#67 - Bone Stress Injuries: Good, Bad, and Ugly with Dr. Tyler Kemp, Part 2

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. In today's episode, we wrap up our two part training on bone stress injuries with doctor Tyler Kemp. In part one, we talked about the differences between bone stress injuries and overuse injuries. We also covered the type of stress fractures and how they're graded, and then we walk through physical examination, imaging, and diagnostic tools that you can use. Today, we'll chat more about how to treat these injuries with examples and case studies. We'll also discuss the phases of return to sport and go over some helpful exercise progressions that you can use to build strength and shorten the recovery period for your patients. So kick back, turn up the volume and take some notes. Let's dive in. Gets kind of fun to as a transition over here to manage the return. You had somebody come in, you identified it, you confirmed on imaging. Now what do you want to do? So? I'm a big fan of d Rose, especially for his time in the Bulls. There was a really good promo that Adidas did after he heard his ACL. It was called the Return, where they were promote a He's coming back, He's going to return better than ever and all that. The problem was d Rose has been plagued with injuries for the remaining bit of his career. Things did not work out at all the way they were hoping. And you contrast that with someone like Adrian Peterson, similar injury ACL obviously different sports, who when he came back he came back stronger and faster than ever, And there was two kinds of distinct mindsets with it. Derek Rose was just trying to get back in general. Adrian Peterson, if you look at interviews, he talks about how his mindset became, if I'm going to be stuck here having to work on my knee, I might as well work on everything else as an athlete so that when I get back, I'm back way better than before. And I want you to adopt that mindset with these patients and with your athletes, of if we're going to get them back to running back to their activity, what are the other things we're going to do while we're stuck here to get them to the next level. So when we talk about the return, quote unquote, I want to split it into three things, so return to participation, return to sport, and return to performance. So return to participation meaning just them getting back to some kind of activity, so if they're a runner, just them starting to run a little bit or be able to do stuff on their own period without any issues. Return to sport meaning getting them back to playing in some way, shape or form. And then return to performance is return to game day, return to race day, being back today where they were. Essentially, Now, the hard question and the question every patient's going to ask you is how long is this going to take? And that's something you have to be able to be really clear with your communication. So this table here is from Marnet at All. It's honestly one of my favorites to references. So this takes all of the information we talked about before and synthesizing it down to some part numbers, so it splits it into the low risk low grade and the up to high risk high grade. And if you look at it, you can't you know something pretty quickly of low risk low grade is about nine weeks, low risk high grades twenty two weeks. High risk low grade is about nineteen weeks and then about the same for high risk high grade. So if you know you have somebody coming in with a low grade for moral shaft injury, you can constantly tell them, hey, this will take about nine weeks to to heal properly, and that's going to be our kind of timeline going forward. So, being practicing in Cincinnati, everybody loves driving out to Hiltonhead and the Carolina is it's a beach town. It takes about ten hours to get there. So the analogy I give to patients is how long is the drive to Hilton Head? And most will say ten eleven inch hours depending on traffic. I'm like, yeah, is that? Is there a way to make that drive shorter? And yeah, we could probably do ten ish on the dot, nine ish, don't stop for the restroom, pack a lunch, drive a little fast, all that. Like can you make that six hours? Like? Well, probably not. And I'm like, on the flip side, is that could that be longer? Could that be twelve hours? Four pen hours? Like? Oh? Absolutely? So you have this loose range and what I always tell patients is this is kind of our time frame. We can go above this or below this. My job is to keep you as close to this timeframe as possible. And bone has defined healing time like any other tissue. So biology drives the bus on this and we need to be able to expand that clearly. So again, the low risk glow grade is about nine weeks, lower risk high grade about twenty two weeks, High risk glow grade nineteen and then the same for the high risk high grade. And then this helps inform the kind of hard conversation as well of if you have somebody come in, say they're a high school runner, and end of September, if they have a high risk stress fracture in a risky area, they're season's over now, then your mindset needs to be how can I prepare them for the next season? How can I get them back better and stronger than before. Again, here's the MRI classification showing the different grading scales here. So getting into the nitty gritty of the return three phases, we want to do an active rest, an active rest with some kind of rehab or physical exercise, and then rehab with tolerance testing with the return to sports. So the active rest of finding something when they're in the ACUT stage, again, assuming they don't have any reason to be non weight bearing or something like that. Finding something they can do that at least keeps them active, and especially for runners, to keeps them a little samee. So if running is entirely out of the question, or if they have a high grade injury, finding alternatives swimming and biking are two great examples, just so that they can keep some cardiovasque their endurance at that time. Phase two, once they're at a pain free stage, being able to add some kind of exercise in there. We know that runners are chronically undertrained on the strength and conditioning side, This is a great time to fix those issues. And then Phase three is the rehab tolerance testing, starting to test drive different mileage and speed and grading their symptoms and then ultimately getting them back to their sport. So getting specific with the return to run a couple of things. One, it needs to be boring and pain free. Boring and pain free and boring is exactly what it sounds like. It's not going to be them doing a four minute mile up a trail or something. They're gonna have to drastically reduce their page. The other thing is that it has to be pain free. So if they have anything zero to ten scale. If they have anything above a zero, you need to regress because the bone is actively healing. We need to make sure we're not irritating it. I had a personal situation with a patient where I had cleared them to run way too soon and they ended up re injuring it. Why well, one I told them they were fine to run, and they decided to run. They went back to their same amount of mileage, and they actually had a recurrence of their stress injury. I don't think it had healed one hundred percent. So we basically reversed our clock. But you need to be if you're going to use the timeline, have that framework moving forward. So using things easily like walking. So if they're going to go run for thirty minutes at their stage, have them to go five to ten in a walk on either end book at that and then it's easy of easy way to kind of be honest with themselves of hey, I'm walking down this trail, I'm starting to feel these simoms maybe all bail on this run. And then you can even play with some programming things of alternating days, having them walk two days, run another, walk one day, run another and kind of changing it as you add back in or increase their amount of days that they're active running progression. Really great rule of thumb is the ten percent rule, So don't add more than ten percent either mileage or intensity week to week. It's a great way to kind of keep the lid on things for somebody that's going to want to jump their mileage something dramatic from thirty miles a week to sixty miles a week. And within that you can play with three specific variables, frequency, duration, and intensity. So frequency the number of times in a week or a set period that activities performed, duration, how long that occurred, and then the intensity their their pace, their RPE if you want to play to something like that, So frequency getting them from if they're normally somebody who's ten days a week, let's go for something like five or six, and we can start them from two days a week and then getting up to three and then four, five, and then get them back to their normal training frequency in the week. So if it's five, gradually get them back to five. After that, you can start to play with the duration in terms of mileage or minutes. I like playing with minutes because their intensity. When we change that later they might be doing an eight minute mile versus a six minute mile, and then I'll obviously change their mileage. So play for the duration at time and then the intensity getting them back to what their preferred paces. So if they're training for a seven to fifteen minute mile pace, you might be starting somewhere high at eleven minute mile and then working your way down as the last variable. So the three things we play with are the frequency, the duration, and then the intensity. A little chart from British Journal Sports Medicine just emphasizing the role of strength training for runners, a number of number of great health side effects with that, and then what I touched on before with the Adrian Peterson example, this is a great time. Strength training two to three times a week is considered the minimum for a healthy lifestyle for all of Americans. This is a great time for them to fill in those gaps. Do they have decreased hipp endurance because you get this deadlifting, putting some weight on, it's not going to hurt them to return stronger than they were before. And then also them working out will have a positive effect on the bone. We talk about that dynamic tissue of bone. They're gonna build muscle, but they can also build boney they're loading it up, it's gonna give it a great training stimulus. And there are some ways you can creatively have them train deadlifting, squatting, things like that while you're waiting to see if it's going to even be safe for them to run. And it's a great way to test drive things further. And again, what can we strengthen for the long term? Do they have other issues? I've always had any glue A week quad great, now is our time while we're waiting for this bone to heal, for us to get back in a lot better fashion. And then practically some nutrition or lifestyle things. So do the basics very well. Sleep? Are they getting seven eight hours a night of sleep? If they're getting two and a half, all the perfect programming and training in the world is going to be lost on them. If they're never having a chance to recover nutrition, their chloric intake. Are they just are they eating enough or are they chronically under calorie because them being under calorie is going to make things really difficult from that bone debt perspective, and they're never going to be able to pay that off. And then nutrition wise, there's a few studies with stress fractures in US military recruits going through basic training. Vitamin D and calcium have consistently been shown to help the recovery of b sis. And this kind of makes sense. If someone had a muscle injury and you could increase their approaching update in a given day, that's probably going to help them. It's going to make things more bioavailable. Bone is made up of calcium, indeed, magnesium, a bunch of other things. If you can make that more available for that person, it's certainly not going to hurt. I'm moving forward in some ranges that have been thrown out or about six hundred one thousand I use and then calcium about two hundred milligrams a day. So and also I'm not really proponent of supplements, but you can generally get it relatively cheap Walmart, Kroger, stuff like that. Easy way to add that into their diet as they're bouncing back from this injury factors. Black Friday deals are going on now, and we've got something huge in store for this year. Curious, Well, here's the scoop. So click on the Black Friday link in our show notes to get on the list. 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Now back to the show with Dan, what we ended up doing is basically had to shut down his cross country season, which is super unfortunate, and then since his high grade in a high risk area, we ended up having to shut him down for the twenty some weeks and then at that point we got him back to a little bit of biking and swimming. We did that for about six weeks and then at that point we had it in some strength conditioning stuff. He will be returning back to track this year, so it should be pretty exciting. But it was a really long process and it was the conversation of fighting. I want to get back to running as quick as possible, but it's one of those you have to just do once and get it over with in a good fashion. So now I'll kind of open up to some Q and a I'm sorry if I rambled too much. Wonderful, Thank you so much. I think this was a great presentation and really gave some insight into these bone stress injuries. I do have a few that have come in. One person was asking about how you approach discussing these injuries with your patients. Obviously, a bone stress injury is something that comes from overuse. It's something that a lot of times very how do we say, maybe motivated athletes and those that love to run, love to do their sport, they end up getting these type of injuries. How do you approach these conversations in a way that makes them actually listen to your recommendations, pause on some of those activities that could cause their injury to get worse, or as you mentioned before you had a patient that went back a little too early and had to reinjury. First off, it's really hard because some people are stubborn and they will not listen to you, and I don't I don't have a good answer for the person that don't listen to you at all, but that's one that it sounds terrible. That's one of the reasons I really like the MRI because sometimes patients don't believe you even though you have just checking all the boxes for what's going on. I really like being able to show the MURY report of you have a fracture, you have an active fracture, or the beginning stages of a fracture in your leg. If I broke my arm, I wouldn't continue to live my life. I would obviously change things, like for where we're at right now, we have to change otherwise this is gonna get worse. And generally that can get some buy in. And then one of my favorite phrases is just growing in. I do this once, so it's gonna stink. We're gonna have to modify your training for now. I never say I'm gonna shut you down or you can't run. I really try to avoid that. But I'll just say we're going to modify your training for now and give them a clear narrative about what their PAS is going to look like. If hey, mister Smith, you have all the signs of a stress fracture, it's this grade. The timeline for this is X amount of weeks. My goal is to keep you as close to that timeline as possible, and then after that kind of have an open conversation. Absolutely, and we've talked about this several times before on our other webinars as well, that whole component of that patient conversation of making sure that you're keeping it positive, that you're not necessarily using negative language or things that really leave your patient feeling defeated or like catastrophizing what's already going on. One of our other attendees was asking, in your example of the runner who went back too fast and did too much and had that reinjury, were you kind of back to square one after that? Or when that happens, is there a setback that maybe requires a different approach, such as something that's low risk or some stress related signals that reappear on the MRI. So with that person, it was not quite back to square one. It was a maybe a square twoish, and at that point I didn't understand the framework for the different weeks depending on the injury, so I was way too confident of I think he was five weeks out and I had cut him loose to said, hey, you're paying free to go for it. After that, we basically had the conversation of look, I based on your exam, I think you're in not square one but square two, and we're gonna have to wait about six weeks minimum for any activity before you go into that. And then another detail with that specific patient was he got briefly into bodybuilding of that time, so he had put a very very lean guy put on a good deal of muscle in a very short period of time. And then just the reality of him adding another fifteen pounds of muscle and then pounded the pavement with that. That was just a new stimulus for his bones as well. So that was another variable with him, absolutely, And that's actually a great segue into the next question. In your experience with these injuries, and obviously in the research that you've also reviewed, are you finding that there are specific comorbidities that oftentimes are present with these injuries or certain specific maybe even if people are playing multiple sports within the same season, or like you mentioned someone who's an avid runner and they're also bodybuilding. What are you seeing kind of across the board that might show some correlation to this type of injury specifically. Yeah, So the multi sport athlete is a more common one of just their go, go go, They're doing a ton of things. That's something I've seen. The other thing is just nutrition of they're just not eating enough for their correct demands. You'll hear about the female athlete triangle where they might be some disminor reage and just not eating enough calories. So it's the multi sport athlete and the person that is just not eating anough that I see as kind of indicators. So that's something you want to have that chat with the athlete or their parents there they're just like, hey, they can have a calorie surplus, and especially on the recovery side, like if they have this injury and they're trying to get back, you want there to be as much as many calories and nutrients available to their bodies. That's healing. You don't want to be trying to short change that absolutely, and I think that's another really great question too. What type of supportive therapies do you recommend for your patients while they're healing. I know you probably have some go to recommendations for that recovery trifecta of sleep, hydration, and nutrition, but then beyond that, what are the types of things that you encourage your patients to do while they're not necessarily hitting that specific exercise the same way they used to, or maybe they're doing their rehab exercises instead. How do you support them throughout their recovery? I guess on the automodality side, like I have not seen anything on the from research standpoint or personally that's been super helpful. There was some research for like some shockwave therapy to help with healing bone stress injuries. The problem with that though, is it showed the same timeline of recovery with or without it. So I have a discourage patients from using that just because if the timeline for them is nine weeks, and if they have the shockwave then it's nine weeks as well, it's not really going to make much of a difference. So I haven't seen anything on like modalities like that or norma tech or anything fancy. It's just it's not super fancy. It's just eating, giving their body time to recover, and then managing the return to run. Speaking about the multi sport athletes that you've seen with this type of injury, oftentimes we hear from a lot of sports docks that they're encountering more and more young athletes, your youth that are ages between even as young as eight into high school that tend to have these overused injuries. We see a lot of uptick in Tommy John's injuries obviously, I'd imagine you're seeing a lot of bone stress for these multi sport athletes as well. How do you have that conversation with the parents, how do you involve the coaches or even the healthcare support team at their school or on their team to make this a better conversation and a conversation that kind of sticks with these people who were kind of the decision makers guiding these young athletes. Yeah, so the biggest thing is it sounds cliche, but having good communication, especially with the coaches. I don't chiropractor. There's a lot of baggage or assumptions that can come with that. So whenever I reach out to the coach. It's never in the framework or the mindset of here's my way, this is how we're going to do it. It's always couched with this is your athlete, I'm just coming alongside to help, and here are my concerns. So I found that's a lot more receptive with chatting with coaches and communicating of just I'm just coming alongside to help your athees and if they perform better or get better quicker, we all went. So that's helped the same thing with on the healthcare side. Can think of a situation where we just had to email and work with the surgeon because we're really concerned it was a high grade for moral stress injury that it was going to be a possible displacement case. And it worked out because the athlete was very resistant to us changing their training. We basically had to have them stop running for a three week minimum period and they actually needed to be non weight bearing. And it worked out that us and the arth were on the same page because good Way, that author gave them a kind of come to Jesus meeting about hey, you have to be non weight bearing. I'm having you get a pair of crutches right now. In a great way that actually kind of scared them into thinking, Okay, this is actually serious. I have a fracture in my hip that I'm walking around with. I need to be actually really careful with this. Absolutely, And in your experience, who do you feel like has been one of the biggest advocates and one of your biggest supporters in terms of other healthcare providers that you can usually count on to kind of get on board with your recommendations and really support them so that it's not just one voice but multiple for that athlete. I think it orthow has been really helpful because more and more orthopedics are getting picky, which is great, Like, you don't want to have a surgery unless you absolutely need it, so their job is to figure out if this is surgical or not as quickly as possible, but for them to see it, and I think there's a lot more credibility with the orthopedic telling you. But it's always it's really convincing when you have two providers, especially like a surgeon telling you the same thing and being on the same page, or even setting it's silly in old school, but even setting a facts ahead before their appointment that just allows us to all be on the same page and we're all saying the same message and narrative with the patient. So to answer your question orthopedics and having a chat beforehand is really helpful. Absolutely, and we've heard that time and time again from providers that if you really want to work well with other provide is part of that. Sports med team communication is key and just being sure that you're having that conversation as soon as that patient comes in your office so that they're in the loop. Someone else was asking for a ball sport athlete, how do you test return to run still building up run walk intervals or do you use a different approach to prep for return to sports such as sprinting, start and stop. This person mentions that there's a lot of research for cross country runners, but a little less published on ball sport athletes. But as you noted, there seems to have been a really big uptick post COVID in these type of injuries with ball sport athletes. Yeah, that's a really fantastic question. It's a lot a little different because the cross country athlete, they're running up to twelve miles or whatever, they're doing much for their distance. I haven't seen a lot of great specific testing for the multi sport athlete, basketball, baseball, things like that. The biggest thing is just tolerance testing. Start low of is it painful for them to walk around? If it's If it's painful for them to walk into your office, that's going to be a problem. You need to wait till it's pain free and without issue, and then just start playing with it. Like I have a pair of cones in the back, Like I will go out to the our back office. We have a little parking lot area, and like just have them light jog and sprint and things like that, and we'll check in with that after a few visits and see if they can even handle that. So, more specifically, with returning to run, I would say, for the person that asked that question, could they be more specific about running in general or running within that sport. It looks like they were specifically talking about ball sport, and of course please write in and let us know if there's something better to clarify there. But the options were do you do kind of building up run walk intervals or do you have a different approach such as sprinting with starts and stops. I would imagine this would be especially critical for like a basketball player or someone that's doing a lot of those sprints where they're starting and stopping a good Yeah, and it's specific to the sport, but you just have to start tailoring it to what their activity is going to be. So for the basketball example, get out the cones and see how they can handle or see what they can do with the running back and forth. Wonderful. And again, if you have any further points of clarification on that, if you could write in with those, I'll go ahead and ask the last question we've received now while you're doing that, and then we can certainly circle back to it. One question was involving supplements. Do you have any specific supplementation that you recommend for these athletes, not only while they're recovering from this injury, but something that they could implement into their diet moving forward to prevent reinjury in the future. Yeah, that's a great question. What I've done is that protocol of the two hundred million grand with calcium and then six hundred minimum for the I use a vitamin D if I have an active athlete, especially if they've had a previous history of this, I recommend not year round, but within season that they are supplementing with those two specifically, that's a great option. And then just from the nutrition standpoint, I think the criteria is now one gram of protein per day for preferred body weight, So if their preferred body weight is two hundred pounds, that they're at least getting tw hundred grams of protein in their day. And especially with the run, they're using so much muscle tissue things like that, that helps with the recovery process. And also protein is used in some small ways with bone reconstruction as your body's repairing, So those three would be a great place to start. Absolutely, thank you. Another question here, do you do much with lower weight bearing such as crutches initially, boots for lower extremity, et cetera. What type of devices or racing do you recommend? Generally, I'll just have an crutches or something like that from Walmart, CBS, things like that. I don't have a preference on the boot, whatever is just most practical for them. If the question is more of able to do anything with them when they're in a crutch or things like that, the answer is yes. So that's where we get to be a little creative. So say somebody has a significant stress fracture of their foot, like bikings out of the question. We can't do any swimming things like that. If they have access to their local gym or even their why like something like a handbike just for them to get some kind of stimulus. And then also there's some research about any kind of strengthening having an osteogenic effect. So if they can do anything lower limb for six weeks, this is a great time for us to explore what kind of upper body exercises they can do. It just is not going to hurt them as an athlete or a runner to get stronger. But then also from a hormone standpoint, if they are working out, they are sending off cellular signals for anabolic production and that's going to go everywhere. That's a signal that is sent through the bloodstream. So them working out in general is going to send cellular signals throughout the body, which can certainly help that bone as a lower left Again, Doctor Camp, thank you so much. We really appreciate you coming on today. That's it for today's episode. Be sure to tune in for episode sixty eight, where we dive into a brand new training in the world of cutting edge treatment tech with shockwave therapy for post surgical care with doctor David Rednick. This is one you won't want to miss, especially if you've been considering adding a shockwave device to your clinical toolkit. Episode sixty nine drops in two weeks. Be sure to keep an eye on your inbox. Follow us on social media for all of our Black Friday Cyber Monday deals that are starting right now. If you're not on our email list, what are you waiting for? Click on the sign up link in our show notes to receive our weekly Factor five Things Friday email. This is where we share free resources to grow your business and elevate your patient care, along with exclusive discounts and early access offers for certification programs, free webinars, and hands on courses. All of this is packaged in a nice and simple five Things format that's easy for you to skim and scroll. We'll see you next time. 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