Longitudinal Tibia Stress Fracture Risk During High-Volume Training: A Multiscale Modeling Pipeline Incorporating...

Tibia stress fractures are prevalent during high-intensity training, yet a mechanistic model linking longitudinal training intensity, bone health, and long-term injury risk has yet to be demonstrated. The objective of this study was to develop and validate a multiscale model of gross and tissue level loading on the tibia including bone remodeling on a timescale of week. Peak tensile tibial strain (3517 μstrain) during 4 m/s running was below injury thresholds, and the peak anteromedial tibial strain (1248 μstrain) was 0.17 standard deviations away from the mean of reported literature values. An initial study isolated the effects of cortical density and stiffness on tibial strain during a simulated eight week training period. Tibial strains and cortical microcracking correlated with initial cortical modulus, with all simulations presenting peak anteromedial tensile strains (1047-1600 μstrain) near day 11. Average cortical densities decreased by 7-8% of their nominal value by day 11, but the overall density change was <2% by the end of the simulated training period, in line with reported results. This study demonstrates the benefits of multiscale models for investigating stress fracture risk and indicates that peak tibial strain, and thus injury risk, may increase early in a high intensity training program. Future studies could optimize training volume and recovery time to reduce injury risk during the most vulnerable training periods.