#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 2-part training on bone stress injuries.

With Dr. Tyler Kemp. In part 1, 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 walked 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.

It's kind of fun to, as we 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 hurt his ACL. It was called The Return, where they were promoting 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 2 kind of distinct mindsets with it. Derrick 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 gonna get 'em back to running, back to their activity, what are the other things we're gonna do while we're stuck here to get them to the next level? So when we talk about the return, quote unquote, I wanna split it into 3 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 to 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 Harnett et al. It's honestly one of my favorites to reference. So this takes all of the information we talked about before and synthesizing it down to some hard 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 kind of, you know, some pretty quickly of Low-risk, low-grade is about 9 weeks. Low-risk, high-grade's 22 weeks. High-risk, low-grade is about 19 weeks. And then about the same for high-risk, high-grade. So if you know you have somebody coming in with a low-grade femoral shaft injury, you can confidently tell them, hey, this will take about 9 weeks to heal properly. And that's gonna be our kind of timeline going forward. So being practicing in Cincinnati, Everybody loves driving out to Hilton Head in the Carolinas. It's a beach town. It takes about 10 hours to get there. So the analogy I give to patients is how long is the drive to Hilton Head? And most will say 10, 11-ish hours depending on traffic. I'm like, yeah, is that, is there a way to make that drive shorter? And they're like, yeah, we could probably do 10-ish on the dot, 9-ish. Don't stop for the restroom, pack a lunch, drive a little fast, all that. Like, can you make that 6 hours? They're like, well, probably not. And I'm like, on the flip side, Is that, could that be longer? Could that be 12 hours, 14 hours? So like, oh, absolutely. So you have this loose range. And what I always tell patients is, this is kind of our timeframe. 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 explain that clearly. So again, the low-risk, low-grade is about 9 weeks. Low-risk, high-grade, about 22 weeks. High-risk, low-grade, 19, 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, their, their 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, 3 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 sport. So the active rest, finding something when they're in the acute 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 keep them a little sane. So if running is entirely out of the question, or if they have a high-grade injury, finding alternatives— swimming and biking are 2 great examples— just so that they can keep some cardiovascular endurance at that time. Phase 2, 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 3 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 4-minute mile. up a trail or something, they're going to have to drastically reduce their pace. And the other thing is it has to be pain-free. So if they have anything— 0 to 10 scale— if they have anything above a 0, 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 reinjuring 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 100%, 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 30 minutes at their stage, have them do a 5 to 10 minute walk on either end, bookend 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 symptoms, maybe I'll bail on this run. And then you can even play with some programming things of alternating days, having them walk 2 days, run another, walk 1 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, the 10% rule. So don't add more than 10% in 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 30 miles a week to 60 miles a week. And within that, you can play with 3 specific variables: frequency, duration, and intensity. So frequency, the number of times in a week or a set period that activity is performed. Duration, how long that occurred. And then the intensity, their, their pace, their RPE. If you want to play with something like that. So frequency, getting them from— if they're normally somebody who's 10 days a week, let's go for something like 5 or 6. And we can start them from 2 days a week and then getting up to 3 and then 4, 5, and then get them back to their normal training frequency in the week. So if it's 5, gradually get them back to 5. 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 8-minute mile versus a 6-minute mile, and that'll obviously change their mileage. So play with the duration and time, and then the intensity, getting them back to what their preferred pace is. So if they're training for a 7:15 mile pace, you might be starting somewhere high at 11-minute mile and then working your way down as the last variable. So the 3 things we play with are the frequency, the duration, And then the intensity. A little chart from British Journal of Sports Medicine just emphasizing the, 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 for strength training. 2 to 3 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 hip endurance because you get this runner 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 going to build muscle, but they can also build bone. They're, they're loading it up. It's going to 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 a weak glute, a weak 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 Or lifestyle things. So do the, do the basics very well. Sleep— are they getting 7, 8 hours a night of sleep? If they're, if they're getting 2 and a half, all the, 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 caloric intake— are they just, are they eating enough, or are they chronically undercalorie? Because them being undercalorie 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 U.S. military recruits going through basic training. Vitamin D and calcium have consistently been shown to help the recovery of BSIs, and this kind of makes sense. If someone had a muscle injury and you could increase their protein uptake 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, vitamin D, magnesium, a bunch of other things. If you can make that more available for that person, it's certainly not going to hurt them moving forward. And some ranges that have been thrown out are about 600 to 1,000 IUs, and then calcium about 200 milligrams a day. So, and also, I'm not really a proponent of supplements, but you can generally get it relatively cheap. Walmart, Kroger, stuff like that. Easy way to add that into their their diet as they're, they're bouncing back from this injury.

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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 was high grade in a high-risk area, we ended up having to shut him down for the The 20-some weeks. And then at that point, we got him back to a little bit of biking and swimming. We did that for about 6 weeks. And then at that point, we added in some strength conditioning stuff, and 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 the fighting.

We want—

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&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 and 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 a reinjury.

And 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 won't listen to you at all. But that's one of the— 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— you're checking all the boxes for what's going on. I really like being able to show the MRI report of, you have a, you have a fracture, you have an active fracture, or the The beginning stages of a fracture in your leg. If I broke my arm, I wouldn't continue to, 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, we're only gonna 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, you can't run. I really try to avoid that, but I'll just say we're gonna modify your training for out and give them a clear narrative about what their path's gonna look like. Hey, Mr. 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 two-ish. 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 5 weeks out and I had cut him loose and said, hey, you're pain-free, 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 2. And we're gonna, we're gonna have to wait about 6 weeks minimum for any activity before you go into that. And then another detail with that specific patient was he got briefly into bodybuilding at 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 15 pounds of muscle and then pounding 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, 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 caloric demands. You'll hear about the, the female athlete triangle where they might be having some dysmenorrhea and just not eating enough calories. So it's the multi-sport athlete and the person that is just not eating enough that I see those kind of indicators. So that's something you want to have that, 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 cal— as many calories and nutrients available to their bodies as it's healing. You don't want to be trying to shortchange 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, on a modality side, like I have not seen anything on the, from a 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'd have to discourage patients from using that just because if, if the timeline for them is 9 weeks and the— if they have the shockwave and it's 9 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 Normatec 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 docs that they're encountering more and more young athletes, your youth that are ages between even as young as 8 into high school that tend to have these overuse 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 are kind of the decision makers guiding these young athletes?

Yeah. So biggest thing is, it sounds cliché, but having good communication, especially with the coaches. I'm a 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 athlete. And if they perform better or get better quicker, We all win, so that's helped. 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 were really concerned. It was a high-grade femoral stress injury that it was going to be a possible displacement case, and it worked out because the 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 orth were on the same page because. good way that ortho 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 ortho 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, for them to see it, and I think there's a lot more like credibility with the orthopedic telling you, but it's always, it's really convincing when you have 2 providers, especially like a surgeon telling you the same thing and being on the same page, or even sending— it's silly and old school, but even sending a fax 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. And that, 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 providers as 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 types of injuries with ball sport athletes.

Yeah, that's a really fantastic question. It's a lot, it's a little different because the cross-country athlete, they're running up to 12 miles or whatever. They're doing a much further 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 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 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 bit.

Yeah. And it's specific to the sport, but yeah, we 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, 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, no, that's a great question. What I've done is that protocol of the, the 200 milligrams of calcium and then 600 minimum for the IUs of 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 2 specifically. The, that's a great option. And then just from the nutrition standpoint, I think the criteria is now 1 gram of protein per day for preferred body weight. So if their preferred body weight is 200 pounds, that they're at least getting 200 grams of protein in their day. And especially with a runner, they're, they're using so much muscle tissue, things like that, that helps with the recovery process. And then also protein is used in some small ways with bone reconstruction as your body's repairing. So those 3 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 bracing do you recommend?

Generally, I'll just have them get crutches or something like that from Walmart, CVS, 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, am I 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 biking's out of the question, we can't do any swimming, things like that. If they have access at their local gym or even their Y, like something like a hand bike 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't do anything lower limb for 6 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 heal that's in their lower lip.

Again, Dr. Kemp, 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 68, where we dive into a brand new training in the world of cutting-edge treatment tech with shockwave therapy for post-surgical care with Dr. David Rednick. This is one you won't wanna miss, especially if you've been considering adding a shockwave device to your clinical toolkit. Episode 69 drops in 2 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 signup link in our show notes to receive our weekly Factor 5 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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