Health & High Performance

Health & High Performance Helping you achieve your health & performance goals In pain? Sports injuries?

Call our experienced team of Sports Chiropractors & Physiotherapists based in Mont Albert North, to get you on the road to recovery. With a special interest in:
- Sports injuries (i.e ankle sprains, hamstring strains, ACL injuries)
- Running injuries (achilles tendinopathy, ITB, heel pain, knee pain)
- Back pain, neck pain & headaches

Utilizing the most modern techniques in assessment & treatment, we aspire to help you achieve your health & performance goals.

Can pain tell us whether a bone has healed?🦴Pain is important in the assessment and management of a bone stress injury.B...
01/09/2026

Can pain tell us whether a bone has healed?🦴
Pain is important in the assessment and management of a bone stress injury.

But it is not a direct measure of:
• How much structural damage is present
• Whether a fracture line has developed
• How quickly the injury is healing
• Whether the athlete is ready to run

Bone is innervated, but that innervation is not distributed uniformly.
Sensory nerve fibres are most abundant in the periosteum, followed by the bone marrow, with substantially fewer found within mineralised cortical bone.

This means the pain experience may depend partly on which tissues are involved, rather than simply reflecting the extent of structural damage.

Two athletes with different injuries may therefore report similar pain.

Two athletes with apparently similar injuries may report very different pain.

Pain can also change as local inflammation, mechanical distortion, load exposure, expectations and broader contextual factors change, without necessarily indicating an equivalent change in bone integrity.
This does not make pain irrelevant.

Pain and focal tenderness remain important clinical signals and should help guide loading progression. But they should be interpreted alongside:
🔸 Injury location and associated fracture risk
🔸 Cortical versus trabecular involvement
🔸 Presence or absence of a fracture line
🔸 Imaging findings when clinically indicated
🔸 Walking and functional loading tolerance
🔸 Recent training exposure
🔸 Nutritional, hormonal and skeletal health factors

The takeaway: Pain can help guide management.

Pain alone cannot grade a bone stress injury, confirm healing or clear an athlete to return to running.

🎧 In the latest episode of The Rehab Runway, Nathan Carlson joins me to discuss femoral neck and shaft BSIs, including diagnosis, imaging, rehab, return to run, blood tests and DXA.
Listen now on Spotify, Apple Podcasts or YouTube: https://www.healthhp.com.au/the-rehab-runway/femoral-bone-stress-injuries

📚 References
PMID: 39141251, 23825184, 27199772, 32062002, 33964414

The hip flexor strain that isn’t.Vague hip or groin pain in a runner can easily be labelled as a hip flexor strain, addu...
27/08/2026

The hip flexor strain that isn’t.
Vague hip or groin pain in a runner can easily be labelled as a hip flexor strain, adductor issue, labral problem or FAI-related pain.

But femoral neck bone stress injuries can present in a very similar way.

Features that should raise suspicion include:
🔸 Gradual onset of symptoms�🔸 Groin or lateral-thigh pain�🔸 No clear strain mechanism�🔸 Worsening tolerance to running�🔸 Pain with walking or weight bearing�🔸 Painful hip flexion or internal rotation�🔸 Symptoms that are progressively worsening rather than simply fluctuating

A positive resisted muscle test does not automatically confirm a muscle injury, and no single clinical test can reliably exclude a femoral neck BSI.
The pattern matters.

When the history, symptom behaviour and loading response do not fit a straightforward muscle strain, consider the femoral neck and escalate appropriately.

🎙️ This post was inspired by my conversation with Nathan Carlson on The Rehab Runway, where we explored the diagnosis, management and broader work-up of femoral bone stress injuries.

https://www.healthhp.com.au/the-rehab-runway/femoral-bone-stress-injuries

🦴 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

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