Welcome to the PT Rebels Podcast.

This is the place to learn how you can become a PT rebel and take charge of your own health and wellness. We will help you find answers to your questions about pain, injury, and the path towards healing and the most efficient and effective way possible.

I’m your host, Dr. Gina F.

On today’s episode, I wanted to talk with you all about bone stress injuries. There are overused injuries that we commonly see in our clinic and involve repeated loading a bone with strenuous weight-bearing activities such as running, jogging, sprinting, marching, and oftentimes involve inadequate recovery periods, overreaching over-training and relative energy deficit in sport, which we’ve talked about over the last few episodes. So bone stress injuries represent. Failure of skeletal bone to withstand repetitive loading. This leads to structural fatigue, localized bone pain, and tenderness around the area. Bone stress injuries that we commonly see are involve runners, track and field athletes, endurance athletes, gymnasts, dancers, and oftentimes military recruits. Bone stress injuries are very common in the military and in combat athletes. People who have, or athletes who have recently started a new or intense physical activity are at most risk for bone stress injuries, or those athletes who have significantly increased the volume or intensity of training over the last four to six weeks, oftentimes present with symptoms related to bone stress injuries in our clinic, bone stress injuries differ in severity. Oftentimes. Initially we see bone stress. Either in the clinic or on imaging that involves edema around the periosteum or the outer covering of the bone, and oftentimes that can lead to more significant effects deeper into the bone with more severe con conditions. When those bone stress reactions progress to stress fractures when an athlete comes into the clinic, I just wanted to give you a picture of how we evaluate an athlete for a bone stress injury potentially. So oftentimes we receive calls from either coaches, parents, or athletes that they’re having leg pain or head pain, or shin pain or shin splints. So when the athlete comes into the clinic, we do a thorough evaluation of their functional mobility. So we’ll watch the athlete walk, we’ll watch them in a functional squat or lunge pattern. We screen up and down the entire chain of the body. So we look at lumbar mobility, thoracic mobility, hip mobility, knee and ankle, foot mobility. We look at the entire chain and movements for potential dysfunction. We also obviously listened to their history in report of symptoms over the past several months, just to get an idea of when their pain started Oftentimes. You’ll start to hear a story in the clinic about the athlete telling you that over the last one to two months their training load increased significantly. They might be a runner who also plays soccer or who also, you know, does as a gymnast or who does another, or plays tennis, does another sport in addition to ramping up their training in cross country, for instance. They might also be. At the height of competition in soccer, we have several athletes who are multi-sport athletes at a young age, and oftentimes they are very driven and very intense athletes and don’t wanna slow down a bit for any of the sports. And so when they start to develop leg pain, they just start icing it, maybe put a compression sleeve on it, if that takes some Advil and keep going. By the time they reach our clinic, they oftentimes tell us that. They feel very fatigued. They have pain in the legs, heaviness in the legs. They have pain over the shin area, for example, or in if it’s a hip, they feel pain in the hip or even the groin. Sometimes pain was sitting and we start to just listen to the story and put the pieces of the puzzle together. So upon examination, let’s say that athlete has hip pain, for example, I have seen five athletes in the last year. Femoral stress fractures, two males and three females, and one was a collegiate female runner. The other two were high school female runners, and the other two were male high school runners. Very competitive, very talented athletes, and they came in with the history of. Either hip thigh or growing pain or all three of those symptoms. In most cases, those athletes had continued to run. They had sought out help from their high school athletic trainer or physician. Some of them had had X-ray imaging, which was negative, and upon evaluation, what we noticed when we started testing their head mobility head flexion was limited and they started to have pain in either in the thigh or their groin. That was their familiar reproducible pain. Pain increased with flexion adduction and internal rotation of the hip, and also reproduce their groin hip, and oftentimes thigh pain, stress fractures in the femur can present with vague hip or leg pain. So that’s important to note, especially when it’s early on. We were able to identify at least three cases that I remember this year of a bone stress injury before it became a femoral stress fracture, which was good for that athlete. For those athletes, I should say, because they were able to avoid longer time away from sport. So another test that I like to do is a test in sitting where the athlete is sitting on the side of the table and we put a fist under their thigh and provide a pressure on the thigh or femur called the fulcrum test in all five cases that I saw with femoral stress fractures this year. They had a positive fulcrum test that reproduced their familiar pain in the femur. Another test that was positive in all of these athletes who either had bone stress injuries or stress fractures in their femur was a positive hop test. So I just had them hop on that leg five times if they could, and that reproduced their thigh pain. In some instances, it was vague. In some instances they said their muscle just felt tight or a little sore or. Some cases they said, oh yeah, that’s my deep thigh pain. First of all, we understand how to screen for this as sports medicine professionals in dealing with runners. Number two, it’s important to identify these signs and symptoms of bone stress injuries early on in these athletes because it can help avoid a full fracture in the femur where they have to have a surgical intervention, but also helps ’em avoid prolonged time away from sport. The one collegiate female athlete that I’m discussing had, has had significant time away from her sport. She’s had to go through a lengthy rehab process because of the. Stress fracture that she had in her femur. So we really just wanna help athletes avoid that. It’s also important to understand that we are going to take the time to evaluate and tease out these issues, but also in the state of Colorado, physical therapists have the ability to order imaging. Oftentimes X-ray imaging for bone stress injuries is negative. So if we feel like an athlete has a bone stress injury, we can order an MRI. Facilities that we use can usually get the patients in within 24 to 48 hours. If we order those MRI images, we can usually get the results back from the radiologist within two hours. So. There is a very quick turnaround time, so we avoid the athlete having to go see their primary care physician or go see an orthopedist. Oftentimes the wait time for that is two weeks or more, sometimes up to six or eight weeks. And then once they order the MRI, there’s usually another week to two waiting time for approval or authorization. And then once they get the MRI, it can take another week for that orthopedic physician to get back to them. So oftentimes an athlete who has potential bone stress injury, if they go through some of the more traditional medical channels, can have to wait six to eight weeks for an answer or diagnosis. And when they see us, they can have an answer oftentimes within 24 to 48 hours. So that is, I think, groundbreaking in the field of sports medicine and sports physical therapy. Our physical therapists at our clinic have advanced training in imaging and being able to understand how and when to order imaging. Helping that patient navigate through that process. We are doctor level trained. I am a fellow with American Academy of Orthopedic Manual Physical Therapy, and I received advanced training in radiological imaging. And so I feel confident knowing when and how I should order that imaging, but not in the interpretation of that imaging fellowship. Trained radiologist will review that imaging and send their reports to us, and then we can guide the patients in their. Recovery from that point on, either referring them back to the orthopedic position if needed, or just guiding them in a gradual loading process back to return to sport. Some of the signs and symptoms that athletes, coaches, athletic trainers, and physical therapists need to look for. When it comes to bone stress injuries are number one. Oftentimes a bone stress injury will be very localized. So for instance, with medial tibial stress response, that could be at the distal tibia, middle tibia, or even proximal. They’ll, the pain will be very localized. Oftentimes it’ll feel hot. Oftentimes the patient will be tossing and turning at night and not able to sleep well due to the pain. Even simple weight bearing activities like walking through the house, walking up or down stairs, or even pain at rest while they’re sitting in the car, in the classroom. Will be painful, typical like shin splint type pain that tends to be more muscular, will not feel that way. So those are some of the ways you can start to listen to the history and the story of the athletes. You were talking about their pain in order to help recognize some of the more serious signs and symptoms and red flags of bone stress injuries, and I also wanted to tie this back to over training overreaching and relative energy deficiency. In sport, it’s very common for all of these things to be related. Oftentimes, athletes who are endurance athletes in particular, are low in iron when they have their ferritin levels checked. Those ferritin levels are low. If their vitamin D levels are often low, oftentimes these athletes will have a general feeling of fatigue, heaviness in the legs, achiness. Sometimes they’ll have deficiencies in magnesium or calcium as well. Oftentimes, athletes that we see are athletes who have nutritional deficits that are not intentional, but maybe they are gluten-free, dairy free. Gluten intolerant have other GI issues, and so they really just have a difficulty in getting the proper nutrients that they need for their sport. So it’s important to recognize the signs and symptoms of, again, over-training overreaching relative energy deficiency in sport, and how it all ties in and plays together with tensile bone stress injury. When a patient comes to see us with potential bone stress injury and. We have concerns that they do have nutritional deficits. The first thing I do is refer them to a sports nutritionist who specializes in athletes who are either winners or higher endurance athletes. Oftentimes nutritionists who understand energy demands of soccer players of football players, and what have you. It’s essential that they meet with these nutritionists. I’m not a nutritionist, I’m not a dietician, but it needs to be someone who is certified as a dietician and especially important if they have experience with athletes so that they can help identify key indicators and key nutritional deficiencies in those athletes that could be contributing to these injuries. These athletes with bone stress injuries have to sit out of sport for a significant amount of time, whether that be 3, 4, 5, 6 months down the line. So that really is tough mentally on these athletes. So again, it’s vital to have a sports medicine team that you can refer patients out to, such as a sports psychologist, so that these athletes can talk with that sports psychologist and get the help they need. In order to deal mentally with being away for their sport for so long. Other key factors that can contribute to bone stress injuries are just a faulty training program if athletes aren’t allowed to get adequate rest and recovery time. If they’re training seven days a week without a rest day, or if they’re not incorporating deloading in their training programs every four weeks. I think it’s important once a month to include a deload week. The coaches and sports performance professionals that I know who are respected in their sport do incorporate a deload or de training week in order to allow those athletes to catch up and recover from. Some of the harder weeks of training that they’ve had. I think it’s also important to look at shoe wear times. The athletes that we see have shoes that are either inappropriate or inadequate for their sport, or they just are worn out. So it’s important to check the athletes’ shoes. Make sure that they’re the right shoe type for that athlete, and also make sure that, that the shoe is just not worn out and doesn’t need to be replaced. Another controversial topic is the carbon fiber shoes that you see, especially in runners you see them wearing, and I see kids training in these shoes throughout the week. I don’t think these shoes were designed to be trainers. I think they were designed to be racing shoes. So athletes who are training especially at higher volumes or with higher intensity, faster speeds who are wearing these shoes throughout the week for training, I think they’re more prone to injury, and I think that possibly could be why we’re seeing more bone stress injuries in these types of athletes. Some of the bone building activities for runners that I wanted to talk about that are good choices for improving bone health overall would be speed work. Important to incorporate speed work or sprinting when you’re talking about training programs, even for endurance athletes, I think it is important for them to do speed work as well, but also just keeping in mind that we don’t wanna increase their overall intensity or training load by more than 10% per week. I think heavy and fast resistance training is essential. I know a lot of endurance athletes or coaches have been reluctant to incorporate heavy resistance training in their programs, but I think the evidence only speak to the importance of heavy resistance training in order to increase tissue resilience in bone, muscle ligament, tendon, and I think that will only serve our athletes well, especially as they. Temperature into the high school, collegiate and professional realms. Other excellent choices for improving bone health are box, step jumps. Box jumps with weight vest, and zigzag Hopping exercises are activities that really are not as involved with bone building, are walking or fast walking, mountain biking or treadmill running. In order to improve bone health, you really have to stress that bone with higher loads. So aqua jogging, swimming, road biking, stationary walk, stationary, cycling, walking. Those are not necessarily top choices for improving bone health. And so. Some of the top strength and conditioning coaches that I respect most are involving plyometric training and speed training and heavy lifting into their programs. Even when you’re talking about more endurance athletes and training for those athletes, and I think in the long run, this is one thing that can help our athletes improve their overall own health. Another thing that I wanted to discuss is that the primary contributor. To tibial bone stress forces, we often see bone stress injuries in the tibia. The primary contributor to those bone forces are muscles. Half muscles, in fact, have a three to four times greater contribution to tibial bone forces than impact forces. And why this matters is in order to reduce tibial bone loading in the runner recovering from a tibial bone stress injury, or stress fracture. We must reduce the calf muscle forces, not necessarily the impacts. And on the flip side, it’s really important to make sure that, especially in runners, as your athletes are incorporating not only those plyometric loading activities, but also doing to activities that strengthen the gas shock and soleus muscles. So the gastroc muscles are the calf muscles that are higher in the leg, lower leg soleus muscle is the muscle right below that, which is really powerful. In producing plantar flexion force when running uphill because it is a plantar flexor when the knee is bent. So the gastroc soleus muscle complex is essential to strengthen, and it’s really important to strengthen those under higher loads so that you have the tissue resilience to be able to withstand those loads as you increase your training volume. However, if you are recovering or returning back to running. And from returning to running from a bone stress injury. In order to reduce the overall plantar flexor or calf horses, you would want to reduce the running speed. You could run at a higher drop shoe or a rock or sole shoe and increase your overall run cadence by five to 10%. Many of the runners who I see who I’m trying to adjust their overall ground reaction forces are loading if they have some biomechanical deficits. I just ask them to increase their cadence by five or 10%, and I teach them how to do that. And we know from research that that just increasing their cadence alone helps you reduce a lot of biomechanical deficiencies that we see in these athletes. So just to wrap this up, I wanna emphasize that at Vic PTM performance, we have physical therapist. To our experts in helping to identify bone stress injuries and the factors associated with that, and we can help point you in the right direction. As athletes, we can help order imaging for you and help set up a team for you. Uh, course nutritionists, counselors, mental health professionals, and we can communicate with your coaches and advocate for you in order to help. Come up with a plan specifically tailored for you to heal from these types of injuries and help prevent them in the.