Ep 384: Tibial Bone Injury Q&A - All Your Questions Answered

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:

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Your Hosts:

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

🏃‍♂️‍➡️ Timothy Studley - Instagram @timothy_physio

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