WEBVTT
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Hi guys, Welcome to another episode
of The Factor podcast. I'm your host,
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Jessica Riddle. If this is your
first time tuning in, welcome and
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thank you for listening. Today we
kick off a new two part training titled
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bone Stress Injuries, The Good,
the Bad, and the Ugly with doctor
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Tyler Kemp. Now, I don't
know about you, but when I hear
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the phrase bone stress injuries, there
is absolutely nothing good that comes to mind.
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In fact, it serves as just
another reminder for me why I am
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not a long distance runner. If
you put me on a peloton bike,
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I can ride for fifty miles no
problem. But if you see me running
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outdoors with any kind of speed,
it's probably because something is chasing me.
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And I can't imagine that I'm different
from a lot lot of your patients who
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are active recreational athletes. I regularly
work out five to six times each week,
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but inevitably there are times that I
push too hard for too long,
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or I'd use bad form and end
up with a nagging injury. Stress fractures
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are actually quite common, but did
you know that there are different subtypes of
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fractures that can vary depending upon the
mechanism of injury and the location. Did
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you know that females are more likely
than males to suffer from bone stress injuries.
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We will cover these topics and a
lot more on this episode in the
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next, including the different types of
stress fractures, the importance of imaging for
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accurate diagnosis, and a grading scale
that you can use for neck injuries.
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Our guest instructor for this training is
doctor Tyler Kemp. Doctor Kemp is a
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chiropractor practicing outside of Cincinnati, Ohio. He has a passion for working with
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athletes and clinical interests in treating tenanopathies
and bone stress injuries. He utilizes joint
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mans, manipulation, rehab, and
acupuncture in his patient care. And while
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his daily practice involves treating a diverse
range of patients, the office is focused
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on athletics has allowed him to specialize
in treating bone stress injuries commonly seen in
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runners. All righty, guys,
today is going to be an episode chock
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full of great information that you can
implement into practice right away. Let's get
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started. Well, Thank you Jessica, and thank you guys for joining me.
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So quick background about myself. I
am a chiropractor by trade. I
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practice in a sports medicine style multi
doc office outside of Cincinnati, Ohio.
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I've been really fortunate to work with
in a number of settings and see a
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lot of different patients, and that
has made me interested in working with athletes.
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That's not primarily what I see day
to day, but as a chiropractic
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office that sees a lot of athletes, naturally see a lot of runners,
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and a number of runners do deal
with bone stress injuries. So we'll talk
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about a number of things about what
treatment management and stuff looks like in our
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chat today, So loose outline,
we'll go through some things with the anatomy
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and define a few terms what risk
factors and features of history look like.
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And then kind of on the second
part and frankly a little more importantly,
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we'll talk about some return to score
rehab and things like that, because it's
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great if you can catch these injuries, it's a lot trickier to get them
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to, frankly where they need to
be on the back end. So by
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the end of this I want three
things to happen. One, you to
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have an idea of how to identify
a stress fracture early, choose the right
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type of imaging, and then finally
have an idea of returning them to their
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score, their day to day activity, or back to running in general.
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So first we need to define a
few terms. So what is bone itself
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is what is ttrus fracture? So
we need to think about bone as a
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dynamic, living tissue. It's not
just the framework that our muscles and joints
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kind of hang off of. It's
active. So we're always dealing with,
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going back to physiology in school,
the process of building up and breaking down
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of bone. So we have our
osteoblasts those cells that build bone back up,
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and osteo class those that break it
away, and it's always this constant
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back and forth. The problem we
run into is when we're breaking down more
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than we're building back up. It's
no different then if you spend more than
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you make. You can use credit
cards for a while, but after that
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it gets a little tricky. Unfortunately, our bone doesn't have a line of
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credit. It's going to run what
I like to call a bone debt by
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starting to lay down less quality or
less good level of bone, and that's
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going to cause an issue as somebody
is active and continues to progress. So
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the loose definition for a BSI is
an overuse injury due to an imbalance of
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excess bone damage and inadequate or lack
of time for repair. So specifically,
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this exists on a spectrum. So
on the far end we have our stress
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reaction and on the other end we
have a completely fracture. And so on
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the far end we have our stress
reaction. That's where we're starting to see
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the lack of response to to load. We were starting to see things like
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a periosteal reaction that connective tissue layer
starts to get irritated. As it gets
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worse, we have this stress fracture
where we actually start to form a break.
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We start to form a fracture lined
within the bone. And specifically bones
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are generally two broad types. We
have the cornical bone, the outer portion
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that kind of thick area, and
then trabecular or spongy bone. In a
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stress fracture, we're starting to actually
start to form that fracture into the bone.
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And then on the far end,
and the area we never want to
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go if possible, is complete fracture, where we have had so much accumulated
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trauma that that bone is so weak
it's fracturing through. And that's where you
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get into some really messy things such
as displacement of bone fragments or the associated
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joint. So if we can avoid
that, that's going to be pretty crucial.
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So I wanted to make this a
little practical. So this is a
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case from a local high school athlete. They had some issues at the end
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of their track season where we'll call
it a case oftion splints, where they
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had to pause their training for a
little bit and then got better in about
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two three weeks, and then they
had about four weeks left the season,
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so they had this brief pause where
they were out of training and then they
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went back into it, and then
cross country is their preferred sport over track,
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so they started to aggressively increase their
mileage over several week period to kind
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of prepare for the coming season.
Over the course of that time, they
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started to notice this kind of deep
nagging hip pain. It was getting difficult
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just walking around home is almost impossible
to run. And for those reasons and
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some things we'll talk about on the
physical exams side, we ended up get
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an MRI and it confirmed a Grade
four stress fracture of the proximal femur or
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the from aal neck. So that's
great that we caught it. But as
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we go through, I want you
to think about we'll call this this person
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Dan, how do you want to
help Dan manage this injury? And then
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how can you or what's going to
be the best way to get them back
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to his sport in the next season, and things contribute. We'll use Dan
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as a stereotype, but there are
a number of factors that contribute to these
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types of injuries. I call it
the rule of twos. There's three parts
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to it, which is a little
confusing. The three things are too much,
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too soon, and too little.
So too much meaning too much load,
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too much volume, things like that, like this could be the training
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knowledge in their week, or it
could be the number of like training sessions
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per week. Too soon, that's
the frequency, so that again like the
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two a day going from two or
three days a week to ten days a
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week. The math doesn't work on
that. And then finally, too little
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meaning to arrest, too little time
for them to recover. This is somebody
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who is just going back to back
to back without creating any time for buffer.
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And in a weird way, we
got to see this with the COVID
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pandemic so I'll use a high school
athlete as an example. You can have
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somebody that might be playing year round
sport in some way, shape or form,
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or a varied athlete. Maybe they
do football in the fall, they
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do basketball in the winner, and
they do track in the spring, so
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for most of the year they have
some amount of training stimulus and they have
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a pretty active threshold. The problem
we had is depending on where you were
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in the country, from January to
May or even longer, depending on where
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you're at, a lot of sports
were shut down and then it was kind
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of that slow return to normalcy that
we saw in the fall, and a
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lot of it was a push to
let's at least get back to sports that
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they're outdoors. Some of these things
can be done safely, let's go for
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that. And it was this huge
disconnective. You have these you have athletes
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who've been training your you suddenly give
them a six month period where they're not
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really able to do any kind of
activity, and then you're expecting them to
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return back to their previous level.
So is this huge gap And we saw
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it a lot in that fall time, especially especially on the runner side,
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because that's the stereotype of all these
high school athletes coming in with a ton
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of these injuries because it was this
huge disconnect of the training load and then
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the return to sport timeline. So
hopefully we won't see a surge like that
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in the coming years, but it
was interesting. On the slide here you'll
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see a brief study. This is
a twenty fifteen title is Epidemiology of Stress
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Fracture Injuries among US High School Athletes
two thousand and five and six to twenty
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twelve to twenty thirteen. Big overview, big thing that came out was this,
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So sixty five percent of injuries resulted
in three things of these stress fractures.
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One three weeks or more of time
lost, medical disqualification, or the
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end of season, so three weeks
of times lost that they were out for
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at least three weeks medical disqualification,
their season is over, and then finally
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end of season meaning by the time
they had gotten better, their season had
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ended. And nobody wants any of
those things. So it will go into
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this a little bit later on,
but a lot of these injuries, depending
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on the location or the grade,
that will determine your healing timeline and it
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allows you to have a better more
frank conversation with a person in front of
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you about how long this is going
to take. So who is kind of
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your your stereotype or your archetype about
who's going to come with this injury.
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So one, there's a slight preference
for female over male for a number of
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reasons. And then I've seen anywhere
from eighty to nine or ninety percent of
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all stress fractures that occur in the
lower limb. There are a handful of
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injuries that might come in the upper
clabical scapula humorous, they're fairly uncommon.
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So the majority of stress fractures are
going to be basically below the belt from
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an anatomy standpoint, And whenever you
have an actively a more active person come
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in, you need to have a
few things that should tip you off that
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this is an issue. So I
want you to think about playing the odds
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with your patient's examine history. I'm
not encouraging at all gambling with your patient's
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health or being unsafe or something like
that, but thinking about what's the most
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likely thing that this is, and
how can I screen or how can I
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sift through to figure out if it's
something else? Relatively quickly and there's a
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number of historical features that are going
to come in. One, they're generally
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a runner, an athletic person,
somebody's pretty active. They're not going to
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have a good story about what caused
it. It's not a fall, it
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wasn't they got sideswiped at a game
or something like that. It's just this
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random pain with no specific onset.
Generally can be focal too. They will
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gesture to one area or they'll be
able to outline it with their fingers.
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Another hallmark is they'll have pain with
activity, and then pain that'll stick around.
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So maybe they'll they'll have pain during
their run and then it sticks around
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for a couple of hours after or
even into the next day. And then
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be specific with your questions. There's
going to often be recent changes in activity
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assaws. One recently where superactive runner, but they started added basketball in just
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winter time and all that, and
dat has started to raise the suspicions for
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that just because they're already running a
ton on their own, they're doing a
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ton of mileage, and they're doing
another activity in their week that just the
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demands of it for the bone debt. There's there's only so much margin in
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there. At Southeast Professional Education Group, we are incredibly selective about the courses
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based courses, and because of this,
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we only launch new courses a few
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so I am beyond excited to announce
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In this hybrid course format, you'll
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Not only does this course prepare you
to add acupuncture to your treatment offerings,
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Exam. You can register for the
full program or choose to only complete specific
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course modules that interest you. Learn
more at the acupuncture link in our show
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notes, or visit online dot Sports
dash Seminars dot com for details. And
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then moving on, we need to
couch everything into the degree of risk,
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So I'm fond of the phrase do
you know harm? We want to have
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an idea of how can we produce
harm or problems with our patients. Now
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there's some things like risk factors which
contribute. Those are broken into intrinsic and
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extrinsic, so intrinsic things we might
not be able to change a whole lot,
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male versus female, their individual biomechanics. Nutrition. I'm not saying that
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we can't provide nutrition recommendations, but
if somebody doesn't have adequate access to nutrition,
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that can be a tricky thing and
an ex forensic thing. Their training
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program, their mileage, things like
that they're terrain, whether they're being on
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asphalt all the time, the road, trails, grass, things like that.
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Variety is your best friend on that. And then finally sho style and
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wear. I used to be really
into the exact biomechanics of the shoe.
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More broad principle is just look on
the bottom of their shoe. If they've
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worn all the tread off, it's
probably time for a new pair. And
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I think that's a real easy,
easy criteria there. And then continuing with
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risk, each region of anatomy is
associated with a different level of risk.
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So on the higher side, well
high and low risk, so high risk
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is defined of the odds that they're
increased, odds that they're being a progression
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of the injury, failure of conservative
care, or the need for surgical intervention.
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So the high risk areas include the
anterior tibia, the fomoral neck,
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and then the sessiment bones. The
low risk metatarsals post your media tibia,
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fibula for moral shaft different than the
phomoral neck, and then the sacram impels.
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So based on these areas you can
start to build out the timelines of
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what's the recovery, what's the healing
going to look like? Overall? So
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have this list in your head,
especially if you see active people. So
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is what's your physical examin going to
look like? Do the good stuff,
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range your motion, palpate the area, ask the patient to show you where
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it hurts, have them walk,
have them run. In some really further
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progress cases, they're going to have
a really hard time weight bearing. One
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00:15:52.080 --> 00:15:54.519
of my favorite quotes is from one
of the local high school coaches. He
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says, no high school kids should
be limping. So if you have a
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young athlete come into your office they're
limbing, it's probably something more concerning.
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It's probably not a simple sprain strain, and then there's some orthopedic tests you
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can do. Now specifically, there
are a number of different tests you can
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do for stress fracture. One of
the most common ones that's helpful is the
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hop test. It seems silly,
but have them hop on a single leg
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00:16:19.559 --> 00:16:25.799
affected side versus unaffected side. If
that is enough to induce pain, some
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00:16:25.879 --> 00:16:29.960
kind of bone injury needs to be
on your radar. And then practically,
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if it hurts just for them to
hop two times on your office carpet,
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00:16:33.919 --> 00:16:37.120
it has to be much more painful
or much more problematic for them to be
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00:16:37.200 --> 00:16:41.120
just pounding it over the course of
mileage on the road. So, once
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you have a patient that you're concerned
about BSI, we need to figure out
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00:16:45.639 --> 00:16:48.720
if there's going to be the need
for imaging or what's appropriate imaging. So
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there's a lot of different options X
ray, m RI, CT, ultrasound,
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00:16:55.159 --> 00:16:59.519
things like that. When we're when
we order any image, we want
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to think about the value of that
test. So the two terms I want
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00:17:03.160 --> 00:17:07.960
to bring out our sensitivity and specificity. So if a test is very very
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00:17:08.000 --> 00:17:11.920
sensitive, that means if it's negative, we can confidently rule that out.
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If a test is very specific.
That means we can rule something in.
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So if we're going to be trying
to rule out a stress fracture, we
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want tests that are a screen tool
that are going to be very sensitive for
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00:17:26.160 --> 00:17:30.400
allowing us to cross that off our
list and move on. Let's talk about
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extra real quick, so pretty cheap, pretty easy access. In most offices,
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you might have it in your office
or you might work in a group
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where you can walk the patient down
the hall. The problem with the X
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ray is it's very specific. There's
always something you might see, you might
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00:17:45.000 --> 00:17:51.160
see some subtle change. It's not
very sensitive. And the problem is a
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lot of these when they're lower grade
A one or two, it's out of
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00:17:52.960 --> 00:17:57.599
a grading scale of four, one
or two can often be undetected on X
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00:17:57.680 --> 00:18:02.839
ray. I've seen a figures where
essentially, unless it's A three or more
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00:18:03.240 --> 00:18:04.519
in terms of the grading scale,
you're not going to see it ourn X
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00:18:04.640 --> 00:18:07.799
ray. And that's where it could
become a bit of a headache of you
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00:18:07.839 --> 00:18:11.759
get the X ray, X rays
clean as a whistle and you're confident to
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00:18:11.839 --> 00:18:15.160
walk away from this as a possible
diagnosis. You're treating for a couple of
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00:18:15.200 --> 00:18:18.400
weeks patients not getting better, you
have to change, you get an X
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00:18:18.480 --> 00:18:22.599
ray again, and then it's gotten
worse. So X ray is an option,
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00:18:22.160 --> 00:18:26.200
just not the preferred option, and
it's relatively easy to miss. Now
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00:18:26.240 --> 00:18:30.200
I want to be sensitive to if
you work in a situation where there's a
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00:18:30.200 --> 00:18:33.160
lot of insurance that you might have
to get the X ray first and then
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00:18:33.240 --> 00:18:37.599
be able to get some other imaging
modality. So I understand having to play
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00:18:37.599 --> 00:18:42.240
that that reindeer game. So MRII
itself is our is our gold standard for
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00:18:42.519 --> 00:18:47.400
a number of reasons. One,
it allows us to see individual grading scale,
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00:18:47.480 --> 00:18:52.039
so zero to five, and you're
able to contrast on like T one
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00:18:52.200 --> 00:18:55.720
T two weighted image. You'll generally
see it down on one, up on
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00:18:55.799 --> 00:19:00.920
two. They'll be ill defined dema
throughout. But what I like about MRIs
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00:19:00.680 --> 00:19:03.079
you can see a lot more.
You can see the bon edema. And
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00:19:03.119 --> 00:19:08.839
then also they're very specific grading criteria, and that grading criteria I'll show a
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00:19:08.960 --> 00:19:15.279
table at the end that grading criteria
can be plugged in to return to run,
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00:19:15.359 --> 00:19:18.920
return to recovery time. So it
gives you a nice framework, especially
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00:19:19.079 --> 00:19:23.200
when you're working to set expectations with
your patient about how long is this going
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00:19:23.240 --> 00:19:26.160
to take? Or how are we
going to manage this going forward. It
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00:19:26.200 --> 00:19:30.000
gives you a nice framework and roadmap
for them, especially if they're saying,
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00:19:30.039 --> 00:19:33.599
well, I want to get back
in two weeks and things like that.
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00:19:33.119 --> 00:19:37.640
It makes things a lot easier for
you from a communication standpoint. The stables
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00:19:37.680 --> 00:19:41.039
from a native this is the classification
again. Grade one through four or five
268
00:19:41.160 --> 00:19:47.160
is complete fracture and you can just
see the different criteria for the level of
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00:19:47.319 --> 00:19:52.759
edema and then what is seen with
or without the fracture line diagnostic ultrasound.
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00:19:52.839 --> 00:19:56.480
It's another potential imaging modality some states
scope of practice, it might not be
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00:19:56.559 --> 00:20:00.920
readily available. What is nice about
it is you can see stuff in real
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00:20:00.960 --> 00:20:03.559
time. So if you can if
you can touch it with your hands,
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00:20:03.640 --> 00:20:07.119
you can scan it. So if
somebody is pointing to the middle of their
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00:20:07.400 --> 00:20:11.599
shinn er tibia, you can take
a probe right there and scan it.
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00:20:11.640 --> 00:20:14.880
And sometimes it's a lot cheaper than
the MRI and you can see it in
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00:20:14.920 --> 00:20:18.920
real time. Again, that just
depends on what's available to you and what
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00:20:18.960 --> 00:20:22.319
your license looks like. So getting
back to the injuries himself, we'll talk
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00:20:22.480 --> 00:20:29.559
Most common areas are tibia, tarsal
levicular metatarsals, femur, neck and shaft,
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00:20:29.599 --> 00:20:32.720
and then pellas and safe room.
For this, I'll kind of focus
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00:20:32.799 --> 00:20:37.200
on tibia and femur since there tibia
is much more common, and then femur
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00:20:37.599 --> 00:20:41.240
has the most moving pieces in my
mind, so tibial stress fracture, So
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00:20:41.359 --> 00:20:47.160
what's that going to look like?
They're going to come in pain focal to
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00:20:47.279 --> 00:20:51.839
the anterior tibia pain with more activity. I call it the pinky test personally,
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00:20:51.920 --> 00:20:55.680
where if they can take the tip
of their pinky and tap where it
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00:20:55.759 --> 00:21:00.200
hurts. Generally, that's a really
specific indicator that that's what's going on again,
286
00:21:00.240 --> 00:21:04.799
your other historical features changes in trading, superactive things like that. There's
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00:21:04.799 --> 00:21:10.160
two tests that's not taught a whole
lot in school. Milground Research out of
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00:21:10.240 --> 00:21:15.640
Israel has this study. They did
two quick tests with a combined sensitivity of
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00:21:15.640 --> 00:21:18.720
one hundred percent. So if these
two tests are negative, you can feel
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00:21:18.759 --> 00:21:22.359
pretty confident about walking away from this
diagnosis. The two things are one pain
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00:21:22.440 --> 00:21:26.839
on palpatient, does it hurt if
I poke that area? And then second
292
00:21:26.839 --> 00:21:30.400
hot test, how doing the patient
perform a single like hop test over that
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00:21:30.519 --> 00:21:36.039
area? If they that reproduces their
pain and it's painful. There you have
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00:21:36.079 --> 00:21:41.200
some confidence about this being concerning emerging
BSI. And then quickly just it's often
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00:21:41.200 --> 00:21:45.319
a mimicker where you have medial tibul
stress syndrome or shin splins present with or
296
00:21:45.599 --> 00:21:52.720
mimicking about BSI. Generally a couple
of things just look that are different.
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00:21:52.799 --> 00:21:56.720
One, look the hot test the
pain on palpatient. Second, if it's
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00:21:56.759 --> 00:22:00.119
shin splins, the area of pain
is a lot more broad throughout the shaft
299
00:22:00.200 --> 00:22:04.960
instead of one focal area, and
that's due to the kind of periostatis with
300
00:22:06.000 --> 00:22:11.279
the tibia and like the muscular attachments
there, So it's this more diffuse nonfocal
301
00:22:11.319 --> 00:22:15.079
pain instead of just that that pinpoint
area. And then looking into the other
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00:22:15.680 --> 00:22:18.720
other one of my favorites, the
femur itself. I remember that we have
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00:22:18.799 --> 00:22:23.279
those two types. So we have
the shaft the long portion of the bone
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00:22:23.319 --> 00:22:29.319
that's on the low risk category,
and then we have the neck itself approximal
305
00:22:29.440 --> 00:22:32.839
end that's in the high risk category. So you'll often have a patient come
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00:22:32.839 --> 00:22:36.799
in with this this deep, really
achy pain. Every patient I've seen with
307
00:22:37.000 --> 00:22:41.519
a formeral neck stress fracture, the
phraser views is it's in there deep or
308
00:22:41.559 --> 00:22:42.920
they'll they'll be trying to show me
where it is and then just keep on
309
00:22:42.960 --> 00:22:45.200
poking. They're like, I wish
my hand could go deeper. I could
310
00:22:45.240 --> 00:22:49.039
poke more in because that's it's beneath
me even more my hand is out there.
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00:22:49.400 --> 00:22:52.599
And a couple of things we'll see, especially with the neck is really
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00:22:52.599 --> 00:22:56.440
intense pain. With the hop test, there's a test known as fol chrome
313
00:22:56.519 --> 00:23:00.279
test. You can see it on
the picture there. That's where you'll take
314
00:23:00.319 --> 00:23:03.880
your hand and bring it underneath the
patient's formal shaft. Take your other hand
315
00:23:03.880 --> 00:23:07.200
and press over that area. That
allows you to kind of put a little
316
00:23:07.319 --> 00:23:11.480
one pressure onto the shaft itself.
But two, you're jamming the head of
317
00:23:11.519 --> 00:23:17.119
the femur up into the into the
alia. If there's irritation, inflammation,
318
00:23:17.440 --> 00:23:19.799
easy way to irritate it, and
then other orthopedic tests might be helpful for
319
00:23:19.960 --> 00:23:23.599
baar fi dear, you're just seeing
how easy is this irritate. So the
320
00:23:23.720 --> 00:23:27.880
historical features where the changes in activity
load pain, things like that, and
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00:23:27.920 --> 00:23:32.160
then if you're reproducing it with just
moving their hip around and the patient's talking
322
00:23:32.160 --> 00:23:34.720
about it being in their deep,
this needs to be on your radar relatively
323
00:23:34.759 --> 00:23:41.680
quickly. So the reason I'm so
interested in the formal stress fracture is one
324
00:23:41.759 --> 00:23:45.079
is the highest risk, but two
it has some different subtypes that aren't well
325
00:23:45.119 --> 00:23:48.440
touched on. So specifically, there
are are three types for the femur.
326
00:23:48.599 --> 00:23:55.279
One if there is a stress fracture
on the superior the upper side versus on
327
00:23:55.279 --> 00:23:59.960
the bottom side versus all the way
through, So on the top side that's
328
00:24:00.119 --> 00:24:03.680
referred to as a tensile stress fracture, bottom side is referred to as compressive.
329
00:24:04.039 --> 00:24:08.119
And then you can have a complete
which is no bleno that involves displacement.
330
00:24:08.680 --> 00:24:12.720
So if it's a tensil top side
that has it's like a forty percent
331
00:24:12.839 --> 00:24:19.160
increased chance of that progressing, meaning
to crack further, versus on the compressive
332
00:24:19.160 --> 00:24:23.720
that bottom side is much less likely. So even knowing the subtype can be
333
00:24:23.759 --> 00:24:26.920
really helpful once you have the MRI
about how you want to move forward with
334
00:24:26.960 --> 00:24:33.079
this and how you want to manage
this, and again harping on the role
335
00:24:33.119 --> 00:24:36.759
of the MRI, you can see
from this table here it's American Journal Sports
336
00:24:36.880 --> 00:24:40.799
Medicine. This is for the neck
itself talking about the grading scale. And
337
00:24:40.839 --> 00:24:44.279
then they followed the number of athletes
and saw how long it took them to
338
00:24:44.359 --> 00:24:48.440
return to run. So for a
Grade one it is about seven, for
339
00:24:48.519 --> 00:24:53.000
a Grade two about fourteen weeks,
three about fifteen, and then four about
340
00:24:53.200 --> 00:24:57.799
seventeen to eighteen. So look at
the huge difference, So seven versus fourteen.
341
00:24:59.400 --> 00:25:03.440
Once you a grade one to grade
two, you essentially double the timeline.
342
00:25:03.039 --> 00:25:10.279
And grade one is about two ish
months, give or take. Grade
343
00:25:10.359 --> 00:25:14.480
two we're talking three four months or
more and going beyond that. So the
344
00:25:14.680 --> 00:25:18.839
sooner you can catch these, the
better things are going to be for everybody
345
00:25:18.880 --> 00:25:22.119
involved. If you can catch an
injury at a grade one manage it,
346
00:25:22.400 --> 00:25:26.039
you have a better shot to get
them either back to their events or to
347
00:25:26.079 --> 00:25:30.599
their season than Grade two fourteen weeks
of healing time, like a lot of
348
00:25:30.599 --> 00:25:34.440
sport is going to be over before
then, and that's frustrating for everybody involved.
349
00:25:34.440 --> 00:25:40.759
So as soon as you can identify
these, that's that's optimal. And
350
00:25:40.839 --> 00:25:45.440
again with the study about the epidemiology, a lot of these result in three
351
00:25:45.480 --> 00:25:48.680
weeks of time loss, the medical
disqualification or the end of season. Again,
352
00:25:48.720 --> 00:26:03.200
the soonest you can catch these,
that's going to help everybody. That's
353
00:26:03.240 --> 00:26:06.640
it for today's episode. Be sure
to tune in for Part two, where
354
00:26:06.640 --> 00:26:11.319
we discuss the phases of returning to
activity after a bone stress injury, as
355
00:26:11.359 --> 00:26:15.839
well as talk about some helpful tips
for maintaining fitness and strength during the recovery
356
00:26:15.880 --> 00:26:19.680
period. Doctor Kemp will also share
a few fascinating case studies and offer advice
357
00:26:19.759 --> 00:26:25.640
on how to have effective conversations with
parents, coaches, and healthcare providers.
358
00:26:26.039 --> 00:26:29.440
You won't want to miss it.
Episode sixty seven drops in two weeks.
359
00:26:30.160 --> 00:26:33.200
Be sure to check out our show
notes for special offers from our sponsors and
360
00:26:33.279 --> 00:26:37.279
a link to our Factor sixty second
survey for the week. You'll also find
361
00:26:37.279 --> 00:26:41.720
a link to view the full recorded
replay of this webinar. If you're more
362
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of a visual learner, you can
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sure to follow the show and give
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bit helps. We'll see you next
time. Hey guys, if you like
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what you heard today, I encourage
you to visit our website at Factor hyphenstore
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dot com that's spelled fa k tr
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be sure to check those out.
1
00:00:15.119 --> 00:00:19.039
Hi guys, Welcome to another episode
of The Factor podcast. I'm your host,
2
00:00:19.160 --> 00:00:22.559
Jessica Riddle. If this is your
first time tuning in, welcome and
3
00:00:22.600 --> 00:00:27.280
thank you for listening. Today we
kick off a new two part training titled
4
00:00:27.320 --> 00:00:31.879
bone Stress Injuries, The Good,
the Bad, and the Ugly with doctor
5
00:00:31.920 --> 00:00:35.600
Tyler Kemp. Now, I don't
know about you, but when I hear
6
00:00:35.640 --> 00:00:40.880
the phrase bone stress injuries, there
is absolutely nothing good that comes to mind.
7
00:00:41.320 --> 00:00:45.200
In fact, it serves as just
another reminder for me why I am
8
00:00:45.280 --> 00:00:48.759
not a long distance runner. If
you put me on a peloton bike,
9
00:00:48.880 --> 00:00:52.880
I can ride for fifty miles no
problem. But if you see me running
10
00:00:52.880 --> 00:00:57.039
outdoors with any kind of speed,
it's probably because something is chasing me.
11
00:00:57.880 --> 00:01:00.960
And I can't imagine that I'm different
from a lot lot of your patients who
12
00:01:00.960 --> 00:01:06.599
are active recreational athletes. I regularly
work out five to six times each week,
13
00:01:06.719 --> 00:01:08.959
but inevitably there are times that I
push too hard for too long,
14
00:01:10.599 --> 00:01:15.680
or I'd use bad form and end
up with a nagging injury. Stress fractures
15
00:01:15.760 --> 00:01:19.200
are actually quite common, but did
you know that there are different subtypes of
16
00:01:19.239 --> 00:01:25.519
fractures that can vary depending upon the
mechanism of injury and the location. Did
17
00:01:25.519 --> 00:01:29.519
you know that females are more likely
than males to suffer from bone stress injuries.
18
00:01:30.480 --> 00:01:33.560
We will cover these topics and a
lot more on this episode in the
19
00:01:33.599 --> 00:01:38.000
next, including the different types of
stress fractures, the importance of imaging for
20
00:01:38.079 --> 00:01:42.480
accurate diagnosis, and a grading scale
that you can use for neck injuries.
21
00:01:42.439 --> 00:01:47.920
Our guest instructor for this training is
doctor Tyler Kemp. Doctor Kemp is a
22
00:01:48.000 --> 00:01:53.239
chiropractor practicing outside of Cincinnati, Ohio. He has a passion for working with
23
00:01:53.280 --> 00:01:59.799
athletes and clinical interests in treating tenanopathies
and bone stress injuries. He utilizes joint
24
00:01:59.840 --> 00:02:04.319
mans, manipulation, rehab, and
acupuncture in his patient care. And while
25
00:02:04.319 --> 00:02:08.039
his daily practice involves treating a diverse
range of patients, the office is focused
26
00:02:08.080 --> 00:02:14.560
on athletics has allowed him to specialize
in treating bone stress injuries commonly seen in
27
00:02:14.680 --> 00:02:17.599
runners. All righty, guys,
today is going to be an episode chock
28
00:02:17.680 --> 00:02:23.479
full of great information that you can
implement into practice right away. Let's get
29
00:02:23.520 --> 00:02:35.719
started. Well, Thank you Jessica, and thank you guys for joining me.
30
00:02:35.840 --> 00:02:38.719
So quick background about myself. I
am a chiropractor by trade. I
31
00:02:38.840 --> 00:02:44.319
practice in a sports medicine style multi
doc office outside of Cincinnati, Ohio.
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I've been really fortunate to work with
in a number of settings and see a
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lot of different patients, and that
has made me interested in working with athletes.
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That's not primarily what I see day
to day, but as a chiropractic
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office that sees a lot of athletes, naturally see a lot of runners,
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and a number of runners do deal
with bone stress injuries. So we'll talk
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about a number of things about what
treatment management and stuff looks like in our
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chat today, So loose outline,
we'll go through some things with the anatomy
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and define a few terms what risk
factors and features of history look like.
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And then kind of on the second
part and frankly a little more importantly,
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we'll talk about some return to score
rehab and things like that, because it's
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great if you can catch these injuries, it's a lot trickier to get them
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to, frankly where they need to
be on the back end. So by
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the end of this I want three
things to happen. One, you to
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have an idea of how to identify
a stress fracture early, choose the right
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type of imaging, and then finally
have an idea of returning them to their
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score, their day to day activity, or back to running in general.
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So first we need to define a
few terms. So what is bone itself
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is what is ttrus fracture? So
we need to think about bone as a
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dynamic, living tissue. It's not
just the framework that our muscles and joints
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kind of hang off of. It's
active. So we're always dealing with,
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going back to physiology in school,
the process of building up and breaking down
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of bone. So we have our
osteoblasts those cells that build bone back up,
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and osteo class those that break it
away, and it's always this constant
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back and forth. The problem we
run into is when we're breaking down more
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than we're building back up. It's
no different then if you spend more than
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you make. You can use credit
cards for a while, but after that
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it gets a little tricky. Unfortunately, our bone doesn't have a line of
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credit. It's going to run what
I like to call a bone debt by
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starting to lay down less quality or
less good level of bone, and that's
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going to cause an issue as somebody
is active and continues to progress. So
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the loose definition for a BSI is
an overuse injury due to an imbalance of
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excess bone damage and inadequate or lack
of time for repair. So specifically,
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this exists on a spectrum. So
on the far end we have our stress
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reaction and on the other end we
have a completely fracture. And so on
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the far end we have our stress
reaction. That's where we're starting to see
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the lack of response to to load. We were starting to see things like
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a periosteal reaction that connective tissue layer
starts to get irritated. As it gets
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worse, we have this stress fracture
where we actually start to form a break.
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We start to form a fracture lined
within the bone. And specifically bones
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are generally two broad types. We
have the cornical bone, the outer portion
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that kind of thick area, and
then trabecular or spongy bone. In a
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stress fracture, we're starting to actually
start to form that fracture into the bone.
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And then on the far end,
and the area we never want to
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go if possible, is complete fracture, where we have had so much accumulated
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trauma that that bone is so weak
it's fracturing through. And that's where you
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get into some really messy things such
as displacement of bone fragments or the associated
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joint. So if we can avoid
that, that's going to be pretty crucial.
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So I wanted to make this a
little practical. So this is a
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case from a local high school athlete. They had some issues at the end
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of their track season where we'll call
it a case oftion splints, where they
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had to pause their training for a
little bit and then got better in about
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two three weeks, and then they
had about four weeks left the season,
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so they had this brief pause where
they were out of training and then they
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went back into it, and then
cross country is their preferred sport over track,
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so they started to aggressively increase their
mileage over several week period to kind
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of prepare for the coming season.
Over the course of that time, they
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started to notice this kind of deep
nagging hip pain. It was getting difficult
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just walking around home is almost impossible
to run. And for those reasons and
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some things we'll talk about on the
physical exams side, we ended up get
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an MRI and it confirmed a Grade
four stress fracture of the proximal femur or
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the from aal neck. So that's
great that we caught it. But as
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we go through, I want you
to think about we'll call this this person
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Dan, how do you want to
help Dan manage this injury? And then
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how can you or what's going to
be the best way to get them back
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to his sport in the next season, and things contribute. We'll use Dan
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as a stereotype, but there are
a number of factors that contribute to these
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types of injuries. I call it
the rule of twos. There's three parts
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to it, which is a little
confusing. The three things are too much,
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too soon, and too little.
So too much meaning too much load,
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too much volume, things like that, like this could be the training
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knowledge in their week, or it
could be the number of like training sessions
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per week. Too soon, that's
the frequency, so that again like the
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two a day going from two or
three days a week to ten days a
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week. The math doesn't work on
that. And then finally, too little
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meaning to arrest, too little time
for them to recover. This is somebody
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who is just going back to back
to back without creating any time for buffer.
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And in a weird way, we
got to see this with the COVID
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pandemic so I'll use a high school
athlete as an example. You can have
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somebody that might be playing year round
sport in some way, shape or form,
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or a varied athlete. Maybe they
do football in the fall, they
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do basketball in the winner, and
they do track in the spring, so
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for most of the year they have
some amount of training stimulus and they have
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a pretty active threshold. The problem
we had is depending on where you were
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in the country, from January to
May or even longer, depending on where
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you're at, a lot of sports
were shut down and then it was kind
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of that slow return to normalcy that
we saw in the fall, and a
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lot of it was a push to
let's at least get back to sports that
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they're outdoors. Some of these things
can be done safely, let's go for
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that. And it was this huge
disconnective. You have these you have athletes
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who've been training your you suddenly give
them a six month period where they're not
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really able to do any kind of
activity, and then you're expecting them to
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return back to their previous level.
So is this huge gap And we saw
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it a lot in that fall time, especially especially on the runner side,
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because that's the stereotype of all these
high school athletes coming in with a ton
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of these injuries because it was this
huge disconnect of the training load and then
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the return to sport timeline. So
hopefully we won't see a surge like that
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in the coming years, but it
was interesting. On the slide here you'll
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see a brief study. This is
a twenty fifteen title is Epidemiology of Stress
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Fracture Injuries among US High School Athletes
two thousand and five and six to twenty
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twelve to twenty thirteen. Big overview, big thing that came out was this,
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So sixty five percent of injuries resulted
in three things of these stress fractures.
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One three weeks or more of time
lost, medical disqualification, or the
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end of season, so three weeks
of times lost that they were out for
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at least three weeks medical disqualification,
their season is over, and then finally
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end of season meaning by the time
they had gotten better, their season had
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ended. And nobody wants any of
those things. So it will go into
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this a little bit later on,
but a lot of these injuries, depending
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on the location or the grade,
that will determine your healing timeline and it
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allows you to have a better more
frank conversation with a person in front of
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you about how long this is going
to take. So who is kind of
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your your stereotype or your archetype about
who's going to come with this injury.
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So one, there's a slight preference
for female over male for a number of
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reasons. And then I've seen anywhere
from eighty to nine or ninety percent of
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all stress fractures that occur in the
lower limb. There are a handful of
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injuries that might come in the upper
clabical scapula humorous, they're fairly uncommon.
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So the majority of stress fractures are
going to be basically below the belt from
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an anatomy standpoint, And whenever you
have an actively a more active person come
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in, you need to have a
few things that should tip you off that
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this is an issue. So I
want you to think about playing the odds
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with your patient's examine history. I'm
not encouraging at all gambling with your patient's
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health or being unsafe or something like
that, but thinking about what's the most
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likely thing that this is, and
how can I screen or how can I
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sift through to figure out if it's
something else? Relatively quickly and there's a
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number of historical features that are going
to come in. One, they're generally
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a runner, an athletic person,
somebody's pretty active. They're not going to
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have a good story about what caused
it. It's not a fall, it
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wasn't they got sideswiped at a game
or something like that. It's just this
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random pain with no specific onset.
Generally can be focal too. They will
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gesture to one area or they'll be
able to outline it with their fingers.
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Another hallmark is they'll have pain with
activity, and then pain that'll stick around.
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So maybe they'll they'll have pain during
their run and then it sticks around
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for a couple of hours after or
even into the next day. And then
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be specific with your questions. There's
going to often be recent changes in activity
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assaws. One recently where superactive runner, but they started added basketball in just
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winter time and all that, and
dat has started to raise the suspicions for
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that just because they're already running a
ton on their own, they're doing a
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ton of mileage, and they're doing
another activity in their week that just the
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demands of it for the bone debt. There's there's only so much margin in
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there. At Southeast Professional Education Group, we are incredibly selective about the courses
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00:12:35.799 --> 00:12:41.440
we host on our online learning platform. We only want to offer our students
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the best, most dynamic, evidence
based courses, and because of this,
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00:12:45.840 --> 00:12:50.639
we only launch new courses a few
times each year. We are unapologetically selective,
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so I am beyond excited to announce
that new courses have just launched and
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00:12:54.480 --> 00:13:01.039
registration is now open for our Chiropractic
Acupuncture one hundred hours cert cation program.
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In this hybrid course format, you'll
complete a mixture of self paced virtual coursework
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00:13:05.600 --> 00:13:09.919
and attend four live hands on sessions
in beautiful West Palm Beach, Florida.
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00:13:11.080 --> 00:13:15.240
Not only does this course prepare you
to add acupuncture to your treatment offerings,
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00:13:15.480 --> 00:13:20.720
it also fulfills the requirements to qualify
you to sit for the nbce's Acupuncture Board
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00:13:20.799 --> 00:13:24.799
Exam. You can register for the
full program or choose to only complete specific
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00:13:24.840 --> 00:13:30.200
course modules that interest you. Learn
more at the acupuncture link in our show
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00:13:30.200 --> 00:13:39.080
notes, or visit online dot Sports
dash Seminars dot com for details. And
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then moving on, we need to
couch everything into the degree of risk,
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So I'm fond of the phrase do
you know harm? We want to have
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an idea of how can we produce
harm or problems with our patients. Now
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there's some things like risk factors which
contribute. Those are broken into intrinsic and
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extrinsic, so intrinsic things we might
not be able to change a whole lot,
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male versus female, their individual biomechanics. Nutrition. I'm not saying that
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we can't provide nutrition recommendations, but
if somebody doesn't have adequate access to nutrition,
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that can be a tricky thing and
an ex forensic thing. Their training
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program, their mileage, things like
that they're terrain, whether they're being on
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asphalt all the time, the road, trails, grass, things like that.
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Variety is your best friend on that. And then finally sho style and
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wear. I used to be really
into the exact biomechanics of the shoe.
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More broad principle is just look on
the bottom of their shoe. If they've
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worn all the tread off, it's
probably time for a new pair. And
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I think that's a real easy,
easy criteria there. And then continuing with
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risk, each region of anatomy is
associated with a different level of risk.
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So on the higher side, well
high and low risk, so high risk
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is defined of the odds that they're
increased, odds that they're being a progression
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of the injury, failure of conservative
care, or the need for surgical intervention.
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So the high risk areas include the
anterior tibia, the fomoral neck,
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and then the sessiment bones. The
low risk metatarsals post your media tibia,
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fibula for moral shaft different than the
phomoral neck, and then the sacram impels.
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So based on these areas you can
start to build out the timelines of
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what's the recovery, what's the healing
going to look like? Overall? So
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have this list in your head,
especially if you see active people. So
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is what's your physical examin going to
look like? Do the good stuff,
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range your motion, palpate the area, ask the patient to show you where
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it hurts, have them walk,
have them run. In some really further
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progress cases, they're going to have
a really hard time weight bearing. One
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of my favorite quotes is from one
of the local high school coaches. He
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says, no high school kids should
be limping. So if you have a
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young athlete come into your office they're
limbing, it's probably something more concerning.
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It's probably not a simple sprain strain, and then there's some orthopedic tests you
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can do. Now specifically, there
are a number of different tests you can
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do for stress fracture. One of
the most common ones that's helpful is the
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hop test. It seems silly,
but have them hop on a single leg
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affected side versus unaffected side. If
that is enough to induce pain, some
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kind of bone injury needs to be
on your radar. And then practically,
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if it hurts just for them to
hop two times on your office carpet,
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it has to be much more painful
or much more problematic for them to be
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just pounding it over the course of
mileage on the road. So, once
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you have a patient that you're concerned
about BSI, we need to figure out
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if there's going to be the need
for imaging or what's appropriate imaging. So
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there's a lot of different options X
ray, m RI, CT, ultrasound,
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things like that. When we're when
we order any image, we want
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to think about the value of that
test. So the two terms I want
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to bring out our sensitivity and specificity. So if a test is very very
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sensitive, that means if it's negative, we can confidently rule that out.
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If a test is very specific.
That means we can rule something in.
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So if we're going to be trying
to rule out a stress fracture, we
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want tests that are a screen tool
that are going to be very sensitive for
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allowing us to cross that off our
list and move on. Let's talk about
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extra real quick, so pretty cheap, pretty easy access. In most offices,
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you might have it in your office
or you might work in a group
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where you can walk the patient down
the hall. The problem with the X
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ray is it's very specific. There's
always something you might see, you might
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see some subtle change. It's not
very sensitive. And the problem is a
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lot of these when they're lower grade
A one or two, it's out of
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a grading scale of four, one
or two can often be undetected on X
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ray. I've seen a figures where
essentially, unless it's A three or more
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in terms of the grading scale,
you're not going to see it ourn X
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ray. And that's where it could
become a bit of a headache of you
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get the X ray, X rays
clean as a whistle and you're confident to
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walk away from this as a possible
diagnosis. You're treating for a couple of
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weeks patients not getting better, you
have to change, you get an X
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ray again, and then it's gotten
worse. So X ray is an option,
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just not the preferred option, and
it's relatively easy to miss. Now
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I want to be sensitive to if
you work in a situation where there's a
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lot of insurance that you might have
to get the X ray first and then
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be able to get some other imaging
modality. So I understand having to play
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that that reindeer game. So MRII
itself is our is our gold standard for
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a number of reasons. One,
it allows us to see individual grading scale,
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so zero to five, and you're
able to contrast on like T one
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T two weighted image. You'll generally
see it down on one, up on
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two. They'll be ill defined dema
throughout. But what I like about MRIs
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you can see a lot more.
You can see the bon edema. And
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then also they're very specific grading criteria, and that grading criteria I'll show a
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table at the end that grading criteria
can be plugged in to return to run,
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return to recovery time. So it
gives you a nice framework, especially
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when you're working to set expectations with
your patient about how long is this going
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to take? Or how are we
going to manage this going forward. It
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gives you a nice framework and roadmap
for them, especially if they're saying,
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well, I want to get back
in two weeks and things like that.
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It makes things a lot easier for
you from a communication standpoint. The stables
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from a native this is the classification
again. Grade one through four or five
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is complete fracture and you can just
see the different criteria for the level of
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edema and then what is seen with
or without the fracture line diagnostic ultrasound.
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It's another potential imaging modality some states
scope of practice, it might not be
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readily available. What is nice about
it is you can see stuff in real
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time. So if you can if
you can touch it with your hands,
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you can scan it. So if
somebody is pointing to the middle of their
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shinn er tibia, you can take
a probe right there and scan it.
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And sometimes it's a lot cheaper than
the MRI and you can see it in
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real time. Again, that just
depends on what's available to you and what
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your license looks like. So getting
back to the injuries himself, we'll talk
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Most common areas are tibia, tarsal
levicular metatarsals, femur, neck and shaft,
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and then pellas and safe room.
For this, I'll kind of focus
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on tibia and femur since there tibia
is much more common, and then femur
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has the most moving pieces in my
mind, so tibial stress fracture, So
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what's that going to look like?
They're going to come in pain focal to
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the anterior tibia pain with more activity. I call it the pinky test personally,
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where if they can take the tip
of their pinky and tap where it
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hurts. Generally, that's a really
specific indicator that that's what's going on again,
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your other historical features changes in trading, superactive things like that. There's
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two tests that's not taught a whole
lot in school. Milground Research out of
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00:21:10.240 --> 00:21:15.640
Israel has this study. They did
two quick tests with a combined sensitivity of
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one hundred percent. So if these
two tests are negative, you can feel
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pretty confident about walking away from this
diagnosis. The two things are one pain
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on palpatient, does it hurt if
I poke that area? And then second
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00:21:26.839 --> 00:21:30.400
hot test, how doing the patient
perform a single like hop test over that
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00:21:30.519 --> 00:21:36.039
area? If they that reproduces their
pain and it's painful. There you have
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some confidence about this being concerning emerging
BSI. And then quickly just it's often
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00:21:41.200 --> 00:21:45.319
a mimicker where you have medial tibul
stress syndrome or shin splins present with or
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00:21:45.599 --> 00:21:52.720
mimicking about BSI. Generally a couple
of things just look that are different.
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00:21:52.799 --> 00:21:56.720
One, look the hot test the
pain on palpatient. Second, if it's
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shin splins, the area of pain
is a lot more broad throughout the shaft
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instead of one focal area, and
that's due to the kind of periostatis with
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00:22:06.000 --> 00:22:11.279
the tibia and like the muscular attachments
there, So it's this more diffuse nonfocal
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00:22:11.319 --> 00:22:15.079
pain instead of just that that pinpoint
area. And then looking into the other
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other one of my favorites, the
femur itself. I remember that we have
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those two types. So we have
the shaft the long portion of the bone
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that's on the low risk category,
and then we have the neck itself approximal
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00:22:29.440 --> 00:22:32.839
end that's in the high risk category. So you'll often have a patient come
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00:22:32.839 --> 00:22:36.799
in with this this deep, really
achy pain. Every patient I've seen with
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00:22:37.000 --> 00:22:41.519
a formeral neck stress fracture, the
phraser views is it's in there deep or
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00:22:41.559 --> 00:22:42.920
they'll they'll be trying to show me
where it is and then just keep on
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00:22:42.960 --> 00:22:45.200
poking. They're like, I wish
my hand could go deeper. I could
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00:22:45.240 --> 00:22:49.039
poke more in because that's it's beneath
me even more my hand is out there.
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00:22:49.400 --> 00:22:52.599
And a couple of things we'll see, especially with the neck is really
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00:22:52.599 --> 00:22:56.440
intense pain. With the hop test, there's a test known as fol chrome
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00:22:56.519 --> 00:23:00.279
test. You can see it on
the picture there. That's where you'll take
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00:23:00.319 --> 00:23:03.880
your hand and bring it underneath the
patient's formal shaft. Take your other hand
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00:23:03.880 --> 00:23:07.200
and press over that area. That
allows you to kind of put a little
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00:23:07.319 --> 00:23:11.480
one pressure onto the shaft itself.
But two, you're jamming the head of
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00:23:11.519 --> 00:23:17.119
the femur up into the into the
alia. If there's irritation, inflammation,
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00:23:17.440 --> 00:23:19.799
easy way to irritate it, and
then other orthopedic tests might be helpful for
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00:23:19.960 --> 00:23:23.599
baar fi dear, you're just seeing
how easy is this irritate. So the
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00:23:23.720 --> 00:23:27.880
historical features where the changes in activity
load pain, things like that, and
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00:23:27.920 --> 00:23:32.160
then if you're reproducing it with just
moving their hip around and the patient's talking
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00:23:32.160 --> 00:23:34.720
about it being in their deep,
this needs to be on your radar relatively
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00:23:34.759 --> 00:23:41.680
quickly. So the reason I'm so
interested in the formal stress fracture is one
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00:23:41.759 --> 00:23:45.079
is the highest risk, but two
it has some different subtypes that aren't well
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00:23:45.119 --> 00:23:48.440
touched on. So specifically, there
are are three types for the femur.
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00:23:48.599 --> 00:23:55.279
One if there is a stress fracture
on the superior the upper side versus on
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00:23:55.279 --> 00:23:59.960
the bottom side versus all the way
through, So on the top side that's
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00:24:00.119 --> 00:24:03.680
referred to as a tensile stress fracture, bottom side is referred to as compressive.
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00:24:04.039 --> 00:24:08.119
And then you can have a complete
which is no bleno that involves displacement.
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00:24:08.680 --> 00:24:12.720
So if it's a tensil top side
that has it's like a forty percent
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00:24:12.839 --> 00:24:19.160
increased chance of that progressing, meaning
to crack further, versus on the compressive
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00:24:19.160 --> 00:24:23.720
that bottom side is much less likely. So even knowing the subtype can be
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00:24:23.759 --> 00:24:26.920
really helpful once you have the MRI
about how you want to move forward with
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00:24:26.960 --> 00:24:33.079
this and how you want to manage
this, and again harping on the role
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00:24:33.119 --> 00:24:36.759
of the MRI, you can see
from this table here it's American Journal Sports
336
00:24:36.880 --> 00:24:40.799
Medicine. This is for the neck
itself talking about the grading scale. And
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00:24:40.839 --> 00:24:44.279
then they followed the number of athletes
and saw how long it took them to
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00:24:44.359 --> 00:24:48.440
return to run. So for a
Grade one it is about seven, for
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00:24:48.519 --> 00:24:53.000
a Grade two about fourteen weeks,
three about fifteen, and then four about
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00:24:53.200 --> 00:24:57.799
seventeen to eighteen. So look at
the huge difference, So seven versus fourteen.
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00:24:59.400 --> 00:25:03.440
Once you a grade one to grade
two, you essentially double the timeline.
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00:25:03.039 --> 00:25:10.279
And grade one is about two ish
months, give or take. Grade
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00:25:10.359 --> 00:25:14.480
two we're talking three four months or
more and going beyond that. So the
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00:25:14.680 --> 00:25:18.839
sooner you can catch these, the
better things are going to be for everybody
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00:25:18.880 --> 00:25:22.119
involved. If you can catch an
injury at a grade one manage it,
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00:25:22.400 --> 00:25:26.039
you have a better shot to get
them either back to their events or to
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00:25:26.079 --> 00:25:30.599
their season than Grade two fourteen weeks
of healing time, like a lot of
348
00:25:30.599 --> 00:25:34.440
sport is going to be over before
then, and that's frustrating for everybody involved.
349
00:25:34.440 --> 00:25:40.759
So as soon as you can identify
these, that's that's optimal. And
350
00:25:40.839 --> 00:25:45.440
again with the study about the epidemiology, a lot of these result in three
351
00:25:45.480 --> 00:25:48.680
weeks of time loss, the medical
disqualification or the end of season. Again,
352
00:25:48.720 --> 00:26:03.200
the soonest you can catch these,
that's going to help everybody. That's
353
00:26:03.240 --> 00:26:06.640
it for today's episode. Be sure
to tune in for Part two, where
354
00:26:06.640 --> 00:26:11.319
we discuss the phases of returning to
activity after a bone stress injury, as
355
00:26:11.359 --> 00:26:15.839
well as talk about some helpful tips
for maintaining fitness and strength during the recovery
356
00:26:15.880 --> 00:26:19.680
period. Doctor Kemp will also share
a few fascinating case studies and offer advice
357
00:26:19.759 --> 00:26:25.640
on how to have effective conversations with
parents, coaches, and healthcare providers.
358
00:26:26.039 --> 00:26:29.440
You won't want to miss it.
Episode sixty seven drops in two weeks.
359
00:26:30.160 --> 00:26:33.200
Be sure to check out our show
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360
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