#66 - Bone Stress Injuries: The Good, The Bad, and the Ugly with Dr. Tyler Kemp, Part 1

Hi guys, Welcome to another episode of The Factor podcast. I'm your host, Jessica Riddle. If this is your first time tuning in, welcome and thank you for listening. Today we kick off a new two part training titled bone Stress Injuries, The Good, the Bad, and the Ugly with doctor Tyler Kemp. Now, I don't know about you, but when I hear the phrase bone stress injuries, there is absolutely nothing good that comes to mind. In fact, it serves as just another reminder for me why I am not a long distance runner. If you put me on a peloton bike, I can ride for fifty miles no problem. But if you see me running outdoors with any kind of speed, it's probably because something is chasing me. And I can't imagine that I'm different from a lot lot of your patients who are active recreational athletes. I regularly work out five to six times each week, but inevitably there are times that I push too hard for too long, or I'd use bad form and end up with a nagging injury. Stress fractures are actually quite common, but did you know that there are different subtypes of fractures that can vary depending upon the mechanism of injury and the location. Did you know that females are more likely than males to suffer from bone stress injuries. We will cover these topics and a lot more on this episode in the next, including the different types of stress fractures, the importance of imaging for accurate diagnosis, and a grading scale that you can use for neck injuries. Our guest instructor for this training is doctor Tyler Kemp. Doctor Kemp is a chiropractor practicing outside of Cincinnati, Ohio. He has a passion for working with athletes and clinical interests in treating tenanopathies and bone stress injuries. He utilizes joint mans, manipulation, rehab, and acupuncture in his patient care. And while his daily practice involves treating a diverse range of patients, the office is focused on athletics has allowed him to specialize in treating bone stress injuries commonly seen in runners. All righty, guys, today is going to be an episode chock full of great information that you can implement into practice right away. Let's get started. Well, Thank you Jessica, and thank you guys for joining me. So quick background about myself. I am a chiropractor by trade. I practice in a sports medicine style multi doc office outside of Cincinnati, Ohio. I've been really fortunate to work with in a number of settings and see a lot of different patients, and that has made me interested in working with athletes. That's not primarily what I see day to day, but as a chiropractic office that sees a lot of athletes, naturally see a lot of runners, and a number of runners do deal with bone stress injuries. So we'll talk about a number of things about what treatment management and stuff looks like in our chat today, So loose outline, we'll go through some things with the anatomy and define a few terms what risk factors and features of history look like. And then kind of on the second part and frankly a little more importantly, we'll talk about some return to score rehab and things like that, because it's great if you can catch these injuries, it's a lot trickier to get them to, frankly where they need to be on the back end. So by the end of this I want three things to happen. One, you to have an idea of how to identify a stress fracture early, choose the right type of imaging, and then finally have an idea of returning them to their score, their day to day activity, or back to running in general. So first we need to define a few terms. So what is bone itself is what is ttrus fracture? So we need to think about bone as a dynamic, living tissue. It's not just the framework that our muscles and joints kind of hang off of. It's active. So we're always dealing with, going back to physiology in school, the process of building up and breaking down of bone. So we have our osteoblasts those cells that build bone back up, and osteo class those that break it away, and it's always this constant back and forth. The problem we run into is when we're breaking down more than we're building back up. It's no different then if you spend more than you make. You can use credit cards for a while, but after that it gets a little tricky. Unfortunately, our bone doesn't have a line of credit. It's going to run what I like to call a bone debt by starting to lay down less quality or less good level of bone, and that's going to cause an issue as somebody is active and continues to progress. So the loose definition for a BSI is an overuse injury due to an imbalance of excess bone damage and inadequate or lack of time for repair. So specifically, this exists on a spectrum. So on the far end we have our stress reaction and on the other end we have a completely fracture. And so on the far end we have our stress reaction. That's where we're starting to see the lack of response to to load. We were starting to see things like a periosteal reaction that connective tissue layer starts to get irritated. As it gets worse, we have this stress fracture where we actually start to form a break. We start to form a fracture lined within the bone. And specifically bones are generally two broad types. We have the cornical bone, the outer portion that kind of thick area, and then trabecular or spongy bone. In a stress fracture, we're starting to actually start to form that fracture into the bone. And then on the far end, and the area we never want to go if possible, is complete fracture, where we have had so much accumulated trauma that that bone is so weak it's fracturing through. And that's where you get into some really messy things such as displacement of bone fragments or the associated joint. So if we can avoid that, that's going to be pretty crucial. So I wanted to make this a little practical. So this is a case from a local high school athlete. They had some issues at the end of their track season where we'll call it a case oftion splints, where they had to pause their training for a little bit and then got better in about two three weeks, and then they had about four weeks left the season, so they had this brief pause where they were out of training and then they went back into it, and then cross country is their preferred sport over track, so they started to aggressively increase their mileage over several week period to kind of prepare for the coming season. Over the course of that time, they started to notice this kind of deep nagging hip pain. It was getting difficult just walking around home is almost impossible to run. And for those reasons and some things we'll talk about on the physical exams side, we ended up get an MRI and it confirmed a Grade four stress fracture of the proximal femur or the from aal neck. So that's great that we caught it. But as we go through, I want you to think about we'll call this this person Dan, how do you want to help Dan manage this injury? And then how can you or what's going to be the best way to get them back to his sport in the next season, and things contribute. We'll use Dan as a stereotype, but there are a number of factors that contribute to these types of injuries. I call it the rule of twos. There's three parts to it, which is a little confusing. The three things are too much, too soon, and too little. So too much meaning too much load, too much volume, things like that, like this could be the training knowledge in their week, or it could be the number of like training sessions per week. Too soon, that's the frequency, so that again like the two a day going from two or three days a week to ten days a week. The math doesn't work on that. And then finally, too little meaning to arrest, too little time for them to recover. This is somebody who is just going back to back to back without creating any time for buffer. And in a weird way, we got to see this with the COVID pandemic so I'll use a high school athlete as an example. You can have somebody that might be playing year round sport in some way, shape or form, or a varied athlete. Maybe they do football in the fall, they do basketball in the winner, and they do track in the spring, so for most of the year they have some amount of training stimulus and they have a pretty active threshold. The problem we had is depending on where you were in the country, from January to May or even longer, depending on where you're at, a lot of sports were shut down and then it was kind of that slow return to normalcy that we saw in the fall, and a lot of it was a push to let's at least get back to sports that they're outdoors. Some of these things can be done safely, let's go for that. And it was this huge disconnective. You have these you have athletes who've been training your you suddenly give them a six month period where they're not really able to do any kind of activity, and then you're expecting them to return back to their previous level. So is this huge gap And we saw it a lot in that fall time, especially especially on the runner side, because that's the stereotype of all these high school athletes coming in with a ton of these injuries because it was this huge disconnect of the training load and then the return to sport timeline. So hopefully we won't see a surge like that in the coming years, but it was interesting. On the slide here you'll see a brief study. This is a twenty fifteen title is Epidemiology of Stress Fracture Injuries among US High School Athletes two thousand and five and six to twenty twelve to twenty thirteen. Big overview, big thing that came out was this, So sixty five percent of injuries resulted in three things of these stress fractures. One three weeks or more of time lost, medical disqualification, or the end of season, so three weeks of times lost that they were out for at least three weeks medical disqualification, their season is over, and then finally end of season meaning by the time they had gotten better, their season had ended. And nobody wants any of those things. So it will go into this a little bit later on, but a lot of these injuries, depending on the location or the grade, that will determine your healing timeline and it allows you to have a better more frank conversation with a person in front of you about how long this is going to take. So who is kind of your your stereotype or your archetype about who's going to come with this injury. So one, there's a slight preference for female over male for a number of reasons. And then I've seen anywhere from eighty to nine or ninety percent of all stress fractures that occur in the lower limb. There are a handful of injuries that might come in the upper clabical scapula humorous, they're fairly uncommon. So the majority of stress fractures are going to be basically below the belt from an anatomy standpoint, And whenever you have an actively a more active person come in, you need to have a few things that should tip you off that this is an issue. So I want you to think about playing the odds with your patient's examine history. I'm not encouraging at all gambling with your patient's health or being unsafe or something like that, but thinking about what's the most likely thing that this is, and how can I screen or how can I sift through to figure out if it's something else? Relatively quickly and there's a number of historical features that are going to come in. One, they're generally a runner, an athletic person, somebody's pretty active. They're not going to have a good story about what caused it. It's not a fall, it wasn't they got sideswiped at a game or something like that. It's just this random pain with no specific onset. Generally can be focal too. They will gesture to one area or they'll be able to outline it with their fingers. Another hallmark is they'll have pain with activity, and then pain that'll stick around. So maybe they'll they'll have pain during their run and then it sticks around for a couple of hours after or even into the next day. And then be specific with your questions. There's going to often be recent changes in activity assaws. One recently where superactive runner, but they started added basketball in just winter time and all that, and dat has started to raise the suspicions for that just because they're already running a ton on their own, they're doing a ton of mileage, and they're doing another activity in their week that just the demands of it for the bone debt. There's there's only so much margin in there. At Southeast Professional Education Group, we are incredibly selective about the courses we host on our online learning platform. We only want to offer our students the best, most dynamic, evidence based courses, and because of this, we only launch new courses a few times each year. 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Now there's some things like risk factors which contribute. Those are broken into intrinsic and extrinsic, so intrinsic things we might not be able to change a whole lot, male versus female, their individual biomechanics. Nutrition. I'm not saying that we can't provide nutrition recommendations, but if somebody doesn't have adequate access to nutrition, that can be a tricky thing and an ex forensic thing. Their training program, their mileage, things like that they're terrain, whether they're being on asphalt all the time, the road, trails, grass, things like that. Variety is your best friend on that. And then finally sho style and wear. I used to be really into the exact biomechanics of the shoe. More broad principle is just look on the bottom of their shoe. If they've worn all the tread off, it's probably time for a new pair. And I think that's a real easy, easy criteria there. And then continuing with risk, each region of anatomy is associated with a different level of risk. So on the higher side, well high and low risk, so high risk is defined of the odds that they're increased, odds that they're being a progression of the injury, failure of conservative care, or the need for surgical intervention. So the high risk areas include the anterior tibia, the fomoral neck, and then the sessiment bones. The low risk metatarsals post your media tibia, fibula for moral shaft different than the phomoral neck, and then the sacram impels. So based on these areas you can start to build out the timelines of what's the recovery, what's the healing going to look like? Overall? So have this list in your head, especially if you see active people. So is what's your physical examin going to look like? Do the good stuff, range your motion, palpate the area, ask the patient to show you where it hurts, have them walk, have them run. In some really further progress cases, they're going to have a really hard time weight bearing. One of my favorite quotes is from one of the local high school coaches. He says, no high school kids should be limping. So if you have a young athlete come into your office they're limbing, it's probably something more concerning. It's probably not a simple sprain strain, and then there's some orthopedic tests you can do. Now specifically, there are a number of different tests you can do for stress fracture. One of the most common ones that's helpful is the hop test. It seems silly, but have them hop on a single leg affected side versus unaffected side. If that is enough to induce pain, some kind of bone injury needs to be on your radar. And then practically, if it hurts just for them to hop two times on your office carpet, it has to be much more painful or much more problematic for them to be just pounding it over the course of mileage on the road. So, once you have a patient that you're concerned about BSI, we need to figure out if there's going to be the need for imaging or what's appropriate imaging. So there's a lot of different options X ray, m RI, CT, ultrasound, things like that. When we're when we order any image, we want to think about the value of that test. So the two terms I want to bring out our sensitivity and specificity. So if a test is very very sensitive, that means if it's negative, we can confidently rule that out. If a test is very specific. That means we can rule something in. So if we're going to be trying to rule out a stress fracture, we want tests that are a screen tool that are going to be very sensitive for allowing us to cross that off our list and move on. Let's talk about extra real quick, so pretty cheap, pretty easy access. In most offices, you might have it in your office or you might work in a group where you can walk the patient down the hall. The problem with the X ray is it's very specific. There's always something you might see, you might see some subtle change. It's not very sensitive. And the problem is a lot of these when they're lower grade A one or two, it's out of a grading scale of four, one or two can often be undetected on X ray. I've seen a figures where essentially, unless it's A three or more in terms of the grading scale, you're not going to see it ourn X ray. And that's where it could become a bit of a headache of you get the X ray, X rays clean as a whistle and you're confident to walk away from this as a possible diagnosis. You're treating for a couple of weeks patients not getting better, you have to change, you get an X ray again, and then it's gotten worse. So X ray is an option, just not the preferred option, and it's relatively easy to miss. Now I want to be sensitive to if you work in a situation where there's a lot of insurance that you might have to get the X ray first and then be able to get some other imaging modality. So I understand having to play that that reindeer game. So MRII itself is our is our gold standard for a number of reasons. One, it allows us to see individual grading scale, so zero to five, and you're able to contrast on like T one T two weighted image. You'll generally see it down on one, up on two. They'll be ill defined dema throughout. But what I like about MRIs you can see a lot more. You can see the bon edema. And then also they're very specific grading criteria, and that grading criteria I'll show a table at the end that grading criteria can be plugged in to return to run, return to recovery time. So it gives you a nice framework, especially when you're working to set expectations with your patient about how long is this going to take? Or how are we going to manage this going forward. It gives you a nice framework and roadmap for them, especially if they're saying, well, I want to get back in two weeks and things like that. It makes things a lot easier for you from a communication standpoint. The stables from a native this is the classification again. Grade one through four or five is complete fracture and you can just see the different criteria for the level of edema and then what is seen with or without the fracture line diagnostic ultrasound. It's another potential imaging modality some states scope of practice, it might not be readily available. What is nice about it is you can see stuff in real time. So if you can if you can touch it with your hands, you can scan it. So if somebody is pointing to the middle of their shinn er tibia, you can take a probe right there and scan it. And sometimes it's a lot cheaper than the MRI and you can see it in real time. Again, that just depends on what's available to you and what your license looks like. So getting back to the injuries himself, we'll talk Most common areas are tibia, tarsal levicular metatarsals, femur, neck and shaft, and then pellas and safe room. For this, I'll kind of focus on tibia and femur since there tibia is much more common, and then femur has the most moving pieces in my mind, so tibial stress fracture, So what's that going to look like? They're going to come in pain focal to the anterior tibia pain with more activity. I call it the pinky test personally, where if they can take the tip of their pinky and tap where it hurts. Generally, that's a really specific indicator that that's what's going on again, your other historical features changes in trading, superactive things like that. There's two tests that's not taught a whole lot in school. Milground Research out of Israel has this study. They did two quick tests with a combined sensitivity of one hundred percent. So if these two tests are negative, you can feel pretty confident about walking away from this diagnosis. The two things are one pain on palpatient, does it hurt if I poke that area? And then second hot test, how doing the patient perform a single like hop test over that area? If they that reproduces their pain and it's painful. There you have some confidence about this being concerning emerging BSI. And then quickly just it's often a mimicker where you have medial tibul stress syndrome or shin splins present with or mimicking about BSI. Generally a couple of things just look that are different. One, look the hot test the pain on palpatient. Second, if it's shin splins, the area of pain is a lot more broad throughout the shaft instead of one focal area, and that's due to the kind of periostatis with the tibia and like the muscular attachments there, So it's this more diffuse nonfocal pain instead of just that that pinpoint area. And then looking into the other other one of my favorites, the femur itself. I remember that we have those two types. So we have the shaft the long portion of the bone that's on the low risk category, and then we have the neck itself approximal end that's in the high risk category. So you'll often have a patient come in with this this deep, really achy pain. Every patient I've seen with a formeral neck stress fracture, the phraser views is it's in there deep or they'll they'll be trying to show me where it is and then just keep on poking. They're like, I wish my hand could go deeper. I could poke more in because that's it's beneath me even more my hand is out there. And a couple of things we'll see, especially with the neck is really intense pain. With the hop test, there's a test known as fol chrome test. You can see it on the picture there. That's where you'll take your hand and bring it underneath the patient's formal shaft. Take your other hand and press over that area. That allows you to kind of put a little one pressure onto the shaft itself. But two, you're jamming the head of the femur up into the into the alia. If there's irritation, inflammation, easy way to irritate it, and then other orthopedic tests might be helpful for baar fi dear, you're just seeing how easy is this irritate. So the historical features where the changes in activity load pain, things like that, and then if you're reproducing it with just moving their hip around and the patient's talking about it being in their deep, this needs to be on your radar relatively quickly. So the reason I'm so interested in the formal stress fracture is one is the highest risk, but two it has some different subtypes that aren't well touched on. So specifically, there are are three types for the femur. One if there is a stress fracture on the superior the upper side versus on the bottom side versus all the way through, So on the top side that's referred to as a tensile stress fracture, bottom side is referred to as compressive. And then you can have a complete which is no bleno that involves displacement. So if it's a tensil top side that has it's like a forty percent increased chance of that progressing, meaning to crack further, versus on the compressive that bottom side is much less likely. So even knowing the subtype can be really helpful once you have the MRI about how you want to move forward with this and how you want to manage this, and again harping on the role of the MRI, you can see from this table here it's American Journal Sports Medicine. This is for the neck itself talking about the grading scale. And then they followed the number of athletes and saw how long it took them to return to run. So for a Grade one it is about seven, for a Grade two about fourteen weeks, three about fifteen, and then four about seventeen to eighteen. So look at the huge difference, So seven versus fourteen. Once you a grade one to grade two, you essentially double the timeline. And grade one is about two ish months, give or take. Grade two we're talking three four months or more and going beyond that. So the sooner you can catch these, the better things are going to be for everybody involved. If you can catch an injury at a grade one manage it, you have a better shot to get them either back to their events or to their season than Grade two fourteen weeks of healing time, like a lot of sport is going to be over before then, and that's frustrating for everybody involved. So as soon as you can identify these, that's that's optimal. And again with the study about the epidemiology, a lot of these result in three weeks of time loss, the medical disqualification or the end of season. Again, the soonest you can catch these, that's going to help everybody. That's it for today's episode. Be sure to tune in for Part two, where we discuss the phases of returning to activity after a bone stress injury, as well as talk about some helpful tips for maintaining fitness and strength during the recovery period. Doctor Kemp will also share a few fascinating case studies and offer advice on how to have effective conversations with parents, coaches, and healthcare providers. You won't want to miss it. Episode sixty seven drops in two weeks. Be sure to check out our show notes for special offers from our sponsors and a link to our Factor sixty second survey for the week. You'll also find a link to view the full recorded replay of this webinar. If you're more of a visual learner, you can subscribe to the Factor podcast on Apple, Spotify, iHeartRadio, or the podcast app that works best for you. Be sure to follow the show and give us a five star rating. Every little bit helps. 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