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:
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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:
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🏃 Brad Beer – Instagram & X @Bradbeer and YouTube @PogophysioAu
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