount code PHYSICALPERFORMANCE (one word, capitals) at checkout.

In this episode, you'll hear:

An introduction to surf life saving and Ironman racing: swimming, ski paddling, board paddling and soft sand running combined into one demanding sport

The semi-professional nature of the sport, and how prize money from series like the Shaw and Partners Ironman Series and World Ocean Series has helped athletes

A snapshot of a typical training day and week: double training sessions, four swim sessions, two to three ski paddling and board sessions, two gym sessions, two standalone runs, and Irons sessions combining all disciplines

Typical weekly training hours for competitive athletes — estimated in the range of 15 to 20+ hours per week

Similarities to other endurance sports: shared challenges around shoulder health, running-related injuries, and managing training load, intensity and recovery

Whether discipline-dominant athletes (runners, swimmers, paddlers) experience different injury patterns, and the possible link between strong runners and higher bone stress injury risk via REDs

What first drew Lewis to working with surf life saving and Ironman athletes, including his early experience working alongside elite athletes at Pogo Physio

Common injuries in the sport: shoulder tendinopathies (supraspinatus, subscapularis), low back pain, Achilles tendinopathy, calf strains, ankle sprains, toe injuries, knee pain, bone stress injuries, and trauma-related injuries from craft or contact

Why shoulder health is a season-long priority, while injuries that prevent running (calf strains, ankle sprains, bone stress injuries) carry the biggest time cost due to their impact on race ability

Estimated prevalence of athletes competing while managing a shoulder or low back niggle, and how this may fluctuate across the competitive calendar

An overview of the surf life saving racing calendar: trials, the Coolangatta Gold, and a condensed back-to-back race season with minimal true off-season

Why the Coolangatta Gold's extra soft sand running volume increases physical demand and potential injury risk

Common misconceptions about the physical demands of the sport, including underestimation of the aerobic and neuromuscular demands of soft sand running

The energy cost and muscle activation differences of soft sand running compared to running on grass or road (roughly 1.4–1.6x energy cost, near-double EMG activity in key running muscles)

Why maintaining some running — and ideally some soft sand running — year-round may help reduce injury risk when returning to high-intensity training

Physical qualities to develop for soft sand running: calf capacity, forefoot strength, neuromuscular control, balance and proprioception, and specific gym-based calf training strategies

Why strong road runners can't assume they have the capacity needed for soft sand running

Common training and recovery mistakes: under-fuelling relative to high training demands, and the potential role of low energy availability and REDs in this population

Warning signs of under-fuelling to watch for, including low iron, frequent illness, low libido in males, and menstrual cycle changes in females

The key pillars of recovery for these athletes: sleep, nutrition, well-structured and individualised training programming, and secondary recovery tools like massage, compression and cryotherapy

Quotes / takeaways:

"These athletes are really, really impressive... it really is akin to the traditional triathlete."

"It's a real juggling act, but also then makes it really meaningful to try and help these athletes."

"If we can't sand run, then often that's no racing."

"Go for a run on the sand and see how hard it is."

"I have a hypothesis that if these athletes all did more running, we'd see a heap of bone stress injuries."

"It gets tricky to do it well and do it right consistently."

Time Stamps:

00:00 – Episode introduction: surf life saving and Ironman racing with Lewis Craig

00:31 – What is surf life saving and Ironman racing?

01:30 – Semi-professional status and recent growth in prize money

02:27 – A typical training day and week for a competitive athlete

04:23 – Typical weekly training hours

05:23 – Comparisons to other endurance sports like triathlon

06:23 – Do discipline-dominant athletes get different injury types?

08:05 – What sparked Lewis's interest in the sport

11:28 – Most common injuries: shoulder, low back, running-related

13:26 – Which injuries carry the biggest performance and time cost

14:21 – Prevalence of athletes competing through shoulder or back niggles

16:34 – The surf life saving racing calendar and trials

18:24 – Biggest misconceptions about the physical demands of the sport

18:54 – The energy cost and muscle demands of soft sand running

20:24 – Bone stress injury risk around high-intensity competition periods

20:52 – Underestimating the aerobic demands of soft sand running

23:17 – Why maintaining year-round running and sand running may help

24:16 – Physical capacities to develop for soft sand running: calf, foot strength, balance

26:14 – Why road running fitness doesn't guarantee sand running capacity

26:43 – Common training mistakes: under-fuelling and REDs risk

29:35 – Warning signs of low energy availability to watch for

30:05 – Recovery pillars: sleep, nutrition, training structure

31:34 – Individualised recovery tools: massage, compression, cryotherapy

32:32 – Recap of key recovery pillars and closing thoughts

THE TEAM:

Join the 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 Hosts:

🏃‍♂️‍➡️ Timothy Studley - Physiotherapist at Pogo Physio: Instagram @timothy_physio

💪 Lewis Craig - Physiotherapist and Clinical Lead, Pogo Physio: Instagram @_lewiscraig_

The Physical Performance Show can be found at: Facebook: facebook.com/thephysicalperformanceshowpodcast X: @tppshow1 Instagram: @physicalperformanceshow

Please direct any questions, comments, and feedback to the above social media handles.

In episode 385 of The Physical Performance Show, host Brad Beer sits down with fellow physiotherapist Lewis Craig for a lateral ankle sprain masterclass. Drawing on material the pair recently presented at a Gold Coast orthopedic evening, Brad and Lewis cover the burden and prevalence of lateral ankle sprains, the three-part clinical assessment process, key differential diagnoses, rehabilitation phases, and preventative strategies including bracing and taping.

The episode explores why lateral ankle sprains — despite their reputation as a minor injury — carry a significant risk of chronic ankle instability, and why a thorough, structured assessment is essential to a smooth recovery. Brad and Lewis unpack the different ligament and tendon structures that can be involved, the red flags practitioners need to rule out, the impairment categories drawn from Jay Hertel's model of chronic ankle instability, and how rehabilitation should progress from protection through to return to sport and long-term prevention.

Show Sponsor:

Pogo Physio also offers online Telehealth Consultations for endurance athletes managing bone, tendon, or joint issues — book online at https://www.pogophysio.com.au.

And...

PILLAR Performance is leading a new frontier in the sports nutrition industry through micronutrition innovation. Their Performance Health range is designed to support the crucial hours outside of training and racing, helping athletes return to the start line in peak condition.

One of their newest releases is Collagen Repair, developed in collaboration with Gelita Laboratories and featuring the clinically trialled collagen peptide TENDOFORT. For 15% off your first purchase, head to pillarperformance.shop or, for North American listeners, thefeed.com and use the code PHYSICALPERFORMANCE at checkout.

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 Pogo Physio also offers online Telehealth Consultations for endurance athletes managing bone, tendon, or joint issues — book online at https://www.pillarperformance.shop (or https://www.thefeed.com for North American listeners) and use code PHYSICALPERFORMANCE for 15% off your first purchase.

Partners / links mentioned:

Ortho Tools (Cumberland Ankle Instability Tool / CAIT): mentioned in-episode as the online questionnaire resource

Contact: Lewis Craig — [email protected]

In this episode, you'll hear:

Episode context: Lewis Craig's return to the show after being last on around episode 109, and his progress toward finishing his Sports Masters through the University of Queensland

The burden of lateral ankle sprains: why they're the most common musculoskeletal injury in sport across field and court sports, contact and non-contact alike

Recurrence risk: why roughly 40% of people who sprain their ankle go on to develop chronic instability, and why the one-year mark is a key risk-reduction milestone

Early predictors of chronic ankle instability: the Doherty 2016 study on single-leg landing and drop-jump testing at two weeks post-injury

The three priorities of assessment: ruling out red flags and fractures, forming an accurate diagnosis, and identifying impairments

Screening for fractures: mechanism of injury, the Ottawa ankle rules, weight-bearing ability, and key bony landmarks to palpate

Differential diagnosis: ATFL and CFL sprains (70–80% of ankle sprains), peroneal tendon injuries, bifurcate ligament sprains, deltoid ligament tears, syndesmosis injuries, and talar dome injuries

Why getting a clear mechanism of injury from the athlete is critical to an accurate diagnosis

Identifying impairments: the ROAST consensus and Jay Hertel's updated model of chronic ankle instability — pathomechanical, sensory-perceptual and motor-behavioural impairments

Clinical and objective testing: balance progressions, calf raise endurance and strength benchmarks, and power tests including triple hop, crossover hop and timed lateral hop

The role of patient-reported outcome tools: the Cumberland Ankle Instability Tool (CAIT) and FAAM, and why they're useful for tracking progress and motivation

Rehabilitation framework: protection and appropriate early loading, followed by strength, stability and mobility phases

Managing specific injury types: use of moon boots, orthotics, low-dye taping and ASO ankle braces depending on the structures involved

Addressing dorsiflexion loss: why regaining ankle range of motion is often one of the hardest parts of rehab, and the Torillin infographic on identifying the source of restriction

Late-stage rehab and return-to-sport: hopping, change of direction, and integrating exercises into an athlete's normal training week for ongoing prevention

Bracing and taping as secondary/tertiary prevention strategies to reduce recurrence

Long-term consequences of poorly managed ankle sprains, including links to post-traumatic osteoarthritis and eventual ankle surgery

The biggest mistake athletes make: assuming rehab is "done" once they can run, despite still having deficits in power, change of direction and stability

Lewis's top tip: get every ankle sprain properly assessed, no matter how minor

Quotes / takeaways:

"It's just a simple lateral ankle sprain... and then someone who goes missing for months at a time."

"Four out of ten people who have an ankle sprain go on to develop a chronic instability."

"The better quality of the assessment, the more likely there's an accurate diagnosis."

"It's really hard to sprain your ankle when it's really well strapped or with an appropriate brace."

"Once someone gets running... you can run in a straight line really well and have really considerable deficits still."

"Get it assessed. Understand what you've done and understand what impairments you might have."

Time Stamps:

00:17 – Episode introduction and breakthrough experience

00:23 – Episode 385 introduction: lateral ankle sprain masterclass with Lewis Craig

00:50 – Sponsor: PILLAR Performance and Performance Health

01:15 – Collagen Repair: formulation, TENDOFORT and collagen health

01:44 – 15% PILLAR Performance discount with code PHYSICALPERFORMANCE

02:19 – Welcoming Lewis Craig back to the show

02:48 – Lewis's tenure at Pogo Physio and progress on his Sports Masters at UQ

03:45 – Introducing today's topic: lateral ankle sprains

04:37 – How common and burdensome are lateral ankle sprains?

05:36 – The "she'll be right" attitude and why it's changing

07:02 – Lewis's personal history with recurrent ankle sprains

08:02 – Impact on Lewis's own running and trail running

08:28 – The one-year mark and recurrence risk statistics

09:26 – Predictors of chronic ankle instability: single-leg landing and drop jump

09:53 – The Doherty 2016 study explained

10:51 – The three priorities of assessment

11:21 – Ruling out red flags and fractures

12:45 – Why assessment quality drives rehab outcomes

13:14 – Screening for fractures: mechanism, Ottawa ankle rules, bony landmarks

14:39 – Deciding on imaging: x-ray or MRI

15:06 – Differential diagnosis: the many subcategories of ankle sprain

15:35 – ATFL and CFL: the most common ligament sprains

16:35 – Peroneal tendon injuries

17:04 – Bifurcate ligament sprains

18:04 – Deltoid ligament tears with lateral ankle sprains

18:33 – Syndesmosis injuries and mechanism differences

19:31 – Clinical tests for syndesmosis

20:01 – Talar dome injuries and other easily missed diagnoses

20:30 – Why getting a clear mechanism from the athlete matters

21:29 – Identifying impairments: what it means and why it's important

22:51 – Jay Hertel's model of chronic ankle instability

23:48 – Balancing patient education without causing fear

24:17 – Motor outcomes: strength, power and kinetic chain

24:43 – Assessment time and thoroughness at Pogo Physio

25:08 – Objective testing: dynamometers, balance and calf tests

25:38 – Balance test progressions as return-to-sport criteria

26:37 – Strength testing: inversion, eversion and calf raise endurance

27:07 – Power testing: triple hop, crossover hop and lateral hop tests

27:33 – Using objective markers to guide return-to-sport decisions

28:01 – Patient questionnaires: Cumberland Ankle Instability Tool (CAIT) and FAAM

28:57 – Coping vs non-coping athletes and objective scoring

29:25 – Moving into rehabilitation: individualised management

29:54 – Protection and appropriate early loading

30:20 – Moon boots and protecting specific structures

31:16 – ASO ankle braces for lower-grade sprains

31:45 – The strength, stability, mobility rehab framework

32:14 – Early loading phase: range of motion, balance and strength

32:43 – Addressing dorsiflexion loss

33:13 – The Torillin infographic on restriction sources

33:40 – Progressing balance and strength exercises

34:10 – Preventative efforts and integrating rehab into training

34:40 – Late-stage rehab and return-to-play criteria

35:39 – Bracing and taping to prevent recurrence

36:08 – Long-term consequences: osteoarthritis and ankle surgery risk

37:34 – Lewis's own experience with taping and bracing

38:02 – The biggest mistake athletes make in managing ankle sprains

39:29 – Lewis's top tip: get every ankle sprain assessed

40:27 – Where to reach Lewis Craig for questions

40:52 – Episode close and sponsor reminder

41:20 – Pogo Physio Telehealth Consultations and closing details

THE TEAM:

Join the 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 Hosts:

🏃 Brad Beer - Instagram & X @Bradbeer and YouTube on @PogophysioAu

💪 Lewis Craig - Physiotherapist and Clinical Lead, Pogo Physio Instagram: @_lewiscraig_

The Physical Performance Show can be found at: Facebook: facebook.com/thephysicalperformanceshowpodcast X: @tppshow1 Instagram: @physicalperformanceshow

Please direct any questions, comments, and feedback to the above social media handles.

In episode 384 of The Physical Performance Show, Brad Beer and fellow physiotherapist Tim Studley tackle a wide-ranging Q&A on tibial bone stress injuries. Following the recent bone stress injury mini-series and two-part tibial bone stress injury masterclass, Brad and Tim answer listener questions covering chronic tibial stress responses, recurring shin pain, rehabilitation, plyometrics, strength training, anti-inflammatory medications, and how to reduce the risk of future bone stress injuries.

The episode explores some of the practical clinical questions that arise when athletes are trying to understand persistent shin pain and return to running. Brad and Tim unpack the difference between tibial bone stress injuries and medial tibial stress syndrome (MTSS), explain how workload and tissue tolerance interact, discuss when to introduce single-leg strength and plyometrics, and highlight why a thorough assessment of both biomechanical and biological risk factors is essential for athletes with recurring bone stress injuries.

Show Sponsor: PILLAR Performance is leading a new frontier in the sports nutrition industry through micronutrition innovation. Their Performance Health range is designed to support the crucial hours outside of training and racing, helping athletes return to the start line in peak condition.

One of their newest releases is Collagen Repair, developed in collaboration with Gelita Laboratories and featuring the clinically trialled collagen peptide TENDOFORT. For 15% off your first purchase, head to pillarperformance.shop or, for North American listeners, thefeed.com and use the code PHYSICALPERFORMANCE at checkout.

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 pogophysio.com.au.

Partners / links mentioned:

Show sponsor: PILLAR Performance — 15% off your first purchase using code PHYSICALPERFORMANCE at checkout.

PILLAR Performance: pillarperformance.shop

North American listeners: thefeed.com

Pogo Physio Telehealth Consultations: pogophysio.com.au

In this episode, you'll hear:

Chronic tibial bone stress injuries: whether an experienced ultramarathon runner can adapt to a persistent Grade 2 stress response and continue running without progressing to a stress fracture

Recovery strategies: what sauna, nutrition and strength training may—and may not—contribute to recovery from tibial bone stress injuries

Nutrition and bone health: the importance of adequate calorie and micronutrient availability, and why recurrent bone stress injuries may warrant review with a sports dietitian

Calcium supplementation: what is known about calcium availability and why there isn't a clear tibia-specific dose linked directly to bone stress injury recovery

Recurring shin pain: why an athlete can continue experiencing medial shin pain despite controlled mileage and well-rounded strength training

The three-part clinical framework: biomechanics, workload, and tissue capacity as key areas to investigate when shin pain keeps returning

MTSS versus bone stress injury: why persistent posterior-medial shin pain may represent medial tibial stress syndrome rather than a bone stress injury

Individual differences: why some runners seem more susceptible to shin pain and why comparing your injury history with other runners can be misleading

Plyometrics and single-leg strength: when to introduce spring-based loading, hopping and jumping during tibial bone stress injury rehabilitation

Rehabilitation progression: why single-leg strength work can begin relatively early while plyometrics are generally introduced later

Training the opposite leg: why the unaffected limb should continue to be trained during rehabilitation

Return to running with persistent shin pain: how MRI findings, symptom location and clinical presentation can help distinguish MTSS from tibial bone stress injury

Strength training progression: moving from higher-repetition, lower-load work capacity training towards heavier strength and eventually rate-of-force and plyometric training

Anti-inflammatory medications: what regular use of ibuprofen and diclofenac may mean for bone and skeletal health, and why they are unlikely to be the sole cause of a running-related bone stress injury

Posterior tibial stress reactions: how running workload can exceed bone tolerance and how factors including bone geometry, bone quality, biomechanics and psychology may influence risk

Preventing recurrence: why runners with a previous bone stress injury have a significantly elevated future risk and need to identify and manage their individual risk factors

The role of the gym: why strength and conditioning can help restore muscle capacity, support bone health and prepare the tibia for the demands of running

Hop testing: why a pain-free hop test is useful when assessing tibial bone stress injuries, while recognising that other diagnoses can also produce pain with hopping

The 10 cm palpation rule: why longer areas of shin tenderness are more consistent with medial tibial stress syndrome than focal bone stress injury

Clinical assessment: why practitioners need to consider gait, palpation, loading tests, biomechanics, workload, tissue capacity and differential diagnoses rather than relying on pain intensity alone.

Quotes / takeaways:

"Bone stress is not something that the body adapts to."

"Most people are paying a tax, I always say, to play the game they want to play."

"There's no recipes."

"It's never just one thing."

"You need running workload and that workload exceeds, in simple terms, bone's tolerance."

"Once a runner's had a bone stress injury, they have much heightened risk, six to seven fold for the rest of their running life."

Time Stamps:

00:00 – Episode introduction and breakthrough experience

00:23 – Episode 384 introduction: Q&A on tibial bone stress injuries

00:53 – Sponsor: PILLAR Performance and Performance Health

01:20 – Collagen Repair: formulation, TENDOFORT and collagen health

01:49 – 15% PILLAR Performance discount with code PHYSICALPERFORMANCE

02:18 – Episode begins: listener Q&A following the bone stress injury series

03:24 – How the listener questions were gathered and why these themes matter

03:53 – Chris' question: chronic Grade 2 tibial bone stress injury in an experienced ultramarathon runner

04:23 – Can the body adapt to bone stress and allow an athlete to run through it?

05:49 – Why symptomatic bone stress requires an appropriate deload

06:16 – Sauna, nutrition and other recovery techniques

07:11 – Micronutrients, calories and optimal skeletal health

08:07 – Strength training and progressive restoration of tibial capacity

08:33 – Calcium intake and the importance of sports dietitian review for recurrent injuries

09:57 – Zane's question: recurring medial shin pain despite controlled mileage and strength training

10:52 – Why some runners continue to struggle despite avoiding obvious training spikes

11:51 – The three key areas: biomechanics, workload and tissue capacity

12:19 – MTSS versus tibial bone stress injury

12:46 – Biomechanical strategies and the example of professional triathlete Josh

13:39 – Strength and conditioning relative to the demands of professional triathlon

14:07 – Why recurring shin pain may require a more individualised assessment

15:03 – Why comparing yourself with runners who appear injury-free can be misleading

15:33 – "Paying a tax" to participate in the sport you love

16:02 – Isaac Fishlock's question: when to introduce plyometrics and single-leg strength

16:28 – Plyometrics as a late-stage rehabilitation tool

16:57 – Why bones need spring loading and high rates of loading

17:26 – Introducing single-leg strength early and training the unaffected leg

17:55 – Why the opposite leg may also be at increased risk after deloading

18:18 – Are there strength or pain benchmarks before introducing plyometrics?

18:45 – Why rehabilitation progression needs to be individualised

19:15 – Rhonda Gainsford's question: persistent medial shin pain with a negative MRI

19:45 – Why persistent symptoms can point towards MTSS rather than bone stress injury

20:13 – What an MRI showing no bone stress response can tell you

20:42 – Focal versus longer-length tenderness along the shin

21:10 – Can the runner return to running?

21:41 – The Coil Crew's question: heavy reps versus endurance work for calf raises

22:10 – Starting with higher-repetition, lower-load work capacity

22:41 – Progressing towards heavier strength work

23:09 – The three-pronged calf framework: endurance, maximum strength and spring

23:39 – Clinical benchmarks for calf endurance and reactive strength

24:09 – Ryan Williams' question: can regular ibuprofen or diclofenac cause a stress response?

24:37 – Anti-inflammatories, collagen synthesis and potential effects on skeletal health

25:03 – Why anti-inflammatories are unlikely to independently cause a running-related bone stress injury

26:01 – How a posterior tibial stress reaction develops

26:31 – Running workload versus bone tolerance

27:00 – Bone geometry, bone quality, adolescent sport and other risk factors

27:29 – Why bone stress injuries are multifactorial

27:57 – Reducing future risk through biological and biomechanical risk stratification

28:26 – The heightened recurrence risk following a previous bone stress injury

28:54 – Does going to the gym reduce the risk of future stress reactions?

29:22 – What the research says about strength training and injury prevention

29:50 – Restoring calf size, strength and muscle characteristics after deloading

30:15 – Building an individualised strength and conditioning program

30:42 – Osteogenic exercise and addressing obvious strength deficits

31:10 – Lenny P's question: symptoms greater than 10 cm and a positive hop test

31:37 – Other causes of pain with hopping, including calf injury and MTSS

32:06 – The 10 cm palpation finding and what it suggests

32:35 – Why pain intensity is not a reliable guide to bone stress injury severity

33:04 – Q&A conclusion and invitation for further questions

33:33 – Future expert episodes on femur, foot, ankle and sacral bone stress injuries

33:58 – Episode close and PILLAR Performance sponsor reminder

34:26 – Pogo Physio Telehealth Consultations and closing details.

THE TEAM:

Join the 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 Hosts:

🏃 Brad Beer - Instagram & X @Bradbeer and YouTube on @PogophysioAu 💪 Tim Studley - Physiotherapist

🏃‍♂️‍➡️ Timothy Studley - Instagram @timothy_physio

The Physical Performance Show can be found at: Facebook: facebook.com/thephysicalperformanceshowpodcast X: @tppshow1 Instagram: @physicalperformanceshow

Please direct any questions, comments, and feedback to the above social media handles.

Physical Performance Show – Episode 383 Show Notes

In episode 383 of The Physical Performance Show, host Brad Beer sits down with Professor Franco Impellizzeri, one of the most influential and outspoken voices in athlete load management research, for a wide-ranging conversation on why "load management" is an old concept dressed up in new data, why the acute to chronic workload ratio (ACWR) never held up to scrutiny, and why context — not more metrics — is what separates good decision-making from noise.

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 pogophysio.com.au.

Professor Franco Impellizzeri's work can be explored here:

https://profiles.uts.edu.au/Franco.Impellizzeri

And...

https://scholar.google.com/citations?user=z35F1WAAAAAJ&hl=en

Listen in as we delve into the following:

What "load management" actually means, and why it's a relabelling of concepts coaches have wrestled with since the 1930s–40s

The double-edged sword of the data revolution: from heart rate monitors to today's GPS, wearables, and AI-driven analytics

Commercial and career incentives behind pushing metrics — both from tech companies and researchers

Confirmation bias and why interpreting data without a theoretical framework is "like reading tarot"

The case against the acute to chronic workload ratio (ACWR): its lack of scientific support despite IOC endorsement

A landmark runners' study showing the opposite relationship between ACWR and injury risk — and what that reveals about the field

Why meta-analyses and systematic reviews in load research can be manipulated to "find whatever you like"

The difference between using a metric personally versus promoting it as scientifically validated

Why the most skilled clinicians tend to hold their conclusions with the least certainty

A real-world case study: a soccer training drill "failure" that was actually a video-monitoring blind spot, not a bad drill

The expanding role of data scientists in sport, and why interpretation — not collection — is the real skill gap

Whether AI and machine learning can (or should) replace the sports scientist's judgement

Individualised and personalised training approaches — and why even these are still built on group-level generalisations

Distinguishing signal from noise, and why one "failed" intervention doesn't mean an athlete won't respond next time

Practical advice for coaches and practitioners: accept uncertainty, treat training like a "trial of therapy," and reassess

If he could track only one metric: heart rate (or perceived effort) over power

The push for more honest scientific debate — including a proposed on-air "intellectual sparring" series with dissenting researchers

Quotes:

"Understanding the quantity of training for athletes has been a hot topic since training methodology started... managing load is not new." — Professor Franco Impellizzeri

"When you don't have a theoretical framework and an a priori idea strong and supported, it's like reading tarot, to be honest." — Professor Franco Impellizzeri

"There's zero evidence that this metric can either help or can actually reflect some sort of mechanism." — Professor Franco Impellizzeri, on the acute to chronic workload ratio

"Don't take yourself too seriously." — Professor Franco Impellizzeri

Timeline:

00:00 – Introduction: host's specialist physio training and the load management "viva" question

01:04 – What is load management? An old concept, relabelled

02:31 – From heart rate monitors to GPS: the rise of training data

06:14 – Commercial interests and the risk of becoming "slaves of data"

08:05 – Why load management matters: the drug-dosing analogy

09:24 – Load management as a decades-old coaching concern

10:23 – Confirmation bias and interpreting data "like reading tarot"

13:17 – Championing methodological rigor in sports science

16:33 – Meta-research, honesty, and acknowledging uncertainty

18:22 – Why the most skilled clinicians express the least certainty

19:18 – Origins of the critique of the acute to chronic workload ratio (ACWR)

20:09 – Takeaways for contemporary practitioners on load management models

21:34 – Why the ACWR lacked scientific and conceptual support

23:02 – Training load, time-at-risk, and reframing injury risk

24:24 – The contradictory runners' study and what it implies

26:43 – Cherry-picking and overfitting in load-injury meta-analyses

28:34 – Taking a stronger public stance on social media

30:34 – Science as a self-correcting process

31:31 – The discipline required to properly read and critique research

33:58 – Why data alone can't tell you what to do

34:24 – Case study: the soccer drill that "failed" — until the video told the real story

36:49 – The role (and limits) of data scientists in sport

38:46 – Could AI replace the sports scientist's job?

40:42 – Advice for coaches and practitioners: accept uncertainty

42:09 – Individualised approaches are still a form of generalisation

44:31 – Separating signal from noise — and why not to give up early

46:56 – If only one metric: heart rate over power

48:21 – One piece of advice: "don't take yourself too seriously"

48:51 – This week's physical challenge: swimming without pain

50:16 – What's next: meta-research projects and replication studies

51:43 – A proposal for public scientific debate, and Ian Shrier's work on consensus

56:32 – Why genuine debate is hard to find in science communication today

57:59 – Episode close

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 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

Physical Performance Show – Episode 382 Show Notes

In this episode of The Physical Performance Show, host Brad Beer sits down with Pogo Physio's Tim Studley for Part 2 of their two-part mini-series on shin pain and tibial bone stress injuries. Having covered diagnosis and differentiation between MTSS and tibial bone stress injuries in Part 1, this episode shifts focus to management — mechanics, return-to-run programming, strength and conditioning, footwear, and terrain considerations for runners recovering from (or trying to prevent) tibial bone stress injury.

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 pogophysio.com.au.

Listen in as we delve into the following:

• Biomechanical vs. biological risk factors, and why running intensity matters more than mileage for bone
• Cadence, overstriding, and how a heel-strike pattern increases tibial loading
• Foot pressure distribution, lateralised loading, and how footwear/orthotics can help
• A case study: how cadence cueing, orthotics, heel raises, and calf strengthening resolved recurrent tibial bone stress injury
• Managing anterior tibial cortex injuries: why they're high-risk, slow to heal, and often need surgery
• Moving from time-based to symptom-led (optimal load) management for posterior-medial tibial bone stress injuries
• The five evidence-based criteria for returning to running after a tibial bone stress injury
• Why a 10% increase in pace can cut a bone's fatigue threshold by 50%
• Structuring intensity and volume in a return-to-run program to avoid a "double whammy" of risk
• Strength and conditioning phases: contralateral leg work, weight-bearing progressions, and pre-running plyometrics
• Clinical strength benchmarks for calf raises, leg press, hamstring curls, and hip abduction
• Footwear considerations: heel wedges, rocker-bottom shoes, and the debate around carbon plates
• Surface and terrain: why stiffer surfaces and flat terrain are preferred during return-to-run
• Treadmill running and its effect on distal loading
• What's next: an upcoming Q&A episode, and future instalments covering the femur, sacrum, tarsal bones, and calcaneus

Quotes

"Muscle loads bone." — Brad Beer

"That runner doesn't need to be strong. They need to be uber strong." — Brad Beer, quoting tendon researcher Ebonie Rio

"A 10% increase in pace reduces the fatigue threshold of a bone by 50%." — Brad Beer

Timeline

00:00 – Introduction & sponsor: Pillar Performance 02:26 – Running mechanics and tibial bone stress injury risk 03:18 – Cadence, overstriding, and heel-strike patterns 05:43 – Foot pressure distribution and medial tibial bending 07:39 – Case study: footwear, orthotics, and cadence cueing 08:37 – Overview of bone stress injury management complexity 09:35 – Anterior tibial cortex injuries: high risk, slow healing, surgery 11:30 – Shift from time-based to symptom-led management 14:49 – Balancing speed of return with recurrence risk 15:48 – Five evidence-based return-to-run criteria (Sheeran & Reid, 2024) 18:11 – Why intensity is a greater risk factor than volume 20:35 – Strength and conditioning: matching capacity to running demands 22:29 – Three-phase strength progression: pre-, during-, and post-weight bearing 24:52 – Clinical strength benchmarks for return to running 26:16 – Return-to-run walking milestones and symptom monitoring 27:16 – Pain tolerance guidelines: the "any pain, stop" rule for bone 27:45 – Footwear considerations: heel wedges, rocker-bottom shoes, carbon plates 28:42 – Surface and terrain considerations 29:40 – Treadmill running and distal loading effects 30:39 – What's next: Q&A episode and future bone stress injury series 33:01 – 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 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 380 of The Physical Performance Show, host Brad Beer and Pogo Physio physiotherapist Tim Studley conclude their three-part expert series on bone stress injuries by focusing on what happens after diagnosis. From imaging and prognosis to rehabilitation, return to running, and long-term prevention, this episode provides a practical roadmap for athletes, coaches, and clinicians managing these complex injuries.

Brad explains why identifying the underlying causes of a bone stress injury is just as important as healing the bone itself. The discussion covers deloading, progressive reloading, strength and conditioning, bone-building exercise, and the simple but powerful strategies that can dramatically reduce the risk of recurrence.

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 MRI remains the gold standard for diagnosing bone stress injuries and guiding treatment
• When a clinical diagnosis may be sufficient—and why imaging usually provides better certainty and prognosis
• The three-step rehabilitation framework: identify risk factors, deload appropriately, then progressively reload
• Why treating the underlying cause is essential to preventing repeat bone stress injuries
• How rehabilitation differs depending on injury severity and high-risk versus low-risk bone sites
• Practical principles for returning to running, including restoring volume before introducing intensity
• Why the opposite limb also requires strength and bone loading during rehabilitation
• The role of strength training, plyometrics and osteogenic exercise in rebuilding bone capacity
• Why bone responds best to short, novel loading sessions rather than long continuous exercise
• The concept that "bone cells get bored easily" and how to optimise bone adaptation
• Why multidirectional movement remains important long after returning to sport
• The impact of childhood sport participation and bone geometry on lifelong injury risk
• Brad's personal journey with osteoporosis and what it taught him about endurance athlete health
• Three practical strategies every endurance athlete can implement to reduce bone stress injury risk
• Why recovery—not just training—is where adaptation actually occurs

Quotes / takeaways

"Treat the cause—not just the injury."

"Restore volume before you restore intensity."

"Bone cells get bored easily."

"It's not the training you adapt to—it's the recovery from the training."

"Eat more than you think you need."

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 final episode of the Bone Stress Injury mini-series

02:27 – Clinical testing for femoral neck bone stress injuries

03:26 – Clinical diagnosis versus MRI: when imaging is essential

05:14 – Why MRI improves prognosis and return-to-sport planning

07:03 – The three-step rehabilitation framework: risk factors, deload, reload

08:58 – Deloading strategies for high-risk bone stress injuries

09:50 – Progressive tissue loading and returning to running

10:46 – Why training volume should return before intensity

11:45 – Reloading the unaffected limb during rehabilitation

12:44 – Strength training, muscle function and long-term bone health

14:30 – Why bone cells "get bored" and how osteogenic exercise works

15:56 – Novel loading strategies, multidirectional movement and chaos hopping

17:23 – Childhood sport participation and building stronger bones

19:14 – Brad's personal experience with osteoporosis as an endurance athlete

21:40 – Three practical strategies to reduce bone stress injury risk

24:29 – Skeletal deload weeks and cross-training alternatives

25:27 – Recovery as the key driver of adaptation

26:26 – Final advice for athletes and clinicians

27:49 – Brad's top performance tip: "Eat more than you think you need"

28:18 – Listener challenge: fuel immediately before and after every training session this week

28:56 – Episode close and conclusion of the Bone Stress Injury mini-series

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

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

*]:pointer-events-auto R6Vx5W_threadScrollVars scroll-mb-[calc(var(--scroll-root-safe-area-inset-bottom,0px)+var(--thread-response-height))] scroll-mt-[calc(var(--header-height)+min(200px,max(70px,20svh)))]" dir="auto" data-turn-id= "request-WEB:6a57fa5e-c460-45da-be9f-861e67a1cd4e-2" data-turn-id-container= "request-WEB:6a57fa5e-c460-45da-be9f-861e67a1cd4e-2" data-testid= "conversation-turn-4" data-turn="assistant">

In episode 378 of The Physical Performance Show, host Brad Beer is joined by Pogo physiotherapist Tim Studley for the first instalment of a three-part expert series exploring bone stress injuries. Drawing on decades of clinical experience and the latest research, Brad unpacks the mechanisms behind one of the most common and misunderstood injuries affecting endurance athletes.

This episode explains how bone stress injuries develop, why they occur, and why they're often missed until they become more serious. Brad and Tim discuss the relationship between training load, bone physiology, symptom progression, and risk factors, while providing practical insights for athletes, coaches, and clinicians seeking to identify problems before they become stress fractures.

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 bone stress injuries exist on a continuum—from healthy bone through stress reactions to true stress fractures
• The biology of bone remodelling: osteoclasts, osteoblasts, microcracks, and why recovery is essential
• Why running intensity has a far greater impact on bone stress injury risk than training volume alone
• How a 10% increase in running pace can dramatically reduce the bone's fatigue threshold
• Why many athletes mistakenly blame the "last run" rather than the workload accumulated four weeks earlier
• The importance of deload weeks and allowing the skeleton time to repair accumulated microdamage
• Understanding the Fredericson grading system and what distinguishes stress reactions from stress fractures
• Why shin splints (medial tibial stress syndrome) are not the same as a bone stress injury
• How pain location and symptom behaviour provide more valuable diagnostic information than pain intensity
• Why serious bone stress injuries can sometimes hurt less than relatively minor periosteal injuries
• The progression of symptoms from post-run discomfort to persistent and night pain
• How clinicians assess training history, workload, Strava data, intensity distribution, terrain, and footwear
• The major biomechanical and biological risk factors that contribute to bone stress injuries
• Previous bone stress injuries as one of the strongest predictors of future injury
• The emerging discussion around performance footwear ("super shoes") and potential changes in bone loading
• Why muscle strength and tissue capacity remain important contributors to skeletal resilience

Quotes / takeaways

"A bone stress injury is simply stress of a bone."

"It's not usually the kilometres that catch people out—it's the intensity."

"Don't judge the severity of a bone injury by how painful it is."

"Symptoms often appear around four weeks after the training error—not the day after."

"If it's really obvious, it's probably important."

Show Sponsor

PILLAR Performance creates evidence-based sports micronutrition products designed to support recovery, sleep, health, and performance for athletes and active people.

For all your PILLAR products visit https://PillarPerformance.shop, or for our North American listeners, head to https://TheFeed.com.

🔥 For 15% off your first purchase enter PHYSICALPERFORMANCE at the checkout.

Timeline

00:00 – Introduction, sponsor and overview of the new three-part Bone Stress Injury series

02:27 – Brad introduces expert editions and welcomes Tim Studley

03:54 – What is a bone stress injury?

04:23 – Bone loading explained: intensity versus training volume

06:50 – Bone physiology: microcracks, osteoclasts and osteoblasts

08:44 – Why recovery weeks are critical for skeletal health

09:14 – Bone remodelling timelines and why symptoms are delayed

11:40 – Bone stress injuries versus stress fractures

13:05 – The Fredericson grading system explained

14:26 – Shin splints (MTSS) versus bone stress injuries

15:21 – Why pain severity doesn't reflect injury severity

17:42 – The importance of symptom behaviour over pain intensity

19:08 – The progression of bone stress injury symptoms

20:30 – Taking a running history: training load, Strava and identifying workload errors

22:22 – Why today's symptoms often reflect training from four weeks earlier

23:20 – Biomechanical versus biological risk factors

24:17 – Previous bone stress injuries as a major predictor of recurrence

24:47 – Performance footwear ("super shoes") and emerging research

26:03 – Terrain, footwear changes and other biomechanical considerations

26:57 – Muscle capacity, tissue resilience and assessing the athlete

THE TEAM:

Join the 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 on @PogophysioAu

The Physical Performance Show can be found at: Facebook: facebook.com/thephysicalperformanceshowpodcast X: @tppshow1 Instagram: @physicalperforamceshow

Please direct any questions, comments, and feedback to the above social media handles.

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