Runningmate PT and Performance Coaching

Once a BSI heals, the problem is over 🤥

Bones are good at healing.

Often, once we stop running after a BSI, symptoms subside, and athletes twiddle their thumbs till their doc says they

The lack of pain present with BSI rehab builds a sense of self-confidence in some athletes, leading to problems down the road.

To understand what athletes are up against, we have to understand how BSIs heal.

Bones heal through two pathways,

Non-targeted remodeling is the body’s initial response to injury, laying down a messy canvas to smooth out over time.

Targeted remodeling is the slow, specific process of remodeling the injury site.

Most cortical injuries will heal within 1-3 months, with more spongy locations around the hips and pelvis taking longer.

Most runners return to training around the three-month mark, feeling like their problem is in the rearview mirror.

In reality, they are simply at the earliest stage of healing that allows a small amount of running.

It can take six months for full bone density to return to normal, with 9-12 months needed for full mineralization of calcium in the affected location.

Beyond the physiological processes, most runners won’t feel like themselves till a year after diagnosis, highlighting the need for patience.

I get it.
These injuries take longer than we want.

But rushing back, without understanding the real timelines for bones, is a recipe for simply getting another BSI during recovery.

All BSIs are training errors 🤥

Stress fractures (March fractures) were first described by Ernst Adolf Breithaupt, a Prussian physician in the early 1800s, who found that as soldiers marched, marched, and marched, they could develop bone pain that eventually led to structural failure.

From the earliest days of stress fractures, they were problems with training load.

The “too much, too soon” model.

Even today, we often assume these injuries are solely mechanical problems, with the temptation here that a simple change in training philosophy will prevent the next problem.

“I need more time on the AlterG or Boost.”
“Did you know Parker Valby used the Arc trainer?”
“I’m definitely gonna take a skeletal rest week, moving forward.”

Before you blame a BSI on training, check that their training cup isn’t full of holes.

Rarely do I find that a patient’s BSI is solely driven by silly training decisions.

Often, they are problems of

🩺Health
🥗Nutrition
😩Stress

Masquerading as training problems.

Look at their training log, but then zoom out to the whole person.

Rest is the best medicine 🤥

When a runner is diagnosed with a BSI, they need a period of absolute (or relative) rest.

They need to do less to allow their body to heal and their symptoms to settle before they can progress back to training.

Low-risk injuries can often continue to cross-train and do drills without pain, while high-risk locations regularly require six weeks of non-weight-bearing to minimize the risk of needing surgery.

Rest is necessary, but also works against you.

When we stop stressing our bodies, things get worse.

Muscles lose size, bones become porous, tendons get limp, while cardiovascular fitness plummets.

Again, rest is necessary to minimize the risk of worse outcomes. But that rest means physiologically the athlete is in a worse situation as they progress back to training.

You need to have an honest conversation with your patients, especially those motivated to “maintain their fitness,” which is unrealistic.

The patients who overdo it with cross-training during the early stages of a BSI often end up in a worse position down the road.

Keep them as active as they can, but be honest about how long it will take to get them back to 100%.

All BSIs are the same 🤥

The first of our 5 lies is the idea that bone stress injuries are the same.

Each BSI is unique in both the injury specifics and the individual athlete.

We start with specific terminology.

Often, the terms stress reaction and stress fracture are used interchangeably when they are really different injuries.

🌊Stress reactions are swelling on imaging.
⛓️‍💥Stress fractures are when a fracture line is present.

The timelines for reactions versus fractures differ, so understanding the specific injury is crucial.

Imaging also helps us determine if a BSI is low or high-risk.

Common low-risk injuries in runners are the medial tibia, most metatarsals, the fibula, the sacrum/pelvis, and the calcaneus.

With high-risk locations affecting the femoral neck, the navicular, proximal 5th metatarsal, and anterior tibial cortex.

The advice and management strategies you give your patients can vary greatly.

So you must first understand the specifics of an athlete’s injury.

Tomorrow, we are going to break down why rest isn’t always best. 🛌

Summer Sale ☀️🦴

I became fascinated on bone stress injuries, after realized I was a terrible at treating them.

Over the last decade, I’ve made many mistakes and learned a lot at the diagnosis, rehab, and return to sport of these challenging injuries.

And I’ve distilled that experience into my online BSI course: Rebuild, which is on sale for $375 through June 6th (the cheapest it will ever be).

Here’s what you’ll get 👇

12.75 CEUs in 38 states
13 hours of self-paced video content
My 147-page Stress Fracture Protocols (normally $250)
Lifetime access to all recordings and future updates

You’ll get the course for just $375 or 4 monthly payments of $93.75.

This special rate will expire at 11:59 PM (CST) on June 6th.

You can learn more and sign up at the link in my bio. 🔗

The best femoral shaft test 🧪

The ortho exam for potential femoral shaft BSIs is pretty straight forward.

Fulcrum tests, hip exam, and resisted hip movements can raise suspicion for a femoral shaft BSI.

But the best test may be to have the sit on a stiff surface without foot support for 20-30 seconds.

If it reproduces their symptoms, you need to rule out a femoral shaft BSI.

Clearing BSI to run 🏃‍♀️ 🦴

Returning a BSI to running shouldn’t feel like a guessing game.
�Following a foot BSI, runners need to be able to handle the following before we can run.

▪️Single-leg weight-bearing
▪️Large ranges of motion at the foot
▪️High bending forces
▪️Impact
�Regardless of injury specifics, I want all of my foot BSI patients to pass the following tests before starting a return-to-run testing.��1️⃣Pain-free palpation of the affected location�2️⃣Pain-free passive toe flexion/extension�3️⃣Single-leg stance x 30” in a wobble-free manner�4️⃣Lateral step down x 10 in a wobble-free manner�5️⃣Static pogos x 30�6️⃣Medial/lateral pogos x 20 in each direction�7️⃣Anterior/posterior pogos x 20 in each direction�8️⃣Single-leg hopping 3 x 30�
If a runner passes these tests ☝️ without pain, I’m confident we can start running.

When MRIs aren’t helpful 😭

MRIs are an important tool when dealing with uncertainty.

On rare occasions, they can offer more uncertainty than clarity.

Clinicians need to trust their exam skills and clinical instinct when imaging findings don’t match someone’s clinical presentation.