Luke Nelson - Sports & Exercise Chiropractor

Luke Nelson - Sports & Exercise Chiropractor 🔹Fellow Sports & Exercise Chiropractor (AICE 2019)
🔸President Sports Chiro Australia
🔹Director Health & High Performance
❤️️Family, Running & Sports Chiro

🦴 FEMORAL BONE STRESS INJURIESFemoral neck and femoral shaft BSIs sit at very different points on the risk spectrum.Femo...
21/08/2026

🦴 FEMORAL BONE STRESS INJURIES
Femoral neck and femoral shaft BSIs sit at very different points on the risk spectrum.

Femoral neck BSIs are considered high-risk because of the potential for fracture progression, displacement, non-union and avascular necrosis. But morphology still matters:
🟠 Compression-sided: typically inferomedial and relatively more stable when incomplete and non-displaced.�🔴 Tension-sided: superolateral, with greater risk of propagation and displacement.�🚨 Displaced femoral neck: an orthopaedic emergency with the highest potential consequences.

Femoral shaft BSIs are generally considered lower-risk and usually have a more favourable prognosis, although they are not complication-free.

In pooled data:
Femoral neck�• Return-to-sport rate: 55.3%�• Complication rate: 42.8%�• Mean time to RTS: 107 days

Femoral shaft�• Return-to-sport rate: 95.1%�• Complication rate: 16.2%�• Mean time to RTS: 86 days

These figures reinforce how strongly anatomical location influences prognosis. Femoral neck BSIs had one of the lowest RTS rates and highest complication rates across all lower-extremity BSIs, while femoral shaft injuries were classified as relatively low-risk.

Importantly, the pooled femoral neck figures combine compression-sided, tension-sided and displaced injuries. They should not be interpreted as describing each subgroup equally.

Clinical takeaway:
SITE × SIDE × MRI GRADE × FRACTURE LINE × DISPLACEMENT × ATHLETE FACTORS

Identifying the exact location and morphology is essential before deciding how aggressively to offload, whether orthopaedic review is required and how return to sport should be progressed.

🎧 Want to go deeper?�In the latest episode of The Rehab Runway, Nathan Carlson joins me to discuss femoral neck and shaft bone stress injuries, including diagnosis, imaging, rehab, return to run, blood tests and DXA.

Listen now on Spotify, Apple Podcasts or YouTube.
https://lnkd.in/gRrxFJsu

📚 Reference
Hoenig T, Eissele J, Strahl A, Popp KL, Stürznickel J, Ackerman KE, Hollander K, Warden SJ, Frosch KH, Tenforde AS, Rolvien T. Return to sport following low-risk and high-risk bone stress injuries: a systematic review and meta-analysis. Br J Sports Med. 2023;57(7):427–432. doi:10.1136/bjsports-2022-106328.

Standing or seated calf strength?Flexing the knee changes the mechanical contribution of the plantarflexors: gastrocnemi...
11/08/2026

Standing or seated calf strength?
Flexing the knee changes the mechanical contribution of the plantarflexors: gastrocnemius contribution decreases, while soleus contribution appears to be relatively maintained.

So standing and seated testing can provide different information about plantarflexor force production.

👉 The value is in understanding what each test tells us and interpreting the result within the context of the athlete.

For me, these tests form part of a broader clinical profile, alongside symptoms, running tolerance and sport-specific function.

Rather than asking:
Which test is better?

Perhaps the better questions are:
What am I measuring? Why am I measuring it? And how does that information contribute to the overall clinical picture?

🎧 This was one of the topics discussed with Romain Tourillon on The Rehab Runway: Beyond the Calf Raise- Foot & Ankle Function in the Runner.

Link: https://www.healthhp.com.au/the-rehab-runway/episode-18-beyond-the-calf-raise

Step count is a rehab variable 👣 Rehab load is not just what happens in the gym, during a run, or inside the clinic.For ...
06/08/2026

Step count is a rehab variable 👣

Rehab load is not just what happens in the gym, during a run, or inside the clinic.

For many injuries, the walking accumulated through work, shopping, commuting, parenting and everyday life can meaningfully influence symptoms and recovery.

Monitoring daily steps can help:
👣 Quantify walking exposure�📈 Identify sudden increases in activity�🔍 Explain symptom flare-ups�🎯 Set clearer activity targets�🔄 Progress daily function more deliberately

But step count does not tell the whole story.

8,000 slow, flat steps are not the same as 8,000 fast, hilly steps. Speed, terrain, stairs, footwear, carried load and tissue capacity all change the demand.

A simple approach:
1️⃣ Establish the person’s usual step count and current tolerance�2️⃣ Set a daily range rather than one rigid number�3️⃣ Monitor symptoms later that day and the next morning�4️⃣ Progress gradually when symptoms and function remain stable

Use step count to quantify walking exposure. Use symptoms, function and clinical context to guide decisions.

Strong calves don't always last.Maximal calf strength and calf capacity are different physical qualities, yet they're of...
04/08/2026

Strong calves don't always last.
Maximal calf strength and calf capacity are different physical qualities, yet they're often treated as if they're interchangeable.

A runner may demonstrate excellent peak force during an isometric test, yet perform poorly on a heel raise endurance test.

Another may complete 35+ heel raises with ease but lack the maximal force required for sprinting, hills or higher-speed running.

Neither assessment tells the full story.

Instead of asking:
❌ "Are their calves strong?"

Consider asking:
✅ Can they produce force?
✅ Can they repeatedly produce force over time?

Together, these qualities provide a more complete picture of calf function and may help guide rehabilitation, return-to-running decisions and performance programming.

🎧 This concept was inspired by my conversation with Romain Tourillon on The Rehab Runway: Beyond the Calf Raise: Foot & Ankle Function in the Runner
https://www.healthhp.com.au/the-rehab-runway/episode-18-beyond-the-calf-raise

👇 Which calf test do you rely on most in clinical practice?

The foot-ankle complex does more than push us forward.It must:Absorb energy during early stancePropel the body during pu...
30/07/2026

The foot-ankle complex does more than push us forward.

It must:
Absorb energy during early stance
Propel the body during push-off
Recycle elastic energy through the arch and Achilles

This framework helps clinicians move beyond simply assessing calf strength or ankle mobility, and instead consider how the whole system manages load, transmits force and behaves like a spring.

🎧 Inspired by my conversation with Romain Tourillon on The Rehab Runway: Beyond the Calf Raise: Foot & Ankle Function in the Runner

Listen via https://www.healthhp.com.au/the-rehab-runway/episode-18-beyond-the-calf-raise

Tibial bone stress injuries: Location matters 🦴Not every tibial bone stress injury carries the same prognosis.The anatom...
26/07/2026

Tibial bone stress injuries: Location matters 🦴

Not every tibial bone stress injury carries the same prognosis.
The anatomical location changes the local loading environment, healing potential, risk of complications and expected return-to-sport timeline.

A posteromedial tibial shaft BSI is generally considered low-risk:
✅ 97.7% returned to sport
✅ 2.3% complication rate
✅ Mean return to sport: 44 days

An anterior tibial shaft BSI is a very different injury:
⚠️ Tension-sided and high-risk
⚠️ 75.5% returned to sport
⚠️ 40.9% complication rate
⚠️ Greater concern for fracture progression, delayed union and non-union

Medial malleolar BSIs also warrant caution. Although 92.6% returned to sport and the pooled complication rate was 7.5%, the mean return-to-sport time was 106 days.

Tibial plateau and proximal tibial BSIs are uncommon and appear predominantly medial and compression-sided. They are often considered relatively favourable in young athletes, but the evidence is limited, and there are no reliable pooled return-to-sport or complication estimates. Greater caution is required with articular extension, depression, displacement or an insufficiency-type injury.

In adolescents, proximal tibial physeal stress injury should be considered a distinct entity rather than grouped with an adult tibial plateau BSI. Stress-related physeal injuries remain uncommon, and their incidence and longer-term consequences are not well quantified.

The clinical takeaway?
“Tibial BSI” is not one diagnosis with one prognosis.

Management should account for:
SITE × MRI GRADE × FRACTURE LINE × SYMPTOMS × ATHLETE FACTORS

These pooled estimates are useful for prognosis and communication, but they should not be interpreted as fixed return-to-running timelines for every athlete. The underlying systematic review included 76 studies and 2,974 lower-extremity and pelvic BSIs.

References
Caine D, DiFiori J, Maffulli N. Physeal injuries in children’s and youth sports: reasons for concern? Br J Sports Med. 2006;40(9):749–760. doi:10.1136/bjsm.2005.017822.
Hoenig T, Eissele J, Strahl A, Popp KL, Stürznickel J, Ackerman KE, Hollander K, Warden SJ, Frosch KH, Tenforde AS, Rolvien T. Return to sport following low-risk and high-risk bone stress injuries: a systematic review and meta-analysis. Br J Sports Med. 2023;57(7):427–432. doi:10.1136/bjsports-2022-106328.
Lempainen L, Liimatainen E, Heikkilä J, Roivas M, Sarimo J, Mattila K, Orava S. Medial malleolar stress fracture in athletes: diagnosis and operative treatment. Scand J Surg. 2012;101(4):261–264. doi:10.1177/145749691210100407.
Orava S, Karpakka J, Taimela S, Hulkko A, Permi J, Kujala U. Stress fracture of the medial malleolus. J Bone Joint Surg Am. 1995;77(3):362–365.
Robertson GAJ, Wood AM. Return to sports after stress fractures of the tibial diaphysis: a systematic review. Br Med Bull. 2015;114(1):95–111. doi:10.1093/bmb/ldv006.
Yukata K, Yamanaka I, Ueda Y, Nakai S, Ogasa H, Oishi Y, Hamawaki J. Medial tibial plateau morphology and stress fracture location: a magnetic resonance imaging study. World J Orthop. 2017;8(6):484–490. doi:10.5312/wjo.v8.i6.484.

21/07/2026

MTSS or tibial bone stress injury? Measure the tenderness. 📏

When assessing medial tibial pain, don’t just identify the most painful point. Map the full symptomatic area.

Tenderness extending over at least 5 cm along the posteromedial tibial border is commonly used as part of the clinical criteria for medial tibial stress syndrome.

In contrast, a smaller and more focal area of bony tenderness may increase suspicion of a tibial bone stress injury.

But this is not a standalone diagnostic test. 🧠

Palpation findings should be interpreted alongside:
• Symptom onset and progression�• Pain during and after impact loading�• Rest or night pain�• Local swelling�• Recent changes in training load�• Imaging when clinically indicated

Interestingly, shin tenderness may also have some prognostic value. 🔍

In a prospective study of military cadets who were asymptomatic at baseline, a positive shin palpation test was associated with more than four times the odds of subsequently developing MTSS.

However, this study examined the prediction of future MTSS, not whether palpation can reliably distinguish MTSS from a tibial bone stress injury in an already symptomatic runner.

Diffuse tenderness over ≥5 cm: supports suspicion of MTSS�Focal bony tenderness: increases suspicion of tibial BSI

Use the tape measure to improve the precision of your assessment, not to replace clinical reasoning. 📐

📚References
Mulvad B, Nielsen RO, Lind M, Ramskov D. Diagnoses and time to recovery among injured recreational runners in the RUN CLEVER trial. PLoS One. 2018;13(10):e0204742. doi:10.1371/journal.pone.0204742.
Newman P, Adams R, Waddington G. Two simple clinical tests for predicting onset of medial tibial stress syndrome: shin palpation test and shin oedema test. Br J Sports Med. 2012;46(12):861–864. doi:10.1136/bjsports-2011-090409.
Winters M, Bakker EWP, Moen MH, Barten CC, Teeuwen R, Weir A. Medial tibial stress syndrome can be diagnosed reliably using history and physical examination. Br J Sports Med. 2018;52(19):1267–1272. doi:10.1136/bjsports-2016-097037.

Stress fractures rarely happen because of one bad run.Most develop over weeks of accumulated loading.Bone is constantly ...
16/07/2026

Stress fractures rarely happen because of one bad run.

Most develop over weeks of accumulated loading.
Bone is constantly adapting to the loads you place on it.

If training progresses at a rate the bone can tolerate, it remodels and becomes stronger.
But if loading accumulates faster than the bone can repair itself, microscopic damage begins to build. Eventually, that damage can become a bone stress injury.

This is why, when I review a runner with a stress fracture, I'm often less interested in yesterday's run than I am in what happened over the previous 4–6 weeks.

Questions I ask include:
📈 Has weekly running volume increased?
⚡ Has speed work or hill training been introduced?
😴 Has recovery been compromised?
🍽️ Has energy availability been adequate?

The "mistake" is often not a single session.
It's the gradual accumulation of training load without enough time for the bone to adapt.

That's also why rehabilitation isn't just about getting back to running. It's about understanding what contributed to the injury so you don't repeat the same pattern.

🎙️ I recently sat down with sports physiotherapist Beau Tyrrell on The Rehab Runway to discuss the science behind tibial bone stress injuries, including why they occur, how to rehabilitate them, and how to reduce the risk of recurrence.

Available now on Spotify, Apple Podcasts and YouTube, link https://www.healthhp.com.au/the-rehab-runway/episode-17-tibial-bone-stress-injuries

🙏Thank you Rich W***y for the permission to use your image

More knee load does not automatically mean more knee pain.This graphic compares the estimated peak patellofemoral joint ...
12/07/2026

More knee load does not automatically mean more knee pain.

This graphic compares the estimated peak patellofemoral joint forces produced during different activities.
But it is important to understand what these numbers do and do not tell us.

A higher joint force does not mean an exercise is damaging.

It does not mean it will be painful.
And it does not mean it should be avoided.

Pain is influenced by far more than the size of the mechanical load, including tissue sensitivity, recent activity, recovery, expectations and the individual’s current capacity.

So, what is this information useful for?
It can help us make more informed decisions when gradually increasing knee-joint exposure during rehabilitation.

This may be particularly relevant when managing:
🦵 An irritable or swollen knee�🦵 Osteochondral or cartilage injuries�🦵 Rehabilitation following cartilage surgery�🦵 Patellofemoral pain when certain loads are poorly tolerated�🦵 Progression from strength exercises back towards jumping and running

For example, we may initially select an exercise with a lower estimated patellofemoral load before progressing towards deeper squats, heavier resistance, running and hopping.

But the graphic should never replace the response of the person in front of us.

Symptoms during the activity, the response later that day and the response the following morning remain important when deciding whether the load was appropriate.

Load is information, not a danger rating.

Save this as a guide when progressing knee rehabilitation.

📚References: Hart et al. 2022; Wallace et al. 2002; Escamilla et al. 1998, 2009; Cleather et al. 2013; Goulette et al. 2021; Ristow et al. 2020.

I didn’t rehab my knee by just picking random quad exercises.After my MRI showed a lateral femoral condyle chondral defe...
02/07/2026

I didn’t rehab my knee by just picking random quad exercises.

After my MRI showed a lateral femoral condyle chondral defect, the key question became:
🧠 What does this exercise actually load?

That changed everything.
Some exercises may look similar from the outside, but they don’t load the knee in the same way. A squat, lunge, stair, hop and run can all create different loading demands across the knee joint.

And it’s not just where they load the knee. It’s also how much.
Walking is relatively low load, stairs and squats sit higher, running is higher again, and hopping can be one of the bigger loads.

That doesn’t make any of these activities bad. It just means timing matters.

⚖️ Why not just load by pain?
Because pain is useful, but it isn’t the whole story. With cartilage and bone injuries, the response can be delayed, and this is what I experienced when I pushed things too far.

So I also watched swelling, range, stiffness, next-day response, and where the exercise loaded the knee.

The goal wasn’t to ignore pain. It was to make better decisions than pain alone could give me.

Early rehab was about reducing swelling, restoring range, keeping the quads active, and choosing exercises that didn’t keep poking the injured area.
Then, once the knee tolerated that, the goal was to gradually earn back the more demanding stuff: stairs, squats, hops and running.

📈 The biggest lesson?
Good rehab isn’t just about the exercise. It’s about the right load, in the right range, at the right time.

Science didn’t give me a perfect recipe. But it gave me a better question:
What does this exercise actually load?

Save this if you’re rehabbing a knee injury or work with knee injuries.

📚 References on final slide.

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