Overcoming and Preventing Bone Stress Injuries with Tyler Kemp DC

injuries , and then , of course , how do we prevent these bone stress injuries from happening and really , how do we prevent the recurrence of bone stress injuries , because that is a hugely important topic and some of that really occurs very frequently .

And we'll actually dive into a case study , which is myself , from back in the day when I got a bone stress injury and then I had a recurrent bone stress injury . So , tyler , tell us a little bit more about yourself .

I know we went to school at Logan around the same time and you were one of the about leaders are like kind of club presidents and one of the clubs too . So give us a little bit of a rundown . I know you used to run as well , right ?

I went to a PT initially didn't really help and then ironically we went to a sports chiropractor just on a whim and took a very active approach of like , hey , you don't need surgery , like we can manage this and get you back , and I just thought that was really neat . So that inspired and interested me to pursue that . Personally .

I did go to Logan in St Louis , missouri . I'm currently in an office in a little north of Cincinnati , but my I also had a previous experience at a similar office that was very , very sports medicine based . Got to do some preceptorships there . So that kind of drew my interest with this topic .

Our office had a really good relationship with most of the high school teams and it just felt like we were , you know , diagnosing one or sending an MRI out every single day , and it just got into a point of you know what are we just attracting this ? Is there something missing ?

How do we get better with one catching these and then two , how do we get better with managing them ? So it was , it was born out of this . If I'm going to see a lot of these or say I , you know , quote unquote in the sports chiropractor or treat athletes like I want to actually be able to do it and do it well .

So for me , when I was in you know , running , you know in high school and college , the biggest thing that people feared was a stressy , you know , a stress fracture right , and stress injury is kind of this umbrella term that encompasses basically this broad range of bone injury , correct ?

So it operates on this little spectrum . So on the lower end you have the stress reaction , in the middle you have the stress fracture and then the floor end , which hopefully we don't really ever get , there is actually a complete fracture . So the stress reaction is the train's turn to leave the station . You're starting to have decrease in quality of your bone .

You might even have a thing called a periosteal reaction , which is where that little connective tissue layer around the bone actually gets pissed off . That's the inflammation , that's where it gets kind of sore or tender . The stress fracture is actually where you have some kind of break in cortex . There's actually a crack in the bone .

I want you to think of it starting to crack into it like a piece of chalk , not like a twig that got snapped in half kind of thing . And obviously complete fracture is just something we don't want to avoid entirely . So that's kind of the framework we want to operate in .

So we'll be able to focus more on some of the higher level things today and we'll touch on some of the pathophysiology and stuff like that . But if you're listening to this and you're having trouble keeping up with some of the physiology terms and things like that , then you can go over to that solo episode and you can give that a listen as well .

So we won the freshman division and then a couple of weeks later , just starting to get some pain at the top of my tibia and trying to run through it for a little bit , being really afraid to tell my coach about it , and then having that just progressed to pain with walking pain at rest , and then we couldn't really figure out what it was .

And then weeks later we got an x-ray of my tibia and we saw actually some of that bone remodeling starting to occur and some of that calcium deposition where I had a stress fracture that was healing .

And then I got into track season and I was having a pretty good track season , actually went sub five minutes in the mile , which I was really proud of at that time . And then , like two weeks later , I got to , you know , started having that same like achy pain in my tibia .

Most of the injuries , most stress fractured VSI's occur in the lower extremity and most commonly in runner , desiccant or another sports , hockey , things like that . But we'll use runners are the majority , so we'll use that as the stereotype . But for you , the thing we saw pretty frequently was the rhythm kind of got lost .

We have a kid that does , you know , cross country in the fall , maybe they do winter track or basketball and then they do track in the spring .

They have some steady amount of load throughout their year and then with the pandemic you have you know February , march , basically everything being shut down and then , depending on where you're at in the country , in the fall , sports kind of came back in some modified way for , at least locally , a lot of coaches .

What they ended up doing was they had a , they were trying to manage everything online of just emailing kids there . You know , hey , you know , do X amount of mileage per week , things like that . Well , a lot of kids might not have actually been doing it . You know , sure , coach , I'm hitting 40 miles a week when they're really doing 15 to 20 .

So then when things got back in an organized way , coach says hey , we're going to bump it up to 50 a week , we're going to really push it . 40 to 50 is , you know , one jump , but you know 15 to 50 is a significantly bigger jump . So you're having all these kids going through a huge change in load and then it's just this ugly buildup .

The other thing is and you kind of experienced it yourself is there's a huge lag time between when there's a change in load and then when we're actually going to experience symptoms . So , like , generally it's three to four weeks , it peaks out of five to eight weeks . So we see this .

There's a lot of data the military does because people will join basic training and then a couple of weeks into a month in , they're starting to have these injuries , just because some people might not be well trained . And then they go into basic training which is moderately intense , and that's why you have this . It seems like the most common monthly .

This is just observational data , like September or October is when people really notice it , because you might start training a little harder end of July , early August , couple of weeks in . You're going to notice it a little after Labor Day weekend and then you're kind of pinched because late September , early October , it's okay , I'm dealing with this injury .

Do I just kind of suck it up till states or whatever instead of trying to arrest it and things like that ? And this is this is a common injury and there's a lot of issues with it .

There was one bit of data where it was a data 2014 , where they did like a epidemiology of all stress fractures in high school athletes and 65% of them that had a stress fracture either resulted in medical disqualification and of their season , like they were just done , or they had three weeks or more of time loss .

So the obviously prevention is one goal , but the sooner we catch it , the sooner you have a shot at potentially getting this kid back .

So I was just like training until I couldn't train anymore and then it like really kind of like set off and then in the interim I was really cross training really hard and keeping my engine really fit , which some people are saying it might actually be better to just decrease some of that overall load .

So you , you didn't get a chance to really rest your body from like a metabolic position . You were trying to repair that initial injury and you just didn't have it , didn't have it in you to actually be able to fully recover and that's why you developed the second one .

intense mileage , all the things that are natural and normally associated with training and then these osteoclastic cells come in and they try and debris this micro damage tissue and once they do that , then these next set of cells called the osteoblast can come in and they can relay down these hydroxyapatite crystals for building up and adapting to that stressor .

But there's that lag in between and some things that can really increase that gap include things like energy deficiency , and energy deficiency has two different components One is your energy intake and then the other one is your energy output or what you're doing physically .

So for me I got that stress fracture and then I didn't allow myself to heal as much because I was still like really doing a bunch of energy output in the training room on the bike , where it might have been better for me to just take a week or two of just complete rest right .

You know you tore your hamstring and your black and blue all over or something that are you your meniscus or your sprained ankle , and it's your swollen , all that , like it , just this really intense initially , some achy pain . So you're just thinking , okay , I'm going to run through this quote unquote .

It's diffuse , it's it might hurt while you're running and might and might not it might start to linger after . It's this very slow build . So it's kind of not easy , but it's easy to brush off of . Okay , maybe , maybe I just need to suck it up for a few weeks , maybe I just need to ice it , whatever things like that .

And it's really easy to walk by , like if you're an athlete and you're either hiding it or you don't want to be a quote unquote was . Or you know , if you have a old school coach who just kind of , like , you know , suck it up , buttercup .

And then also just the things of their training style of you know , if they're a high mileage runner and they didn't really recover well from the first one , it's going to just set them up for success , or rather failure . And then other things like just the habits of like sleep and nutrition .

Like , if they're not , if they weren't doing that the first time , they're just going to keep on burning the candle at both ends .

But when we D load one side , we can't forget we're also D loading the other side . We're not giving that side the adequate stimulus necessary to adapt . So now when you return to running , you might have still like a really good , powerful aerobic engine , but now the entire chassis has become a little bit weakened .

So high risk means it has a doesn't generally doesn't have a great blood supply . It has a higher rate of progression , meaning the injury will go from , you know , a grade one to a grade two to a grade three and then finally a higher likelihood of needing old surgery . So that's the type we want to avoid . So these are all tagged by anatomy .

So generally it's the anterior tibia , your shin bone , your femoral neck , your femur , the ball and socket joint for lack of a better term and then the , the sesamoid bone , and then lower risk is more metatarsal , your fibula , posterior medial tip .

So you have these two regions and then so the high risk versus low risk , and then there's the grading of how , how severe it is . So the way you get the grading is through imaging . So there used to be this thing of and it's still really common now of the . The grading scale will guide your treatment . So initially everybody would use to get an x-ray .

Generally we won't see a cortical change till grade three or four , so you might be a grade one or two . You go to your PCP , go to chiropractor whatever clinician . They take a picture , they say , hey , things are looking good , we can cross this off the list . It hasn't gotten bad enough to show up . So you've crossed something off the list .

That's still very apparent and you're continuing to run . That's a huge problem . So from a parent , athlete coach perspective , if you really want to rule this out or diagnose it , mri is the gold standard . One , it's going to , it's going to tell you a ton more information and then two , it's going to give you what the grade is .

The grade is really , really important . So ARNET at all has a nice framework and it compares low risk and high risk and then low grade , high grade , and that gives you kind of a rough timeline for it . So , for example , like a low risk high grade is about nine weeks of recovery versus a high risk high grade is more like 19 weeks .

So it's this huge spectrum , so it's not perfect . Everybody's different , but now it starts to give you a little bit of a framework of how long something's going to take to actually get better . And then it also puts a limit on the parent athlete coach of how long is it going to take , because they're the intuitive desires to rush things .

So when it gets sprains or ankle and it says hey , it's going to be six to eight weeks , they're going to say I'm going to try to do it in five . They're going to try to push that limit . Instead , you're just saying look , biology is going to drive the bus . This is how long it takes to heal , and if we don't let it heal , right , you're going to .

This is going to become a frequent flyer issue .

This is a metabolically active tissue but that doesn't mean that it's a metabolically super quick tissue . We all understand , like , if you have a really a true fracture of a bone , you're going to be in a cast for six to eight weeks , depending on the site of that bone and the extent of that injury .

And with this stress fracture , it's that thing where you might be able to walk without pain . You might not even be able to see it on the X-ray . Actually , usually you don't see it on the X-ray which we talked about and say you know , if you don't see it on the X-ray , that means absolutely nothing .

Like you likely still have a low grade bone stress injury Just hasn't healed yet . I guess just directing , I don't think that's a giga bet . Oh , go ahead , good .

So one thing that they said on this podcast that I really like as a framework of thinking is there's not much we can do to speed up this process , but there is a lot that we can do to slow it down .

Yes , and those things include getting back to running or back to activities too quickly , having poor sleep , having poor nutrition , which oftentimes when you are injured , that's when the ice cream comes out quite a bit , and all these things , which is totally fine for a short period of time , but you need to make sure that you're resolving any energy deficits that

you once had .

So if you're someone who is a candidate or is at high risk for relative energy deficiency in sport red S then you really need to talk to your nutritionist or your sports counselor , et cetera , about getting more nutrition in so that then you can adequately supply your body with not only the calcium but the energy that it needs in order to recover and heal that

bone tissue .

Deep hip pain just in the crease of his pants can't single weight bear . Just walking around the houses and feel good , all these things . Saw him order them around . The first visit he had a grade three at his femoral neck , so he's already the highest risk .

So we immediately just had the conversation of more or less hey , unfortunately your season's over With a grade three . You're looking at about 15 weeks for this thing to really heal . So it was the conversation turned into look cross country's over , I'm so sorry .

What can we do to set you up for success so that when you go to the track in the spring you can actually do it and then we can minimize the odds of you actually having recurrent ? So for him it was 15 weeks , so that's about four-ish months . So he was somebody we didn't really see every week kind of thing because we're just letting it heal .

But for him it was this on ramp of how do we get you back to activity . So we generally use pain as your guide for that . So it's hard for him to walk up the stairs in his socks . At home we're not going to have him run . So we basically waited till he was pain-free with just ambulatory activity and then he had access to the Y .

So the first thing we got him into was it was just giving him the choice between swimming and biking . So he got into swimming 30 minutes twice a week . We started bumping that up to four times a week . We transitioned that to biking after a few weeks and then , when we got to running , our first hurdle was just can you do sustained walking ?

Our goal was to get him to 30 minutes walking pain-free . He had a few times where after the walk he would get pain in his hip for about a day and a half . That told us right there . That was too much .

So when you're returning an athlete to running , it needs to be boring and it needs to be pain-free Either boring in terms of just the intensity and things like that . If we're starting to get the pain kicking out , that tells us it's too much for the tissue . We're spending too much of that money .

you have any pain afterwards , within the first couple of hours , or do you have any pain the next morning ? And that's actually one of the questions that we got through social media was how do you determine if your rehab is the right amount of painful versus too much , too soon ?

And it seems like , even though pain we don't need to make this into a pain science discussion or anything like that . Unfortunately , pain is one of our best markers of if you're healing appropriately . And even if you have a bone stress injury that is unhealthy enough that we need to take action about it .

Because if we just took every single runner and then got MRIs of their tibias , we would see bone stress injuries and bone stress reactions . But many of these individuals be completely non-painful and for them they could still have a very successful season and they may never even feel any symptoms associated with what we see on the image .

So the image versus the perception of pain , these are two different entities and unfortunately , it seems like our marker for getting better is more looking at that perception of pain as our guide to increase loading . Starting out , I think , like you said , super duper boring , even with a 30 minute walk , and then seeing how it goes from there

, and then you like the alternating run walk program too , right .

So then of those 30 minutes you have a 20 minute run and a 10 minute walking period . So you've already even more or less got 20 minutes of running . If 20 minutes of running feels all right , then you can start actually beginning to build up from there . If not , that's kind of your check at the point . It's a lot of .

The analogy I give with a lot of patience is like if you're getting off on an exit that's five miles away , if you had to choose between getting in the exit lane the far right lane 20 minutes away or wait till the last second , you'd choose option A just because you're basically guaranteed to get over , versus trying to cut over .

It doesn't hurt us to build a longer ramp to return to sport . It's easier to walk in the shallow end and keep going than drop them in the deep end .

You're just not pounding the pavement , and that's we know . Low resistance training can be healthy for bones and help its overall resilience . Doing that in addition to your running is going to be incredibly helpful and also just a stronger athlete , it's not going to be a bad thing either .

Yeah and we'll Additionally in terms of preventative stuff , just kind of looking into if you're an athlete , like knowing you're going into a higher loading period . The military's played with us a little bit just because of the stress , injuries and bootcamp .

They've actually done a few studies where they do supplement calcium and vitamin D during and that's been shown to reduce injuries a little bit . So like the range they did was like 200 milligrams of calcium and then like 800 to 1,000 international units of vitamin D .

If you're at a higher risk of it and you're trying to do all the things , that's an easy , relatively cheap thing to do in addition to your overall management , because the two things your bone needs is calcium and vitamin D . Why don't you just supplement with that ? No different than you know , you're a strength-based athlete . It's going to be a pounding protein .

If one keep your macros right the two that's an easy thing you could do .

This also goes along with that , you know , disordered eating or relative energy deficiency as well . We need to have all of our macros in check , including protein , which is really something that a lot of runners , you know , kind of shy away from . But I mean , this is a .

This sport is something , is a sport that really tears up muscles quite a bit and it takes a lot from our bodies . So we have to make sure that . You know , even our running athletes are getting between 1.5 and like 2.0 grams per kilogram of body weight per day in protein every day .

So a lot of people blame like teenagers on to be to saying that they're like lazy and they just don't want to go to sleep and they just want to stay up and watch TV . But there are like chronotypical alterations that push that time period when they're able to fall asleep back multiple hours .

And I just got done reading why we Sleep by Matt Walker and he really goes into that quite a bit . So recognize getting sleep is an uphill battle but it's a necessary battle to have . Sorry , I interrupted you there . What were you going to say ?

I just want to emphasize , like once obviously you know the name of the podcast is Art of Prevention but like once in terms of managing , especially if you're a provider clinician , once somebody has this injury it is on you to make sure it gets managed all the way through . If they crack that thing and they need surgery , you know , get them to the ortho .

But if something's going to take , you know , say it's going to be 16 weeks to heal . That's not . They need to be constantly monitored . Like I can think of an athlete like the third one . I diagnosed , the basically told them the diagnosis told them to rest and get off of it . And then I saw him in the springtime .

The injury was hadn't come back but it was showing signs that it came back and we were able to like , re , re , manage his load and things like that . But I was just thinking like not to be harsh , but we don't trust a 16 year old kid to drive a car , but we're going to trust him to manage his own .

They manage this kind of injury on his own with a high risk of recurrence . Like this is somebody that you could easily , you know , communicate with the parent , with the coach , with the athlete depending on you know , age and their specifics . Of just checking in every few weeks of , hey , how was the two minutes on , one minute and off going ?

How has that been ? Like you don't need them to be in your office necessarily . This is where , like telehealth , can be really easy , but just doing that gradual check in to make sure this thing is continuing to heal and respond well , so that when you get to that endpoint , you get to just they get to go back to training in a safe , healthy , manner .

And even if just having them check in via email , if you're a clinician , like you're going to have to be the one sending the email , like I've made the mistake of telling people to check in with me over email and then you know I'd say 90% of the time they don't , you know , and then that last 10% is the person that you really didn't want to hear from that

much . So if it's a at risk population and at risk athlete that you need to monitor , like you need to send that email , you need to call the parent , you need to call the coach and check in with them and you need to really do a good job of monitoring and not to be like a fear monger or anything like that .

But especially with these high risk things like femoral neck and a navicular is one that we might talk about a little bit later , because that's one that there are a couple of case studies now that are that we're seeing that are showing that navicular stress fractures may be associated with these super shoes and like carbon fiber plates and things like that .

But what's the worst thing that can happen if we don't manage these bone stress injuries appropriately ?

mean worst is complete fracture . So the the ugliest one is the , the femoral neck of his athlete . I mentioned he had the compressive . So I'm like , hey , you have the worst type of injury to get , but you have the set , the better of the two . But he , he was at relatively high risk for fracture .

And to not to be a jerk but to kind of drive a point home , I asked you know his parents were in their own , like do you guys have a pair of crutches at home ? They said yes , I'm like get when he gets home , put him on a pair of crutches . Like he's going to be non weight bearing for two weeks .

And that was to drive the point home because they we went through the MRI together . You could see just this huge white area where the fracture was . And they're asking they're like so he can't run this week or he can't like it just doesn't . You need to use that .

Use the other F word like make it clear , like this is a type of fracture and like you are not going to be competing . Kind of tying into the , the fear mongering , like if you work with coaches , just like let them know , like the basic signs of symptoms .

Or like the athletic trainers , like I think they're back in the day was the , you know , again the suck it up buttercup . But like we were fortunate enough to have a relationship with one coach , like his audit was he's like , look , you know , a 15 year old high school athlete shouldn't be limping around after practice like something's up .

So like that's , that was his cue to just talk to the parents , talk to that center of the athletic trainer of hey , something's up with with Sarah or Sam or whoever , and get the process started . The other thing we kind of talked about this in pre chat is like some there's one or two things where they kind of like mimic each other .

So like shin splints or medial tibial stress syndrome and like an anterior tibia stress fracture can start off looking really similar . And you know you you don't want to over call or freak the person out if it ends up being nothing . But the big delineators is in terms of the , the stress fracture , it's more going to be pinpoint tenor less .

I call it the pink test , like they can touch it with just one spot versus medial uh , empty SS is more of a broad like up to you know , a third or more of the anterior shin where , like they can actually it's almost like they're going to take their whole hand and cover it . The other thing is um the the hop test is really useful .

Just have them single leg weight bear and hop on that side . If they have point tenderness and they have um the um pain with the hop , it needs to be on your radar . If they have no point tenderness and no pain with hop , the sensitivity on that combination is almost a hundred percent . Like that's .

That can allow you to be pretty confident of hey , you know , it's more more shin splints than than a BSI .

So we need to check in with sleep , we need to check in with nutrition , we need to check in with load management and this is not the time to really like ramp things up in a crazy fashion or , you know , if you see , like , oh , a lot of people are hopping to prevent bone stress injuries , now that I've got this , you know egg , now I should do hopping or

something like that . It's like that's when we really need to be careful and kind of treat it like a yellow light where we kind of slow down a little bit and evaluate everything that's going on . We see , why is this , you know , shin splint manifest manifestation of the medial tibial stress syndrome there , right , yeah , 100% .

And you have to be the jerk of saying , hey , this is likely going to get worse if you continue to do this , especially if it's the alternating track , cross country . Just being able to say , hey , how do you want next season to look ?

And getting it off , for , hey , we can make this worse and add to your on ramp or we can wrap this up now it's going to stink . I'm so sorry , this is not how either of us wanted it to go , but we can do a lot of stuff to prevent or minimize and make sure your next season is better and you don't have to be dealing with this .

Now , when is an appropriate time to include strength training ? Because right now it's like we're in December , but if you're our coach and you're listening to this in the middle of the season , you might think , oh well , gosh , we need to start doing some strength training right now .

But when you're already at a high baseline load or you're starting to mix volume and intensity in the middle of the season , these are time periods where it's like we need to really check ourselves as far as adding new interventions or adding new types of load .

So can you tell us a little bit about resistance training and maybe even some pliometric training that everybody could do to ensure that they get adequate bone mineral density ?

So pliometrics it can be just basic hopping drills . Our team always took advantage of having an open field or a track of doing hopping drills or alternating broad jumps or things like that , just to warm up that kind of impact . And then again , just a good minimum threshold is like two days a week of some kind of strength training .

It can all be body weight of just lunges and kind of like deadlifting . There's all kinds of creative team workouts you can do where you're holding somebody else or lifting somebody else as part of the resistance , carrying someone on your back , things like that .

I think we've all had to do that In terms of the return after someone sustained this injury and they're wanting to get back to it . The criteria this is just my opinion . The criteria I've tried to use is if they can run for 30 minutes comfortably ,

that would be a safe time for them to do strength training . Again , if each step . Walking around at home and there are flip flops is uncomfortable . You don't want to load that , so time it with . They're in the relatively comfortable phase and you're starting to build up more .

You could even choose to increase their strength training because you're still pushing the bone and the limits of the bones is as healed . Before you go into , before you go into increased volume or mileage with the running .

The big hype was on ground reaction forces , but we know that we only have a limited data from things like force plates and ground reaction forces , because actually a lot of the load , the tensile loading that really affects the bone , actually comes from the musculature itself .

Right , so we need to train not only looking at ground reaction force the amount of force that's just hitting into the ground with each foot strike but we also need to do things that are going to challenge the intrinsic muscle force as well . Correct ?

So this can go into different topic , different time of like what are the other injuries you're trying to prevent ? Like the stress fracture is an ugly one , but like what are other common tenonitis , tenonopathy , things like that with runners ? A lot of it just comes down to like load management .

Strength training and resistance training covers all of these .

And then if we look at the athlete not only as that four year high school runner , but if we look at them as a human being with an entire lifespan , we know that peak bone mineralization occurs in , you know , the teens and twenties , or not peak bone mineralization , but our peak ability to deposit mineralization in bone , our peak ability to really densify those

bones for the entire lifespan , occurs from basically adolescence and then into the early twenties . So if you're a running coach like , it's easy to think about this individual as a runner that's going to , you know , be in your hands from freshman year to senior year and then they're off onto college or whatever .

But really I would encourage coaches to think of these as human beings that we're trying to create health and a good health span throughout their entire lives , and a lot of that has to do with bone health .

But all these things that you do in the early stages of your life , you know just any kind of physical activity like how many Americans aren't hitting the minimal physical activity guidelines the things you do in your younger years , you know , whether you're athlete , recreational athlete , whatever , set you up , whether you like it or not , for the rest of your life .

So you doing stuff to increase your , your muscle mass , your ability to increase your bone density you are putting . The example I always say with patients is you are putting money in the bone bank that you're going to be able to spend later . Okay , are you having ?

I think we've all seen like the MRI of you know , the average eight-year-old guy and then some eight-year-old Traffly like you . Just see it as a huge difference in that cross-section of tissue .

Who's the person who's gonna have a higher quality of life , who's going to be able to play around with their grandkids , who's gonna be able to live unassisted , unaided , for a longer period of time and just All quality effect you know , just being able to . So , yeah , I appreciate what you're saying about .

Like you know , thinking about these Athletes is just human beings . Like we need to think about people in the near term . It works like what you do now is gonna affect the the later stage of your life . No , he , nobody looks forward to Breaking a hip or being risk of a hip fracture .

You know , if you break a hip , the odds of you being dead in two years is significant . So you can minimize that now and just the the quality of life being able to be an active older adult , it's huge , you know , in terms of one , care for yourself , affinbite valuable and a few patients that older .

I have a few older female patients in their 70s and their runners . They go to the gym frequently and when I'm seeing them , the ace in pains they're talking about is , you know , being sore from a 12 mile run with their brand Versus . I have other patients who , even in their 50s , talking about walking through the grocery store and having . You know , you know .

You know peripheral mypropaneropathy , cautication . You know having problems just like getting out of the waiting air and coming to the office and you're thinking you know the next for these two . You know the two different people I mentioned . The trajectory over the next , you know , five to 20 years , is drastically different in terms of quality of life .

Their health care costs , what this is really off track and it's not related directly to the , the BSI , but just overall . You know , just hitting physical activity guidelines and being able to have that conversation with your patients is huge .

You know , running is a lot of the same load in a unidirectional fashion , so it's a lot of the exact same load over and over and over again , and after about 10 to 20 minutes we stopped stimulating bone cells to turn over and we basically Sees stimulus for those bone cells to adapt , adapt .

However , we are still Exposing that bone to micro strain and micro damage . So if you're doing , you know , a 20 mile run , you know the first two or three miles is when you're really stimulating those osteoblastic cells and all of your bone cells to turn over and adapt .

The remainder of that run you're causing strain and micro damage , but you're not necessarily still getting that same amount of stimulus .

And that's why strength training is so important , because strength training and even short amounts of hopping , like 30 to 60 repetitions of hopping , can be really beneficial and can create a lot of stimulus for bone to adapt , even more so than running .

If you have a kid that does track and does basketball , like they're going to be moving in a multi directional fashion a lot more basketball than with running and that is going to be that's going to stimulate the bone in a lot of ways .

All right , so , tyler , I always like to finish off these episodes talking about Benjamin Franklin and the Philadelphia Fire Department . So you're from Philadelphia , right ?

If we could sum up this entire , you know about an hour long conversation and give somebody a little tidbit , a little golden nugget , if you

will , about preventing bone stress injuries , what would you say ? Yeah , it would be three things . One manage the initial load , be smart with it .

And then just finally , managing your nutrition . Well , like that , nutrition and sleep , really just making sure your body has a chance to recover you . Those are the pieces that will set you off for success and that will help you reduce your odds or , dare I say , even prevent Nutrition , sleep and load management . I love it . Well , take it easy .