Veracity Performance & Recovery

02/26/2025

Navicular bone injuries are high-risk. These injuries are at higher risk of experiencing nonunion and failed healing compared with other bony sites and may lead to the best outcomes with surgery.

To make things complex, x-rays cannot be relied upon and often advanced imaging (MRI, CT scan) is necessary to confirm the diagnosis.

Treatment is debated.

Some authors suggest nonweight bearing for at least 6 weeks to promote healing.

Some authors may recommend surgery of even initially nondisplaced or incomplete fractures based on an expedited return to sport (16.4 weeks) vs nonoperative management (21.7 weeks).

Some authors also suggest surgery may act to reinforce post-healing to minimize the chance of recurrent injury for athletes returning to sport.

Of course, an individualized approach must be taken. Significant factors include the amount of damage and goals of a given runner.

BSIs are complicated. Big shoutout to as the primary source of bone stress injury research. If I have helped you or provided beneficial information, no doubt he’s been a big reason.

02/21/2025

I have some work to do when it comes to impact loading and symmetry.

Data off a quick 31 minute easy run.

Impact loading is comprised of impact magnitude and impact duration.

Impact magnitude is how much impact travels through the lower body, while impact duration is how quickly impact forces travel through the lower limbs. A longer impact duration is indicative of greater running efficiency.

I am showing a protective pattern, with more stress on the right leg each stride.
ai quantifies running form through validated metrics associated with injury risk and performance.

Interested in learning more about your running form? Get your metrics with actionable strategies to improve your running efficiency for less than your next pair of shoes. Shoot me a DM and learn more.

02/16/2025

Session #4 was a success for 's 10k, half marathon, and marathon training programs.

Daily coaching, community, accountability, and shoe fitting all in one to cover your training needs.

Fortunate to present run-specific physical therapy to the program while athletes build toward their target race.

What more do you need? See you for session #5!

02/10/2025

Reframing Rehab

I often hear whether a specific exercise or technique will help resolve an injury. While manual therapy, dry needling, and exercise may all have a place in a given rehab they're all pieces to the puzzle.

Rehab is about placing one's system in the optimal environment to heal from injury. However, we can only manage this so much.

No matter what we do, many injuries will take time.... because your body requires time to heal.

The good news? We often have timeframes of roughly when a specific tissue can heal and when you may return to full sports participation.

Looking at rehab as preparing for a return to sport for long-term health may be a better view than speeding up the healing process for a given injury.

02/03/2025

Radiographs are typically the first line of defense when it comes to imaging.

Oftentimes, radiographs show no bony involvement, leading patients to believe nothing is wrong. This isn’t necessarily the case with bone stress injuries, as we know, early bony issues are missed and may not show up until later weeks.

A 2023 study reports up to 85% of radiographs at symptom onset are negative. Yet repeat radiographs a few weeks later may show new bone formation, indicating healing and confirming the diagnosis.

Further, athletes may decrease activity if they feel pain, leading to some healing before imaging and, therefore, not being visualized on imaging.

Evidence of bony injury may be seen within 2-8 weeks of symptoms. Early radiographs may have as low as 10% accuracy in correctly identifying a BSI. This increases to 30% to 70% in later weeks.

A negative radiograph, therefore, cannot necessarily rule out Bony injury.

Sources

Tenforde, A. S. (2022a). Bone stress injuries: Diagnosis, treatment, and prevention. Demos Medical.

Kaiser, P. B., Guss, D., & DiGiovanni, C. W. (2023a). Republication of “stress fractures of the foot and ankle in athletes.” Foot & Ankle Orthopaedics, 8(3). https://doi.org/10.1177/24730114231195045

DeFranco, M. J., Recht, M., Schils, J., & Parker, R. D. (2006). Stress fractures of the femur in athletes. Clinics in Sports Medicine, 25(1), 89–103. https://doi.org/10.1016/j.csm.2005.08.003

02/03/2025

MRIs are the gold standard for diagnosing bone stress injuries. Per Gaeta et al, MRIs are correct 88% of the time in identifying BSIs and 100% accurate in identifying individuals who do not have a BSI.

Positive imaging findings include periosteal edema followed by bone marrow edema, then progression to a fracture line.

To complicate, some individuals may have periosteal edema on imaging, but this does not necessarily equate to a bony injury. This edema may be present in individuals with no symptoms. Yet, the periosteal edema or bone marrow edema must be present for BSI diagnosis.

MRI is often not the first choice but may be considered at evaluation if there is clinical suspicion for a stress fracture that necessitates restrictive treatment protocol, such as a period of nonweight bearing or cast immobilization

MRI and the Frederickson Scale can estimate the return to sport.
- Grade 1: 2-3 weeks.
- Grade 2-4a, 6-9 weeks
- Grade 4b: 9-12 weeks

Sources
Tenforde, A. S. (2022a). Bone stress injuries: Diagnosis, treatment, and prevention. Demos Medical.

Kaiser, P. B., Guss, D., & DiGiovanni, C. W. (2023a). Republication of “stress fractures of the foot and ankle in athletes.” Foot & Ankle Orthopaedics, 8(3). https://doi.org/10.1177/24730114231195045

01/09/2025

Pain and injury is complex. If it wasn't, they may not be so prevalent.

I like to break down an individual's impairments given how they present, the injury, and what they are trying to return to.

This way, we have several strategies to take to resolve the issue at hand, while recognizing why injury occurred in the first place.

Many factors contribute to a potential injury, yet most will heal when managed appropriately.

01/01/2025

Cuneiform and cuboid bony injuries are rare but may occur.

Along with runners, cuboid BSI may be seen in ballet dancers and gymnasts.

Cuneiform BSIs are rare but may occur in sprinters secondary to high stress through medial cuneiform during the propulsion phase of gait.

Torsional and compressive forces between the planted forefoot and relatively larger hindfoot may play a role in these bony injuries.

If BSI is suspected, x-rays are often the next step but they have poor sensitivity for early BSIs in the cuboid and cuneiform.

Treatment is usually conservative as Cuboid, cuneiform BSI rarely displace.

Successful treatment is typically with immobilization in a walking boot followed by gradual re-introduction into sport as early as 6 weeks.

Cuboid and Cuneiform BSI areas are at an additional risk with plantar fascia pathology, which may destabilize the lateral column of the foot. This may increase the force on the peroneus longus tendon, which runs on the undersurface of the cuboid.

As with other BSI’s, risk factors include:

1. Prior BSI: x6 increased risk for BSI in females

2. Low Bone Mineral Density

3. Medications such as contraceptives, steroids, antacids, anticonvulsants, and antidepressants.

4. Nutritional deficiencies: Calcium and vitamin D, or disordered eating.

12/26/2024

Calcaneal bone stress injuries are the 2nd most common in the foot. Luckily, these tend to heal well with appropriate activity and training modification.

Calcaneal injury may be due to the Achilles' strong pull at its attachment site. The Achilles comprises the gastrocnemius, soleus, and plantaris resulting in the largest, strongest tendon in the body pulling at the calcaneus.

Recurrence may occur with a premature return to activity before resolving the patient’s symptoms and structural integrity.

A 2 Phase treatment regimen may be beneficial

Phase 1: Rest within protected weight bearing and activity restriction until pain-free weight bearing. This may take up to 8 weeks.

Phase 2: Once pain-free, weening off the boot and re-introduction of nonimpact activity Gradual reintroduction of full activity over 6-12 weeks.

Risk factors for this injury include military recruits, female athlete triad, training error, poor nutrition, and certain medications.

Sources

Tenforde, A. S., & Fredericson, M. (2022). Bone stress injuries: Diagnosis, treatment, and prevention. Demos Medical, an imprint of Springer Publishing.

Kaiser, P. B., Guss, D., & DiGiovanni, C. W. (2023). Republication of “stress fractures of the foot and ankle in athletes.” Foot & Ankle Orthopaedics, 8(3). https://doi.org/10.1177/24730114231195045

Tenforde, A. S., Kraus, E., & Fredericson, M. (2016). Bone stress injuries in Runners. Physical Medicine and Rehabilitation Clinics of North America, 27(1), 139–149. https://doi.org/10.1016/j.pmr.2015.08.008

12/20/2024

Bony injury of the tibia is most common among distance runners.

The tibia accepts a significant load during running, around x6-14 one's body weight. This is due to its large weight-bearing function and to the muscles of the calf tugging at this area to counteract high-impact forces.

These occur on the compressive side of the bone and are "low-risk", indicating a good ability to heal without external means (ex surgery). This area has a good blood supply to support healing.

Should they worsen and progress, tibial BSIs might be seen as a continuation of shin splints.

MRI can be used as a prognostic tool to show us an average return to run based on severity.

• Grade 1: 2-3 weeks
• Grade 2-4a, 6-9 weeks
• Grade 4b: 9-12 weeks

12/13/2024

What are some BSI reduction strategies to be mindful of?

1. Build up specific muscles that attach to bony areas at risk for injury.

Most BSIs are fatigue fractures or result when a normal bone is affected by abnormal forces. Muscles may act as a buffer between the stress of running and compressive forces on the bone. A muscle that can tolerate greater stress for longer may protect the site where it attaches.

For example, the lateral hip muscles attach at the lateral femur, this may protect the femur. This is particularly important as the femur represents a high-risk site.

A 1-cm decrease in calf girth equals x4 BSI risk in female track athletes.

2. Optimize Bone Mineral Density

Bone parameters protect against BSI. Optimize this through high-impact activities like jumping, multi-directional movements and powerful movements eliciting a "tugging" effect of a tendon on the bone.

A small difference in cortex diameter has an “exponential effect” on resistance to bending and torsional bone loads.

3. Training

BSIs occur when microdamage accumulates due to insufficient rest, and the bone cannot adapt. Recognizing that there is a lag period between training and new bone formation may assist in preventing BSIs.

4. Footwear

Specific shoe types and orthotics have not been shown to reduce injury rates.

Sudden changes in footwear or running form resulting in changes in loading rates may promote bone stress injuries secondary to abnormal loading patterns a runner is accustomed to.

11/22/2024

11/22/2024

11/21/2024

How do you select a shoe if you’re dealing with shin splints? Watch to find out.

11/21/2024

How do you fix shin splints? Keep Running! We've got to grade it properly to make your running a part of the rehab vs making things worse.

Calf Raise Isometrics in triple extension will encourage strength in the posterior tibialis and soles, both which may be indicated, depending on the case. It also respects the mechanics of running.

Overhead marches are great to work on ankle/foot stability in conjunction with the whole body, since running is a full body movement.

Pogo hops will create a better environment for the bones of the foot/ankle to rebuild and become stronger, since runner alone will not optimize bone health.

Question? Still having trouble? Reach out! There's endless topic to discuss and manipulate with a given rehab process.

11/21/2024

Metatarsal bone stress injuries are the 2nd most common bony injury that affects runners.

Why are they so common? For starters, running is a bottoms-up activity. Distance running's "engine" comes from below the knee, where stress is greatest.

With high demands on the foot, injuries occur. When managed appropriately, metatarsal bone stress injuries tend to have favorable outcomes.

11/20/2024

11/19/2024