In episode 384: Tibial Bone Injury of The Physical Performance Show, Brad Beer and fellow physiotherapist Tim Studley answer all your questions on tibial bone injuries tackle. 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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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
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