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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