Ep 378: Bone Stress Injuries: Causes, Symptoms & Early Warning Signs (Part 1)

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:

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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

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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

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

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