How To Prevent Stress Fractures with Dr’s Amy Touzell and Leesa Huguenin

So even trying to diagnose my own stress fracture with me having a pretty good idea of what was going on was really difficult at that particular time in Victoria with all the restrictions from COVID So I reckon it took six months to settle properly with a bit of help and blood tests and controlling my nutrition and making sure that everything was in my favor. Eventually it turned into a biomechanical problem.

This podcast is brought to you by Trivalo Coaching, where we help triathletes and cyclists like you train smarter to race faster. I'm your host, Jordan Donnelly, and on my left is former Australian Ironman champion and head coach of TR Coaching, Jared Donnelly. Our guests today are two highly qualified individuals in sports medicine, and today we're talking to them specifically about stress fractures in athletes. And let's face it, as an athlete, you hear the word stress fracture and you shudder in your boots. The words feel like a death sentence to any athlete. But Dr. Amy Touzle, an orthopaedic surgeon, and Dr. Lisa Huginen, a sports physician with a wealth of experience in elite and national sporting teams, both of whom deal with stress fractures in athletes every day, are here to come to the rescue. Because this episode certainly put a lot of my misguided fears and anxieties around stress fractures aside. I think that our takeaway from this episode is that every athlete needs to hear this knowledge to have the best chance of preventing or managing stress fractures in their athletic career.

Yeah, it's. It's one of the best discussions we've had in a while. And the information that was coming from these two really experts in their field was. Was gold. And it is a. It is really running a running issue. You can get stress fractures from a lot of other sports as well, but the majority of the time we were really focusing on identifying what is going on and getting early intervention and then doing the rehab properly. So we go through all of those aspects of, are you injured? What do you do about it, and how do you actually fix it? And so there wouldn't be hardly any runner in. In the world who hasn't experienced some sort of foot pain or leg pain that they thought might have been a stress fracture. And there's so many simple things from this podcast that I learned that you could do to really help your body function so much better. And I just thought it was really an overuse injury. But now I'm clearly more informed that there's more to it than that. So I was really excited to hear some really more accurate, detailed information.

Yeah, like you said, if you are a triathlete or a runner, then this definitely applies to you. But even if you're not, if you're just a cyclist or a swimmer, this still applies. Because it doesn't just like you said, it doesn't just come from running, it could come from other aspects. And as Dr. Amy Touzle said herself, she got it from being in the gym. And that was. That is an interesting story that you'll hear in the episode. So without further ado, here is the episode on stress fractures. Lisa and Amy, welcome to the podcast. Thank you very much for joining us. We're very grateful to have you both on. Could you just give us a little bit of a quick recap each or at least I'll let you go first into your history in the sport and your history around stress fractures.

Sure. I'm a sports physician practicing on the Mornington Peninsula. We see a wide variety of athletes and there's a huge triathlon population on the peninsula. So we do come in contact with a number of people who run into problems with overuse injuries. Stress fractures are one of those overuse injuries that we see at the moment. My professional sporting involvement is with aflw and we do see a similar profile of injuries in terms of overuse with the AFLW girls as well. I've got a history of working with high level male AFL as well, but I have also had some involvement with triathlon and gymnastics and other elite sports in the past.

Amazing.

And Amy, so I'm an orthopaedic surgeon, so I tend to see the stress fractures that have either fallen apart or haven't been treated properly and patients have pushed through the pain. So I'm focused on the Mornington Peninsula as well, which is where my relationship with Lisa has come from. I'm mainly foot and ankle and so have seen a lot of stress fractures to the lower limb and many of which have been preventable. And part of this podcast is trying to get a little bit of athlete education and awareness about how important it is to listen to your body and realize there are some injuries that you just don't push through. And my husband does triathlon and I've done triathlon, slash trying to do triathlon whilst my husband is doing triathlon. And I understand the mentality behind endurance events, but it's also really, really important and people need to be aware that these injuries can be catastrophic for some people.

That's why we're excited to have you both on because as a team, we're going to be covering basically everything from prevention right up to if you do have to end up having surgery, which happens to a lot of endurance athletes, what do you do from there? And how do you get back to a return to running? So, Lisa, we really want to dive into big topic stress fracture prevention. Where do you even start when you start thinking about this and what athletes need to know?

I guess the big thing with stress fractures is that they always occur when there's an imbalance between load adaption and recovery in an athlete. And there will usually be an error of training that we can identify that has led to the formation of the stress fracture. So your bones need load in order to strengthen, and a graduated load will result in strengthening. But strengthening occurs through a little bit of damage, followed by a little bit of repair, followed by a little bit more damage and a little bit more repair. And gradually the bones will become more resilient to the forces that are being put through them. If you change that balance in any way, by increasing your load too quickly, by having inadequate nutritional intake, by having hormonal concerns within the athlete, by having biomechanics that are perhaps not ideal, then you can end up just tipping the balance in the favor of the breakdown of the bone. And once the bone breakdown begins, the bone naturally becomes weaker, and then it becomes very hard for it to play catch up. And unfortunately, a lot of that sort of imbalance occurs before the athlete is recognizing anything in terms of symptoms developing. So it really is about having awareness of your training regime, awareness of your training progressions, so that hopefully you can avoid the errors that can cause the bone stress.

Can we just dig into the load to start with? Because you do see, you would obviously think that someone who's new to running. Let's just take running as an example, who hasn't done a lot of running? And we don't have. In our society, we don't have a lot of people who haven't run. It's unusual to get someone who's 30 or 40 who hasn't done some sort of running, whether it's team sport or individual running. But you do get some people who come and they've done very little running. Are they the ones who can't cope with the load? But we also do see people who have been a runner their whole life with really good structure, and you would think strength and conditioning, yet they can still arrive at your office with some sort of pain from a stress fracture. Can you just address that?

Well, I think there's so many different factors that play into bone health that it can be any one of those factors that's out of whack that leads to the bone becoming under stress. So if we do have a new athlete, yes, they are going to be at higher risk if they progress their load too quickly. But you may have somebody who's never run, who's got a very realistic expectation of when they're going to be able to compete, who goes through a 12 month buildup program, incorporates strength and conditioning work into their program, works on calf strength, works on foot intrinsics, has appropriate shoes and good genetics. You know, they might just be built right way for running who can get through that program and come through without any injury whatsoever. And then you may have somebody else who has just one of those factors being a little bit different, who ends up with a stress fracture. I think at the other end with the people who have done lots of running, sometimes it's to do with volume, sometimes it's to do with inadequate recovery times, and sometimes it can be to do with the nutritional component. As in if you're not quite able to take in enough calories to support the volume of running that you've been doing, the metabolic effects that that has on your body actually have a negative impact on your bone turnover. So even if you did exactly the same training, with exactly the same shoes, with exactly the same progressions, and yet you were slightly calorie deficient compared to somebody who was had enough calories, then the changes in your body will make you more prone to bone breakdown. And that's through hormonal influences from the gut on the bone, from the gut on the adrenal glands producing cortisol, which is a stress hormone, which causes bone breakdown. And also the influence of the energy deficiency on estrogen and testosterone levels in the body, which are also imperative for bone turnover. So sometimes the error is as small as, you know, one muesli bar too few per day.

So I want to clarify the amount of factors that could contribute to the stress fracture. And you just mentioned a whole bunch. But are the controllable ones, like load the biggest factors and all these subsequent ones, like your genetic factors, stuff that's completely out of control, more than minor ones, or you can't put it down to that, you can't break down what's bigger.

Unfortunately, not all stress fractures are the same beast. So there are different. Some bones are very sensitive to the nutritional, the hormonal aspects of changes. And that might be something like an avicula or a sacrum or a femur, but other bones are less prone to be affected by that and more prone to be affected by biomechanics or by load. And that might be something like a metatarsal stress fracture or a tibial stress fracture. So if all bones were created exactly equal, it would probably make our life an awful lot easier in educating people on how to avoid these things. But I think generally you can break them down into sort of the more metabolic or the more hormonal stress fractures and the more biomechanical or the more load related stress fractures. Load, however, is an overriding feature. So load, you need to be having a load that is in excess of the bone's ability to regenerate and cope and in order to cause the bone stress. But the other factors involved could be more mechanical or more sort of metabolic.

This is going to be a theme of the podcast. I think with everything you say, it kind of opens Pandora's box to a whole bunch of other things. So I'm going to try really hard to keep it on track. But one of the first things that stood out to me was when the load is increasing and the too much load creates that bone breakdown. Why is that happening in a bone compared to potentially soft tissue breakdown or, or ligament breakdown or something?

Well, it's actually, that's actually the way that all of our tissues cope with increasing load. There's a degree of catabolism or breakdown of the tissue and a degree of formation of new tissue. But in bone, the catabolism is probably a little bit more prominent than it is in, say, muscle. In muscle, we're more likely to just build muscle on muscle, but it takes some damage to build that. But in bone, the process of forming bone, the process of healing a fracture even, is that it resorbs before it then creates new bone. And so I think bone is probably just a little bit more vulnerable to these overuse injuries, whereas the muscles are much more quick at adapting tendons. However, whole different kettle of fish, whole nother podcast, I would say.

Okay, definitely. And so thinking about load, I wanted to ask what is, is there an optimal load progression to that we can or range that we can try and prevent stress? Fract, if you look at all sports, that's impossible to answer. But luckily we are talking about endurance. And if we even go more specific and just think about running. And in triathletes, the running is very, I guess, confined in nature. They're not doing what a lot of other team sports are doing. And it's short, sharp sprints from all angles. They're just running forwards at basically a steady pace. Unless you're a pro athlete, you're not sprinting out of the ranks. So in that sense, if they're just doing more consistent running, is there an optimal load progression week on week?

Yeah, I think. Look, the simplest way to think about load progression, I think, is in the rule of 10%, and I always use this with my athletes, in terms of simplistic approaches, that you don't want to be increasing your run volume by more than 10% run to run, but also you don't want to be increasing your weekly load, your weekly average, by more than 10% week to week. So it gives you some flexibility within that that you can say, well, I'm going to have a. I'm new to running, I'm going to have a 5k run this week, and then my other two runs are going to be two kilometres, and then I can sort of flip that on its head a little bit the following week. But you just try to stay within that 10% rule as much as you can. And obviously that then means that as your conditioning improves, you've got the ability to add more in terms of the actual volume, but in terms of the percentage volume, it's going to still be within the safe level.

So it's really a great insight already. Let's talk about the nutritional aspect of it now. So we've understood that we need to progress slowly with our load. How critical. And triathletes are a little bit different than runners who are just doing single sport, where they've got their run, then they've got recovery. Whereas a triathlete could possibly have done a swim session and maybe a bike session, then a run session in the one day or a bike and a run and. And then expect to back up the next day with a run. How's the nutrition? Where do you see the breakdown if nutrition was the cause of your stress fracture? Just talk us through that.

There's a couple of factors I think, that need to be taken into account, and one of them is people's basal metabolic rates, which do vary from person to person. And so if you're somebody who's naturally got a very high metabolic rate, your calorie requirements are already quite high. And then if you add the requirements of the run and the swim and the run and the next bike and the extra little session, at the end of the day, you're going to need a lot more intake than somebody who has a lower basal metabolic rate. So just for you to survive, you need more calories. And sometimes people who have those High metabolic rates really struggle. When they start adding volume activity in to actually get enough calories in, they feel sick. Their stomach can't actually hold enough calories. Calories. And so I think that, and believe me, I'm no expert on dietetics and nutrition by any means. I rely on the dietitians to help me with this. But often you do need a dietitian involved in a situation like that and you need education not only on what to eat or how much to eat, but the timing of when to eat it to ensure that you're going to absorb your maximal calories and to ensure that you're not going to make your muscle glycogen stores run too low and you're not going to set off these responses in your body where your body literally thinks that it's under high levels of stress and it's basically saying, hey, I'm starving here, I don't have enough calories to do what I need to do. I'm sending out the hormone signals that are going to say, hey, I need to start conserving energy somewhere. And conserving energy somewhere might be okay. I'm not going to let myself get pregnant because there's no way I can feed a baby with this. So my estrogen levels are going to go down and the stress factor of it is going to increase my cortisol levels and my cortisol levels are going to have a negative impact on my bone density. I'm going to keep some of that protein for something else that I need it for. And then also, unfortunately, as your body starts to go into that stress or that kind of shutdown mode, it feeds back negatively onto your gut and your appetite centers as well. And so then it says to you, hey, do you know what, I actually don't want to eat that much anyway. And so now I'm really just going into shutdown. So the tissues sort of become the victim of a process that's all about self preservation.

I was going to ask, how do you, how do you define or measure your own metabolic rate? But I guess is that just going into a whole new topic of nutrition?

Yeah, you can't really measure your own metabolic rate. I mean, you have a fair idea. You know, some people are much find it much easier to gain weight when they're in an off training period or they're eating a little bit more than normal and other people just don't gain weight. I think that's, you know, a good indication, obviously. But if we have an athlete where we feel that energy Deficiency is possibly part of the problem leading to their injuries. We actually get it all measured properly with, you know, thermal testing, and it's quite an involved process.

Jordan, Lisa, can I just ask the question? For women, we do have a very clear sign that you're in that state of preservation and not eating enough. And as you mentioned, you're not ready to have a baby, so your menstrual cycle stops and your periods become irregular. What happens for the boys? How can they tell that they're over.

Training, usually when they get a stress fracture, to be honest, because it's rare for us to measure the testosterone levels for no real reason. Some men may be having some fertility problems and be tested, you know, as a side reason from the fertility. But it's really unusual for us unless we have flags saying that something's going wrong. We don't usually test for their testosterone. So some triathletes do get tested for it because they have come in with their third stress fracture or something like that. But it's not routine as it is with the females, where we do test pretty quickly.

So what do you do then, as an athlete? What do you look for and what are the differences between. Between male and female and what you should be trying to look for? Is there any, or is it a helpless cause?

Look, I think it's pretty hard to know when you're kind of on the edge, because I think being on the edge is often a place that you want to be from a training perspective. You want to be fatiguing yourself, and you want to come out of your sessions feeling like you're pretty cooked because you know that you're getting a fitness effect from that. I think one of the old tricks we used to use for overtraining, which can still sometimes be a little bit valuable, is to just check your resting heart rate very first thing in the morning when you wake up. And if that's starting to have a bit of an uptick, it might be an indication that you're starting to push things a little bit. I think it's important to regularly weigh yourself so that if you are losing weight, that you can recognize that, and to weigh yourself intermittently pre and post runs and swims and bikes so that you know that you're getting enough fluid hydration at least while you are training. I think with girls, really important that if their periods are not happening or if their periods are irregular or the patterning of their periods has changed, that they find flag that as a problem. It's actually quite convenient when you don't have a period and you're an athlete, but it's not actually a good sign for your body. It's telling us that your body's starting to shut down non essential services and that means that things like your bones will then be vulnerable to injury.

How often is that highly correlated to leading to a stress fracture for females compared to. I know a lot of pro female athletes comment on the fact exactly what you just said. They probably prefer not to get their period. They prefer to get to that state. And naturally, when you're training that hard as a pro athlete, you are going to be close to that state. So how do you know that you're right on the edge and that's where you want to be compared to. You are pushing too far and your bones are at risk.

Look, I think any menstrual change is not a good menstrual change. So if a female is not having their period or if they're having very infrequent periods or very irregular periods, it's not okay.

The long term bone health consequences of having irregular periods is actually really significant as well. So your skeleton turns over every four years. So your entire skeleton, all the cells in your skeleton will turn themselves over every four years. And so for young people, the biggest turnover and the biggest ability to lay down bone and be strong for your whole Life is between 20 and 26. And if you're spending those years with irregular periods and not enough estrogen, estrogen helps pack your bones and makes them dense for later on in life. And if you miss that opportunity to lay down good quality bone, you can't get it back in your 40s and 50s when naturally you go through menopause and your estrogen levels drop off anyway. So that stage, it's not only important for injury prevention and making sure that you're eating enough and you're not in that deficit mode, but it's also really important for bone health. In their 40s and 50s, and I see a lot of women who don't present with stress fractures, but they present with real fractures. So fractured neck of femurs, fractured distal radius, fractured proximal humerus from relatively low energy injuries. And they're not athletes, they're women whose bone health is appalling because they've had an entire lifetime of not having an opportunity to lay down enough bone.

And a couple of practical things you touched on there were measuring your resting heart rate in the morning, measuring weight change, potential weight change overall, or just consistently, and then especially before and after sessions, once again, if your resting heart rate is high or any of these things are a little bit off. What you said before, Lisa, it's not directly. You're not saying it's directly going to cause a stress fracture, but it is something that might get there along the way. I guess the overarching principle is that it's a sign that you're over training in some regard, and therefore the increase risk of a stress factor is high. But it could be anything. You could get sick. The risks of a lot of things are high. And that just means you should back up.

Absolutely. You could get sick because we also find that the immunoglobulins in your saliva will go down when that sort of stuff is starting to happen. So then you're at risk of those respiratory viruses being able to stick onto the mucosa and you become ill as opposed to fighting them off before they even get into your nose. Also, I think that it's a sign that potentially your nutrition is not right and you are starting to really push that edge to the point of tipping. And you don't want to get into a position where you are overtrained, because an overtraining situation takes at least weeks, but occasionally up to, you know, six months for us to be able to reverse with you. So recognizing those changes and then making appropriate adjustments to what you're doing early is by far the most beneficial way to address them. And those adjustments sometimes are really hard, because I understand the mindset of triathlon and I understand the mindset of endurance sport, that you want to keep going and you want to see your progressions, and you can, if you've progressed so far, it's very hard to say, oh, I'm going to take a break right now from that progression when you just want to keep going. But often if you do just keep pushing on with that progression, you're only going to do yourself a disservice. And it may just be a small thing, like a week of getting an hour extra sleep a night, a week of, you know, slightly improving your nutrition and dropping back on the training a little bit, you're back on track and off you can go. But if that goes on, if you've had symptoms or signs of this overtraining for a period of, say, six weeks, I would anticipate it's going to take me to 18 weeks to get you better. Whereas if you've had these problems for three days and you take yourself a week off, you're probably going to get better.

It is a really scary thought, isn't it the consequences of ignorance or ignoring the signs and pushing through. And I know the people I coach, they are petrified of. They've worked so hard to get the fitness level they're at. And then for me to say, you need to stop and take a rest, it's like it's the worst piece of information you could possibly tell them because they just fear that their fitness is going to disappear. And we've done many podcasts on this where the fitness just does not disappear overnight. And you will be better off by by doing exactly what you've said and taking that break. Amy, I'm really interested to really get you involved in this conversation about so how easy is it to diagnose a stress fracture? How does the process work when someone ends up in your office.

As an orthopaedic surgeon? People will normally be referred to me either by somebody like Lisa, who's worried that a fracture might need surgery, or by general practitioners in the community, sometimes via a podiatrist or a physiotherapist. So I would usually get a patient from the community, say from a general practitioner or allied health, who would just have foot pain. And no one's quite been able to work out why their foot is sore. Often an X ray is normal and doesn't show any changes, except for some very subtle changes, such as thickening of the bone evident on X ray that I would only have picked up because I've seen it a couple of hundred times, whereas someone who hasn't seen it before might not see it. So patients will normally present to me with niggling, undifferentiated foot or ankle pain that is worse on exercise. And the big thing for me that flags that a stress fracture is going on is night pain. I don't think. I don't know if you see that as much, Lisa, but if somebody has a dull, aching pain at night on the days that they've exercised, that to me is a real red flag that there's something serious and bony going on as a cause of their pain.

How do you know the difference between whether it's bone pain or muscle pain? Yeah, because I just feel like it's a very common thing, even as an amateur athlete to have pain at night. And I always put it down to muscle soreness.

But yeah, I think I think bone pain itself and I actually gave myself a stress fracture during COVID Lisa knows about this one with too much, too much at home CrossFit and it's a very deep ache that happens at night that that it's like a toothache, I think, and, you know, teeth. The bone as well. Like, that's what it feels like. It's like a toothache that's deep in the bone. Whereas having had, you know, other injuries, muscle pain, I think, is very much related to load and movement. You know, like, you turn over and you're like, oh, my shoulder's a bit sore from swimming or from that stress, you know, that strength session that I did. Whereas I find patients that describe a stress fracture, it's like a toothache just in that particular part of their. Their body, and it's related to activities. So it might be present when they're trying to exercise, but then also, if they've had a big day, it's sore that night as well.

I'm intrigued, Amy, that you've had a stress fracture, knowing everything you know about. And. And it's great that you've. You've. So tell us.

So how about I talk from now on?

I want to hear. I want to hear Lisa's point of view.

So was it a lot of. A lot of little things, or was it the load that was the tipping point? Can you just run through your particular injury in your. And the way you caused your own injury and the factors you think contributed to it?

Yeah, I was the perfect storm of disaster, as Lisa knows. Lisa sort of was a bit involved in looking after me as well. So I. It was mid Covid. So I went from doing CrossFit, which I was new, to very enthusiastic about it. Loved it went from being supervised in a gym with having someone watch my technique, to lockdowns and doing at home crossfit completely unsupervised with horrendous technique and weights that were way too heavy. I was stressed as a orthopedic surgeon. My private practice just shut down with all the expenses associated with running a private practice. But at the same time, I was working in the public system as well, doing trauma on call. And this was before vaccinations, before we had masks. And so I was operating on patients that had been in car accidents and had bone infections and tumors and doing all these really, really big cases completely exposed to Covid because they didn't have enough masks and ppe. So I was stressed pretty much all the time. And as a consequence of that, I wasn't eating properly either. So my nutrition was terrible. We had kids at home. Adam, my husband, was trying to manage the homeschooling and so trying to do that and then manage, you know, healthy eating at the same Time, it was just this. Plus, I have terrible running biomechanics from a knee injury. So it was just this perfect storm of disaster. And I had the same. I had niggling deep pain, but I couldn't actually access care either, because I would normally, with my role, I'd normally just walk into the radiology department and go, oh, look, I think I need an mri. Can you have a quick look? But doing that was really hard because elective radiology services were shut down. So even trying to diagnose my own stress fracture with me having a pretty good idea of what was going on, was really difficult at that particular time in Victoria with all the restrictions from. From COVID So it. And it took. I reckon it took six months to settle properly, you know, with a bit of help and blood tests and controlling my nutrition and making sure that everything was in my favor. Eventually it turned into a biomechanical problem, which, you know, I'm still addressing. But all the other factors, I don't think it would have happened without the stress of what was happening to us and our family at the time.

So you didn't get surgery yourself, you recovered. Is that same question you had?

Yeah, yeah, no, no, I had a. I had a sacral stress fracture, which Lisa touched on before. And the sacrum is a sort of big flat bone. A little bit. Look, it looks a little bit like a piece of whiting or a piece of flake. You know, it's just this big flat thing. So trying to fix it is actually impossible. And because it's so big and flat, they tend to heal. I just needed to stop doing what I was doing.

In hindsight, looking back, were you. Did you know, you said you had some warning signs. You probably would have gone and got a scan, but just because there's too much happening in life, you just kept pushing aside. I wonder what your mindset was when the red flags are showing up.

She knew, as do most triathletes with these sacral stresses. They're pretty sore and you know, something's going on, and you just desperately hope that it's not. And you push until you can't. And I think we just need to skip the desperately hope that it's not step where we can and deal with it. Because if we deal with it, if we rested appropriately, if we look for hormonal imbalances, if we fix the nutrition, this is thing will get better, and it will get better relatively quickly. We then reload it in a safe way and it's going to be fine. In the long term, you know, so I think it's that. Trying to avoid that. I'll be right. I'll be right. It's not really. I know, I know. I actually know deep down in my bones that this is not a bone problem, but I'm just going to ignore it and I'm going to be fine. Let's take that step away. Okay, let's go. You know what? I feel like this is probably a bone problem. I'm going to sort out what it is. Because the vast majority of stress fractures, if we get them early, are very, very easily treatable. They don't need to see surgeons, they don't need to go into boots for six weeks, they don't need to do anything different necessarily, except for pull back from the thing that's loading them incorrectly. Improve the nutrition, improve the hormonal environment, they will get better on their own.

That is such comforting news. And I think if that message would go out to more athletes, it would be so beneficial because that is the exact attitude that every runner suffers from. Because getting the stress fracture feels like it would be the end of the world. Because it feels like. Because there's no knowledge, once you diagnose or you're done, you know you're done for six months or 12 months. So you just hopelessly. Exactly what you're saying. You just hopelessly pray that it's not. Whereas if you knew that if you diagnose it early, then it's completely treatable. That is such comforting news. So I guess if you're having any of these symptoms, if you're getting some aching pain at night, anything you've spoken about so far is the first step. Go see a sports physician, go ask for a MRI X ray straight away. What's the first step that you want people to do?

Look, I think getting some attention, getting someone to examine the area first of all and see what they think is going on. Ordinarily, we do still use X rays pretty early on because if you can see it on an X ray, it's definitely there. But MRI is used for sacral stress fractures and for quite a number of them, it doesn't see every stress fracture. Interestingly, occasionally we still have to use a bone scan to see a stress fracture, but we try to avoid that in young people, just from a radiation perspective, because MRI doesn't have any radiation. And so I think get attention either from the gp, the physio, sports physician, someone that you've used before that you trust and get it investigated to the degree that you feel that it needs to be investigated. Sometimes it will be something that is so early that we virtually can't see it on scanning. And that's actually a good thing, like I said, because we can actually then make some changes and get you back on track pretty quickly. There are some stress fractures that even if we do catch them early, we do need to treat them very, very seriously. And that would include perhaps the naviculars or the base of the second metatarsal femoral neck stress fractures, you know, we're going to be a lot more cautious with those. And those ones you may still be looking at somewhere around that 12 week mark to get back. But if we don't catch it early, they can be the 6, 912 month is. So I think regardless of whether you've got a stress fracture that is a high risk stress fracture or whether you've got one that's going to heal quickly, the earlier we get it, the earlier we can actually make the changes that are needed to get you back on track.

That's a great summary. And look, it's so good that Amy, you can firsthand understand how easy it is for the everyday athlete. And with all the knowledge you have, you can still make mistakes. And so it's great for everybody out there listening that there are so many things you can do already that we've heard tonight about things you can do to prevent, such as the load, the nutrition. They're the really good key things. You know, sleep recovery, you know, not doing back to back hard, intense days. There's so many things you can do to prevent this from happening. Is there anything else you want to add to that in the prevention side of what we're talking about?

I think if you get a niggle, you need to stop running. I think cycling is something where the load can be spread a little bit more easily and you don't target a specific landing point and you're not, you don't have two feet in the air. Landing on one foot and swimming's obviously very, very non load bearing. But if you're worried you might have a stress fracture, if you are getting pain at night and if your heart rate's up in the morning and you're getting pain, stop running. But it's for me, looking back, it was a complete no brainer and if you can stop running, you might be able to avoid even the 612 weeks in a moon boot if you just back it off just for a couple of weeks. So stop doing high impact exercise and go back to something that doesn't involve having two feet in the air and landing on an outstretched leg.

What is going to be the point where you say that needs some surgery, some intervention. Where's that come in?

Yeah, I've got some slides if you'd like me to try and share them. I've got a couple that they're really good summaries of stress fractures and the different types of stress fractures that we were talking about. So I'll try and describe them for the people that are just on audio.

Yeah.

Having. Yeah, Yep. So this was a young kid, he's 18. He was joining the draft selection for AFL and he had niggling foot pain for six months. And because it was coming up to draft pick time, he basically ignored it and didn't want to admit that he had foot pain. And it had been going on for six months in both feet. And he went up for a mark, landed, vague story of someone maybe landing on his foot and he felt a crack in his foot and he was initially he was able to keep playing the game but he pulled up really, really sore and then he was unable to weight bear at all the next day on his left foot. So an X ray was shown and the navicular bone is a little boat shaped bone. I don't know if anyone out there has had an injury with their scaphoid, which is a little boat shaped bone in your wrist. If the scaphoid breaks and the blood supply is compromised, it doesn't heal. You can end up with collapse around the wrist. And the navicular bone in the foot has exactly the same problems. So the blood supply to the navicular bone is very tenuous and if it breaks then it can be hard for that blood supply to regenerate and the bone actually dies or the bone just. So this kid had navicular stress fracture which then on that one impact cracked and split apart completely and the bone itself split in the middle right where that blood supply was compromised. And with a little bit of, you know, experience, you can actually see that part of the navicular is very, very white, which suggests that the blood supply to that bone had been compromised for a while. So this is bad and because clear crack, isn't it? Well, it is on the CT scan and it's actually very subtle when you look at the X ray. The big blue arrow for the picture on the left helps, but I've seen this before so I knew the scans to order and you was looking for. But you know, sometimes these are missed as well, which can be A real disaster for patients, but at least he went from having niggling pain to a lot of pain and couldn't keep playing football. So when I saw him, he had this swollen, painful, bruised foot. I saw him about a week after that incident. But on further questioning, and Lisa's going to know where this is going, he also had right foot pain. And when we press that particular bone in his foot and if you, you have a look at your foot on the inside of the foot, just under your ankle bone, there's a little lump of bone there and that's your navicular and pressing that really hurt. So he got an MRI of his other side which showed a stress fracture of his right navicular as well. But that hadn't propagated through yet. So this poor kid had gone the exact same spot. Like exact same spot, same injury, same spot. Yeah. So this poor kid had gone from, you know, looking at going to the draft pick for AFL to having surgery on his left foot because the fracture was displaced. If you look at that X ray, there's two little screws through the navicular. And I took some bone graft from his heel bone and used that to pack where the bone wasn't particularly fantastic, where there was evidence that the blood supply to the bone had started to drop off. So his poor kid had spent on his right foot where the stress fracture was that hadn't propagated. He was in a cam boot and on his left foot he was completely non weight bearing for six weeks. So lots of jokes about his mates. He was rolling around in a wheelchair, he had a nearly scooter. And this is awful for these kids. It's bad for their mental health, it's bad for their development. You know this, he's gone from being really active to nothing. And look, he healed. He was weight bearing in the boot on the right side for six weeks. As I said, non weight bearing on the left side for six weeks. His left navicular united. That was the one we did the surgery on. And then six months later he started a very slow return to running program. And now he's getting a few little niggling injuries such as forefoot bursitis where you get pain underneath the ball of your foot just because he hasn't done anything at all for six months and now he's trying to recondition himself. So that could have all been avoided 12 months ago, you know, and I think that's a really good example of just how stress fractures and getting to me can be prevented.

Yeah, exactly what you say. The consequence of going undiagnosed and delaying.

And I think it's also important to remember that stress fractures early on, Most people will have experienced shin splints or something like that at some point in their lifetime. And stress fractures early on can feel a little bit like shin splints that they hurt. You start running, they feel a bit better, they warm up and then they ache again after you've finished and then they'll gradually progress to be affecting you through more and more of the run and not warming up as well. And then they'll start to give you the aching that lasts a bit longer afterwards. So they're definitely a big continuum of injuries. So initially perhaps, you know, say we've got a thousand spicules of bone in that little area, maybe you've damaged two of them and then once you've damaged four, the pain progresses a little bit more. And when you've damaged eight, the pain progresses a little bit more and by then a couple of them will have recovered. But there's now there's six that are actually damaged, you know, so it's just chasing its own tail and it's just like that, that idea of the snowball going down the hill getting bigger and bigger and bigger and bigger and bigger as it goes. And so if we actually just had flatten the hill out and stop them running for a little bit, it will actually catch up to itself. And perhaps this boy, if he had have known what was going on in his midfield foot and pulled back early, could have actually had a very, very different outcome.

Yeah, and interestingly, that talk about the shin splints is my next patient. So this was a 28 year old runner, little bit like me, stressed during COVID was drinking up to six coffees a day. She had a dairy allergy, so her calcium intake was really low. And she had an anterior leg pain in her initial X rays and was normal. And she had been diagnosed with shin splints, but when we did an mri, she had a stress fracture in her tibia and she had exactly as Lisa had described. So pain that was there when she started. She got going and the pain kind of became manageable and then it got worse at night, so she kept trying to run. And there are a lot of psychosocial issues for stress management and weight loss and trying to maintain, you know, what you think is a healthy body weight compounded with, you know, increased exercise. And again, that's another talk for an entire new, new podcast. But she just kept coming back and coming Back with this recurrent stress fracture, and she just kept running on it, which was really sad because it just took. I think it took about nine months for her to stop seeing me. I don't know if she's popped up with you again, Liz, but it took ages. And that was just because she just kept. She knew the diagnosis. She just couldn't stop herself from running on her foot.

Wow, that's. That's. That's almost hard to believe, isn't it? That you know the answers to the exam, but you still not willing to take it on board and not hard.

To believe at all. Very common, actually. Very, very common. And whether it's a denial or whether it's because the running is such an important part of the stress management, the psychosocial sort of stuff that's going on, or whether there's an element of an eating disorder driving the athleticism, or. Or it's not at all uncommon to find it very difficult for someone to stop.

There has to be a fair amount of pain tolerance there too, isn't there, that you're willing to. Because it would be painful to exercise.

This is also a very stable injury pattern. So this fracture, if you imagine your tibia, which is your lower leg bone, the long. The long bone just above your ankle, this fracture doesn't go through the whole bone. It's only a tiny bit at the back of the tibia. So because when you weight bear, you put a horizontal force through the tibia, it doesn't hurt as much as something like the navicular fracture that we saw before. The line of load on that navicular fracture is right through the load that you put through the foot. So every time you walk, that navicular is spreading apart a little bit more if it's broken, whereas this one, you're actually compressing the fracture. So even though it's painful and it's annoying, it still isn't as bad as an unstable injury, if that. If that makes sense.

Just to clarify, for anyone not looking at the screen and anyone that doesn't know anatomy at tibia, is the big shin bone correct?

That's right. And that's absolutely correct. Except if your stress fracture is at the front of your shin bone.

That's true.

In which case you're at risk of snapping your whole leg. So again, that's one of our high risk and very different stress fractures.

Yeah.

And you touched on the six coffees a day. We kind of brushed over that. But what kind of impact does that have? Is that a major factor? And what and how?

There's a little bit of limited evidence that caffeine can actually decrease your calcium absorption from your gut. So calcium, which is present in a lot of dairy food, green leafy vegetables and red meat, is very, very important for bone health. So your body will suck calcium from whatever source it can get if you're calcium deficient in any way whatsoever. So if you have a lot of caffeine, there is some limited evidence to suggest it stops you absorbing calcium from your gut, which can cause difficulty building up enough of the nutrients in your body to make your bones strong, essentially. And it's not 100% conclusive. And I know that there's a lot of caffeine use in endurance athletes in particular. So it's more if you're having chronic high dose caffeine like six very strong coffees a day, there is some evidence to suggest it's going to put you at risk of having problems with your bones.

So where do we want to go from here? Do we move on to rehab process and what that looks like, what people need to know. You take us through Amy.

Yeah. So the next step, once somebody has a stress fracture, it's been diagnosed, treated and they're healed is the return to onening program. And that's when the allied health physician, that's when the, you know, the allied health practitioners really come into it. And what I find really hard with my patients is patients always want a time frame, they want to know, right, am I going to be back in six weeks? Can I do this race in 12 weeks? And I don't know if you followed Lucy Charles Barclays videos. You know, she had a stress fracture of her neck of femur which was treated, it was on the compression side, Lisa. So they treated it conservatively but she was non weight bearing for a long time and was basically told your season's a write off and you're looking at, you know, a six to 12 month comeback. And she raced a lot earlier. She was back racing at about four months after her injury. And part of the reason that happened is because she hit her rehabilitation goals a lot earlier than what was expected. You know, I think going to the Red Bull facility and having access to everybody and not having to look after children or have a full time job might have had something to do with that. But when people make comebacks from injuries, from any injury, to be honest, not necessarily a stress fracture, they need to hit their hit rehabilitation goals. And one of the things is I work with the physiotherapists and podiatrists in my practice is getting somebody to do 20 single leg calf raises. So once someone is able to do 20 single leg calf raises on their previously injured limb, they're ready to start a return to run program. And that's basically our cutoff. Is that what you use, Lyse?

Yes and no. So one thing I would say say with regards to return to activity, particularly if we're talking lower limb stress fractures, is that you cannot underestimate the impact of the strength and conditioning component, not just the return to the chosen activity. So you can't just go and run to rehabilitate. You need to re pattern and strengthen the muscles that are going to support that bone or the associated joint as well. And so that may include intrinsic foot muscle strengthening. It certainly includes calf strengthening. There's so much evidence for so many injuries that strong calves make a big difference in preventing them, including metatarsal stress fractures, plantar fasciitis, all sorts of different things. Knee. Knee concerns.

Yeah. So are you saying the calf. The calf is impacting no matter where the stress factor is, from the hip down to the foot?

Yeah.

Yeah.

Cool.

Yeah, I am. And it's one of my new little thought processes that's, that's coming on board that, you know, even people with tendon problems around the hip, I suspect largely have a lot of calf deficiencies that are actually creating different loads up around the top of the hip as well. So I think that I agree with Amy on the time frame thing. I think that you can give somebody an estimate of how long you expect it to take for them to get better. But when I'm writing out a return to sport program, I don't put week one, week two, week three. I always put here's goal, level one or level one, level two, level three. And so they have to have ticked off level one before they do level two. And I don't care if that takes three weeks or if that takes three days, but you need to tick all of these levels off before you progress forward. And I think if you're going, and I just, I tell them deliberately, one of my lines is, do not write the finish of your rehab on your calendar because if you don't hit that mark, you feel like you failed, but you haven't failed. You're progressing and we can see the progression. So you need to go through the process and you need to trust the process. And in trusting the process and following the process, the likelihood of this thing happening again is actually much lower as well.

What markers are you using, Lisa? To allow the person to go from level one to level two. What are you looking for in their progression?

Yeah, it probably depends on the type of fracture. To a certain extent. You can't kind of give a blanket. This is how we're going to progress you. But essentially pain is our marker. So initially we will always allow a recovery period of time and that duration will possibly vary depending on what the injury is. That duration may involve some offloading or it might just say, look, you're not running for this period of time, but in your runners you can still do all of your normal walking and whatever. And then depending on the severity of the fracture and the location of the fracture, we will go through things like, okay, now you can introduce some range of motion work and you can introduce some starting your strengthening and you can do this much walking during this period of time. And then once you've knocked that goal off, you're walking distance. Distance can increase when you're walking has got to, you know, you can do 20, 25 minutes pain free. We're then going to start adding in some impact loading with some jogging, but we're still going to tail on and off with walking. And then we're gradually going to build in speed hills and things like uneven surfaces. But again, each plan for, I don't have, say, a photocopied sheet that I hand out to people. I'll generally make each plan for each person as I go, go. And you would never say to somebody, okay, on day 28, you can do a hill run at 80%. Okay, we're not going to introduce hills and speed at the same time. We're going to reload in a way that the muscle can adapt around the bone at the same time.

That's huge for someone to know. Even just that first point of don't set dates, set little goals and targets in the hundreds or, I don't know, maybe thousands of cases you've seen together. What other advice can you impart on people who are in this position? They've had surgery, they've got a bit of a road ahead of them. They might be feeling pretty defeated. They've already felt like a loss being taken away from their sport. What would you like to say to them? What kind of messages do you have? And I guess rules for them to think about to ensure they have as smooth a process back to their sport as possible.

Number one, I think, is to, to say when it's making you feel that way. Because if your treating practitioners know that, then that's something that they can directly help you with. But number two is don't let those fears stop you from seeking help. Because another thing that I do tell people all the time is my goal is to have you out on the park. I don't want you off, I want you out on the park. And so I'm going to give you a plan that gets you, you safely on the park as soon as I possibly can. I'm not here to hold you back unnecessarily. And so I think in general, you can trust your physiotherapist, your osteopath or your rehabilitation specialist, your sports physician, your surgeon that they, they're not trying to just stop you doing stuff for the sake of stopping you doing stuff. They're there to try to actively get you back to where you want to be. So avoiding seeing people is actually probably quite counterproductive.

What I learned from one of our physios who's now a physiotherapist for the sailing team, the Victorian sailing team, which is actually a really hard sport, I found out, I used to think it wasn't really, but they, they get some awful injuries. And what we've had with, with working with this, the sailors, is with this particular physiotherapist is you. When you go back and start running, you need 72 hours between runs to recover. So often people will think, oh, I just need a day off and then I'll go. It's actually 72 hours for your tissues to adapt and recover. And I think that's really important. So when people go back, they will often go back on a walk run program. But you need 72 hours between your walk run program before trying it again, just to allow your body to adapt when you're in that recovery phase. And it does mean you can't cycle and you can't swim in those, those other days. But I, I honestly, when I had my stress fracture, I thought, oh no, when I start running again, I'll just have a day off and then I'll go again and no, and then your timing of that. So if you run in the evening on one day, you give yourself a day and then you go the morning on the next day. That's actually very limited recovery. And so 72 hours is, you know, morning one day, three days later you try again. So I do think that's important for people coming back from any kind of injury.

Is that a risk that it's going to reoccur if you're not giving yourself enough space? Is that what you found yeah, that's.

The time it takes for your tissues to adapt to a new load. So that's the same for people in the gym, for example, doing bench presses and trying to build up, say, chest muscles. Or it's just that's what's been shown that you need to give the amount of time for that body to adapt to load before you start piling it on again.

What point is the 72 hours be allowed to come down to? 48 to 24. We're along that journey and I don't want you to say weeks, but, you know, is it just by feel?

And then that's pain. So there's a whole lot of return to running programs that are out there. And I think Lisa will know a little bit more about this than me, but we do sort of 30 seconds on, five minutes off, and then gradually increase that on that 10% per week. And then once somebody is running comfortably, say 20 minutes to half an hour and doing that 72 hours later without pain, that's when you can start to get back to 48 hours and then think about running daily and get back up to what your normal routine was last.

Couple of questions for this episode. Amy, I know you were keen for Lisa to touch on RED syndrome briefly. And just because that is specific to. That is something that's not limited to, I'm guessing. I don't know. But it's very specific to triathletes and that is about energy and calorie deficiency. Is that correct? Lisa, could you explain it for us?

Us? Yeah. So that's sort of what I was touching on before with regards to bone health risks, that if you do have inadequate calories for your requirements that your body will shift into this kind of self preservation state and you won't be able to turn over your bone as quickly and you will have more stress hormones and you will have less estrogen and you'll have less of the, the pro healing sort of substances running around your body. We call it RED s now or you know, the energy deficiency syndrome. We used to call it the female athlete triad. But again, back to what we said before, this doesn't just affect females, it's just that it's easier to monitor in females in some ways because we can monitor it by menstrual dysfunction as a little bit of a biomarker of when things are starting to go wrong. And look, ultimately it just means that we somehow need to get more food, more calories into these people. But it's a matter of working out how we can do that, how that can be a tolerable thing and how we can pattern it during the day. So it does tend to be something that is very much a multidisciplinary management task. So we'll use potentially psychologists if we need to. We'll use the dietitians, definitely. We'll use the sports physicians, we'll monitor with blood tests and all the rest of it as well. But it is something that can definitely be corrected. And when it is corrected, the difference to the athletes in terms of performance and injury risk, not just bone risk, but soft tissue risk as well, it's enormous. When you see someone come out the other end of having experienced that energy deficiency sort of process, they're a changed athlete. When everything comes back into balance, is.

It manifest in just general energy levels as well and psychological mood and the other.

Surprisingly, most of them still have normal energy levels and normal ability to train. I think it probably could manifest if we were say, looking at an Olympic Sport like a 400 meters or something, where we could have a very distinct and very specific time measure, then we'd probably be able to see that manifesting in changes in performance times. Triathlon, I don't know. I think our window's a little bit wider, you know, so some days you might just have a headwind and that makes you slower. So, you know, it's a bit harder to necessarily measure it as a performance deficit, but it will eventually it will manifest as performance deficits. Poor recovery, increased fatigue, poor quality sleep, the resting heart rate stuff that we talked about. And then it just all spirals into an over training type situation.

Unbelievable knowledge and advice from you both this entire episode. It's exactly the goal we wanted from this episode, was to give as much education as possible and pack as much into endurance athletes about potentially what to look for. It's really hard. And we spoke off air a little bit about how stress factors just seem to pop up and without any knowledge, they just seem to come out of nowhere. And we know that niggles are a sign and like you were saying, Amy, soreness at night. But it's just so common for every athlete to be experiencing all these things, be experiencing signs of overtraining and fatigue to always be on that edge. So all this knowledge helps so much. I'd really like to know from you both any final words you want to get out to the endurance world about stress fractures, about anything to do with what we touched on today, any messages you want them to hear or things to look out for that you'd like more People to be aware of.

My big one is trust us that seek help because the sooner we work out what's going on, the sooner we can get you better and to trust us that our goal is not to pull you out of, out of competition. Our goal is to have you in competition for as long and as. As frequently as we possibly can.

Yeah, I think when you look at races and you've been injured, don't look at your a race, don't look at it and go, oh God, I've paid my flights and I've paid my race fees and I'm going to do it anyway because that's when people end up with, with really bad complications and taking a long time. I think when you look at your race calendar and you're injured, don't try and set that time frame, Set goals for your recovery and then book your races once you recovered or have them in the back of your mind. But don't hang everything on doing a particular 70.3 or a particular sprint distance distance triathlon, because that is setting your body up for disaster as well as the mental side of not being able to reach that goal. So you do need to function on your rehabilitation goals and those little baby steps. And if that means you miss whatever race it will be on again next year or something else will. People get better and they get better a lot quicker if, if they do listen to people like Lisa and trust the physicians that are looking after them.

I think that's unbelievably great way to finish. And those two points, trusting the experts and they'll get you back quicker than you could ever have done if you don't listen to them. And concentrating on your rehab, far out. The best two pieces of advice we've heard for a long time. And so with that, without your expert knowledge, we would never have got to that point. And we, we all know that. We think. No, we think we know what's best for ourselves. But at the end of the day, we make so many mistakes. And as you pointed out, Amy, you're an expert in your area, yet you still ended up with the injury you're trying to prevent. And that's a great example of how easy it can happen.

You keep rubbing that in, Jared.

I know, but, you know, the more I've made, I've made more mistakes than anybody I think, on the planet. Everything that we've talked about in all our podcasts, I've actually done the wrong thing in those. And it's great for me now looking back saying, well, we can prevent these things if we just do the right thing and follow the processes that we should be doing and not try and rush ourselves back into it. Be aware of the warning signs, and these are the really key things we're trying to get across to everybody today in the podcast, is that, you know, the injuries are going to be there for a short period of time if you do the right thing. Basically, that's the summary. I think that we should get out to the people as a final sort of message. And we really want to thank you both for giving so much time tonight to this podcast. And there's a lot more questions that I've got, but we are running out of time and maybe we'll get you back on for another go at this. But yeah, really appreciative of your time and your expert advice. So thank you very much.

Thanks. Yeah, spot on. Yeah. Well, we'll finish the episode there. Again, thank. Big thanks to you both. I'm sure everyone got a lot out of it. I'm sure that we do get questions in and whenever we get experts on, we do often get questions that people would have liked to have heard. So we'll either get them to you and then get an answer from you or we'll get you back on the episode. But thanks very much again to you both for coming on to this episode.