In this episode, Owner of Sisu Performance and Physical Therapy, Dr. Ellie Somers, talks about bone stress injuries, specifically in female runners.
Today, Ellie tells us about differentiating between the male and female runner, and she elaborates on a subjective and objective exam of a bone stress injury. We learn about the most vulnerable sites for a bone stress injury, the misconception about the severity of the diagnosis, and the strategies Ellie uses to get women on to strength and flexibility training programs.
Ellie talks about the concerns that many people have after a BSI, and she gives her younger self some valuable advice, all on today’s episode of The Healthy, Wealthy & Smart Podcast.
- “Female runners have a lot of particular and special needs and considerations when talking about evaluation from a physical therapist perspective, as well as from a communication standpoint, that need to be considered.”
- “When you’re getting someone into your clinic, you don’t want to make assumptions about their circumstance.”
- Things to consider in a subjective exam for a bone stress injury:
- Is the patient grasping why they got into this situation? A bone stress injury isn’t necessary about the shape of their body or foot, it’s a result of limitations of their dietary intake.
- Their menstrual cycle. This can be an uncomfortable conversation for many clinicians, but it is a required question for a subjective exam.
- “If a runner is coming to you explaining that they think they sustained a BSI because of their pronated foot or because they were wearing the wrong shoes, we’ve missed a huge piece of why bone stress injuries actually happen.”
- The most vulnerable sites for a BSI: The femoral neck, the first and second metatarsal, and the anterior tibia, among others.
- The objective exam:
- Palpation, single-leg balance, and walking.
- More explosive movements. These include the single-leg hops and taking steps up or down.
- “You can still be stressing bone and it’s going to heal. When we don’t stress bone enough, it could theoretically take longer and put that bone in a more vulnerable position.”
- “Women athletes are more prone to lower bone density than male athletes are.”
- “Runners kind of have this misconception that running itself actually strengthens bone. In reality, it doesn’t really strengthen bone as much as we’d like to think.”
- “History of bone stress injury is the number one risk factor for new bone stress injury.”
- “There’s no rush. You have your entire life ahead of you to work and refine. As long as you’re working on something, you’re working towards it.”
Running Injuries, Rehabilitation, Therapy, Physiotherapy, PT, Training, Injuries, Sport, Wellness, Health, Recovery, Female Runners, BSI, Bone Stress Injury, RTS
More about Dr. Ellie Somers
Dr. Ellie Somers is a physical therapist, run coach, weightlifting coach and the owner of Sisu (pronounced see-su) Performance and Physical Therapy in Seattle, WA. She also serves as the team physical therapist for the women’s United States Australian Rules Football Team. As a private practice owner and coach, Ellie specializes in work with women athletes, specifically runners and field athletes.
To learn more, follow Ellie at:
Facebook: Sisu Performance PT
Website: https://sisuwolf.com/resources/e-books/return-to-run (FREE gift!)
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Read the Full Transcript Here:
Speaker 1 (00:01):
Hey, Ellie, welcome to the podcast. I’m happy to have you on. Thanks for having me, Karen. So this month we’re talking all about running injuries. Just so people coming onto the podcast is the first time you’re listening this year, sort of changing up the format each month is a different we’re focusing on a different topic. So last month was all about ACL injuries. This month, we’re going to concentrate on running injuries, which is why Dr. Lee summers is here. And today we’re going to be talking about the female runner. So Ellie, my first question is, are female runners, just little petite male runners, and it should be treated as such.
Speaker 2 (00:38):
Well, obviously the answer to that question is drum roll, please. No, yeah, yeah. I think female runners have a lot of particular and special needs and considerations when talking about evaluation from a physical therapist perspective, as well as from a communication standpoint that need to be considered.
Speaker 1 (01:02):
And what kind of, can you kind of differentiate that male runner from the female runner? What are kind of some of the big differences that if you are a physical therapist, a run coach, even a personal trainer, a strength and conditioning coach, what are some things that we need to be aware of in the female runner?
Speaker 2 (01:20):
You know, the way that I think about this, I actually think about it from a bio-psycho-social perspective. So what women are exposed to in our environments, in our engagement with other human beings, with social dynamics and things of that nature is very different than what men are typically exposed to. I also think of it as you know, generally speaking in terms of adaptability, women and men have the same traits and characteristics, but certainly things that need to be taken into consideration for women include our biology and physiology more specifically our menstrual cycle and hormone cycle. So I tend to think of it as a very holistic thing. And what are the things that female runners might be exposed to that set the stage for certain types of injuries or pain experiences that maybe male athletes aren’t or are less likely to be
Speaker 1 (02:22):
Right. Got it. And so now let’s take a common injury that you may see in a female runner, and let’s talk about what you would how you would go about your subjective exam, and then we’ll get into objective exam and some possible treatment options, but let’s take a bone stress injury, pretty common in female runners. So first talk about, well, actually, let’s talk about why is that common in female runners?
Speaker 2 (02:54):
That is a great question. Lots of there’s probably a lot of nuance to answering that question. I think theories abound and I’m thinking of those series. I think that the primary thing that we get exposed to as female athletes is how do I want to phrase this considerations about our body and in the run community? I think it’s a lot more pervasive for women athletes. So not only are women on the whole exposed to messages about their body, that they need to be smaller, that they need to be thinner in the run community itself. Women are then also exposed to this concept that you’d need to be in order to get faster. You need to be thinner. And that sets the stage for eating disorders and diet restriction and limitation that can lead to bone stress injury.
Speaker 1 (03:55):
Got it. Okay. So obviously very sensitive subjects. So the subjective exam becomes all the more important. So walk us through maybe how some questions that you would ask and kind of how you would asking keeping that sensitivity of this may be a person that’s experiencing maybe some eating disorders or experiencing some body image body image issues. So walk us through your subjective exam.
Speaker 2 (04:27):
Yeah. So I think it depends on what they’re coming to you for and what you know already. So depending on your clinical setting, you might already know they’re coming to see me for a bone stress injury. And this person may have already seen a physician and had the imaging done at which point you may not need to dive into a lot of detail there, but I think what you want to try and capture is is this person grasping why they got into this situation. And I think as a clinical provider, that’s working to reduce risk, prevent air quotes around prevent these types of injuries. You need to understand that this person knows that bone stress injury isn’t necessarily a result of the shape of their body or the shape of their foot. It’s the result of really limitations on their dietary intake. So when you’re getting somebody into your clinic, you don’t want to make assumptions about their circumstance, but I think it, it behooves you to start to ask questions around, you know, do they understand why they got this injury?
Speaker 2 (05:40):
And if their answer to you is while I was over-training, you might want to start to dig deeper and figure out if you can fill any gaps and holes there to help them understand that fueling strategies are a big contributor to these injuries. So subjectively there’s that piece to cover. Then I think you also have to think about how do I want to say this their menstrual cycle basically. And I think for a lot of clinicians, these topics can be very uncomfortable, hard to, to talk about, hard to ask questions of, but when you’re doing a subjective exam, this is a required question to be asking, what is your menstrual cycle? Like, are you having regular and normal periods? When did you start your period? At what age, if you’re not comfortable asking these questions in a face-to-face manner, or you don’t think it’s appropriate for you, then they definitely need to be included on your intake forms. And you need to be reviewing your intake forms before you see that person in your clinic. So those would be, I think the two primary things that you need to sort of start to get a picture of, because if a runner is coming to you, explaining that they think they sustained a BSI bone stress injury because of their pronated foot or because they were wearing the wrong shoes, we’ve missed a huge piece of why bone stress injuries actually happen.
Speaker 1 (07:17):
And I really do like including that on your intake paperwork, because then even if, whether you’re uncomfortable asking that question or not, or you are comfortable either way, I mean, either way, quite frankly, you should be comfortable asking that question. I don’t care who you are. You’re a physical therapist, you’re a healthcare provider. That’s a question you should be very comfortable asking because it is part of their medical record. And part of, of like can be part of the reasoning behind these bone stress injuries. But it also gives you if it’s on your intake form, it also gives you more information so that when you are in your subjective exam, you can perhaps hone into that and you can even say, Hey, listen, on my on the intake form, I noticed that you’re not having like regular periods. Can you tell me a little bit more about that and that’s it.
Speaker 2 (08:16):
Yeah, exactly. Yeah. And I think all it will show you is, is this person having energy demand issues? You know, we know that if you’ve lost your period or you’re having irregular periods, it can be a very clear objective indication that your energy in is not matching your energy out. And it’s what we would call somebody suffering from low energy availability or in the, the more maybe more like broad terminology would be relative energy deficiency in sport. And this can cause a host of different and problems. And the last thing you want to do as a clinician or provider is I think miss that, especially in a female runner, because it just sets them up for recurring bone stress injuries, or recurring injuries. And that cycle will just repeat itself.
Speaker 1 (09:11):
Yeah. Now, okay. So you’ve asked those questions. Are you asking questions on how much are you running? How often are you running? Have you picked up your mileage and things like that? Is that something that you’re asking as well?
Speaker 2 (09:25):
100%, because a lot of the times people who are training for a new distance of an event, right? So if I have a person who’s like I was training for my first marathon, they might have sustained a bone stress injury as a result of some of that increase in strength in training while also maybe not matching that with their fueling. So it helps you get a picture of what this person is training for and why they’re training for it and how much training they have. And then you can move forward from there with a more practical plan as a physical therapist on how we’re going to strategize a graded return to activity.
Speaker 1 (10:07):
Got it. Okay. Any, what else are you asking? What else do you need to know from this patient,
Speaker 2 (10:19):
Everything else that you would need to know in a physical therapy exam? I think you know, I think for a lot of folks, these injuries are scary and they’ve disrupted their lives to a great degree. A lot of these runners will have to stop running for months of time. So all of the same questions you would ask, but then I would also add onto that. You want to know, sometimes you want to know, does this person have a registered dietician as part of their care team? Are they working with an endocrinologist? Have they had any blood work done to determine if they were suffering from relative energy deficiency in sport? Do they have a team of people that can help support their progression back to play? Now? I want to be clear. I don’t think every single person who has a bone stress injuries requires a team of people. I think it’s an ideal. And if I’ve got somebody who’s come in, who’s got a bone stress injury, and doesn’t have a team of people I’m planting seeds to get them, that team. So that they’re set up for success.
Speaker 1 (11:34):
Yeah, that makes sense. Yeah. And gosh, I just had a question and it was like in my head and just went it’ll it’ll come back. It’ll anyway, it’ll come back to me. I’ll edit this part out. It’ll come back to me. Cause it was a good one. It’s there it’s there. I just there’s days. It’s just it’s. I was like, Oh, I got to ask this question anyway. If I think of it later, I’ll ask it later and we’ll just splice it in. No one will know the difference. Oh yes. Got it. It’s back. Okay. So is there a difference when someone is coming to you via direct access, just versus someone has already been to a physician, they have been diagnosed with a bone stress injury. Let’s say they had some imaging done. It has shown up where, what is the difference there? Is there a difference in your examination of this person?
Speaker 2 (12:28):
Yes, absolutely. Because, and I work primarily in a direct access capacity. So by when people come to me, they haven’t typically seen anybody else. And now it’s my responsibility to be able to pick up on these things and tell someone, you know, I need you to go see your physician. We need to rule out bone stress injury before we move forward. So from a purely exam standpoint, when somebody is coming to me, who is a runner who potentially has pain at a site that could be risk for bone stress injury, I need to have the evaluation skills to be able to, to rule that in or rule that out to some degree so that we can move them in the right.
Speaker 1 (13:15):
Got it. And what are those sites? What are the most vulnerable sites for a bone stress injury?
Speaker 2 (13:21):
Well, the femoral neck is one of the most vulnerable, I would say anyone who’s coming in, who’s a female athlete. Who’s complaining of anterior hip pain. That’s maybe a little bit vague and is presenting with some of those additional sort of risk factors changes in their menstrual cycle, low energy availability training, abrupt training changes. I’m starting to stew a little bit and get a little bit concerned. So that’s going to be a high-risk stress fracture site, some other high risk stress fracture sites include the first and second metatarsal. And I want to say the anterior tibia as well. It’s likely that I’m forgetting one, but yeah, some of those regions are considered high risk. High risk essentially means that the likelihood for healing is a little bit harder, I guess you could say.
Speaker 1 (14:18):
Okay. All right. Thank you. All right. Now let’s move on to your objective exam. So what kind of things are you looking for? Are you going to say to this person, let’s get you on the treadmill and see what you’re doing with your run? Okay.
Speaker 2 (14:34):
That’s the great part of the subjective exam because the subjective exam is going to lead me into thinking whether or not I need to test for bone stress injury before we pursue running. Right. And there are a couple of things that are going to lead you that some of which I’ve already talked about, but site-specific pain is definitely one of them, localized pain. Sometimes people will point directly to their pain and be like, it’s right here. They can have pain in, I know femoral, neck stress fractures. They can have pain with offloading. So sometimes they’ll say, you know, like stepping off of a step, I suddenly have pain in my hip. So there are things that you’ll just pick up on and then you do not want to get on the treadmill at that point, if you’re suspecting bone stress injury, you need to do the tests to sort of rule it out before you get to the treadmill. Some of those tests that I would do, I think first would probably be about palpation. So depending on the area, you know, the femoral neck is
Speaker 1 (15:42):
D that’s tricky. That’s a tricky one to help paint,
Speaker 2 (15:46):
Be able to get there with your hands, but certainly a medial tibial region or an anterior tibial region. You can palpate that with your hands. And we’re looking for pretty pinpoint tenderness. From there we might get them up and then first have them walk. What’s their walking look like, is there any offloading happening then I might have them do a little single leg balance. How does that feel? A lot of the times people may not have very distinct acute pain with some of these low level impact activities, right? So if they’re presenting with no pain, now this sort of, I’m going to describe it as like this first level, no pain with walking, no pain with single leg balance. Now I want to get them doing a little bit of an explosive move, maybe a step up or step down and determine are they having pain with some more functional tasks? And I think the single leg hop test is a pretty, like just straight up and down. Three hops is a pretty decent maneuver for almost any lower extremity potential stress fracture site. You know, I don’t know the statistics on reliability and validity, but it’s one that I use very regularly with somebody I’m suspecting that. And then from there you can kind of make a determination about how you want to proceed. Typically, speaking of the folks that I work with, they’re going to have pain in one of those moves.
Speaker 1 (17:20):
Yeah. And, and at that point, does it then come down to, if you’re seeing them via direct access, explaining to them, Hey, listen, this is my hypothesis. Let’s get you to a physician at that point. Yes.
Speaker 2 (17:34):
Yeah, yeah. Okay. Yeah. Usually I’m revealing at that point, I’m concerned for bone stress injury. I want to get you, you know, examined for that. So, and they can, you know, go to their physician that they know and that they trust. But I think it’s important depending on the region that we get the right imaging. Certainly if I hip femoral, neck stress fractures suspected, I really want to push that person to try and push for an MRI. So you know, it kind of depends on your relationship with the person and where they’re at on a lot of different levels, but, but that’s what we’re going to be going for.
Speaker 1 (18:15):
Okay. And so let’s say this is someone who has already gone to the physician. They’ve had the MRI, this is diagnosed. So you’ve done your evaluation now, what do you do? I guess the question is, is, are they come, are they non-weightbearing at this point? What are, what are some things that we can do as physical therapists for these patients when they’re coming in? They’ve already been diagnosed?
Speaker 2 (18:37):
Yeah. Well, so many of these athletes don’t get referred to physical therapy in the first place, which I think is a problem. But yeah, if you are getting these people, we really do want to be loading those tissues. And bone responds really positively to stress as long as the environment is you know, a strong, healthy, robust environment as well. So depending on their level, we’re going to be progressively loading those tissues all the way up into the point where they’re cleared for a return to run. So, you know, squats step up step downs. If they’re not cleared to weight bear, you know, we’re definitely doing stuff on the table, that’s just pull it using the muscles around that tissue. And even just by using the muscles around that tissue and the injury, you’re stimulating bone adaptations that are positive.
Speaker 1 (19:37):
And so I guess the, the thing that might come into a patient or a therapist is, well, if I’m non-weightbearing, I don’t really want to do anything with this side. Cause what if I make it worse? Right. So is it, is this injury, let’s say we’re talking about a femoral neck BSI, is this injury so fragile that if you’re doing things in a non-weight bearing capacity, can that make it worse?
Speaker 2 (20:05):
Not typically. You know, I, I, I tend to think that people who have had BSI or are so much more resilient than they get credit for, I have had and seen, and I don’t commend this necessarily. So many runners who have run through BSI and there is, there is some toxicity there to unpack that we don’t need to do today, of course. But all that tells me is that you can still be stressing bone and it’s going to heal. And I think what we know is that when we don’t stress bone enough, it could theoretically take longer and put that bone in a more position. So in my opinion, all of these athletes with BSI need to go to a physical therapist so that they can load those tissues up. Yeah,
Speaker 1 (20:56):
No, that makes, that makes perfect sense. And I just wanted to kind of make that distinction because I’m sure if someone is told, Oh, you have a bone stress injury, you know, scary, scary, right. Very scary. And that’s where I think the team comes in. Like you said, assembling this team around that, around that runner is so powerful,
Speaker 2 (21:20):
Right? I mean, gosh, I think those soft skills are invaluable when working with women who have had BSI, because so many of these runners it’s like totally ruined their perception of who they are and their worth and their value. And so you have to be really good at being a kind and generous and thoughtful and considerate to that person’s experience because it’s still very much in a way I’m going to use the word trauma to them. And I think not everyone is going to be ready to work with a mental health therapist or work with a registered sport dietician. But I think as their support person, your job as a physical therapist is to really listen to what’s going on and gain some of that trust so that you can softly nudge them in those directions and work them towards a more robust, healthy lifestyle.
Speaker 1 (22:23):
Yeah. Because you don’t want this single bone stress injury to set off a cascade of other events. That could be really detrimental to them. Not only as an athlete, but just as a person.
Speaker 2 (22:36):
Right? Yeah. I mean, women athletes are more prone to lower bone density than male athletes are. I’m just women in general. Let’s just use women in general and runners, you know, runners kind of have this misconception that running itself actually strengthens bone in reality. It doesn’t really strengthen bone as much as we’d like to think. And all that means as women is we need to be thinking about other ways to strengthen our bones. If that’s something we care about.
Speaker 1 (23:08):
Right. And that’s where a good strength training program comes in for runners because I have spoken and I have treated plenty of runners and runners like to run when you tell them, Hey, you, we should get you on a robust strengthening program. It’s like, what a no. So, yeah. So now let’s say you’re, we’re still in the treatment process. So we’re, we’re past the, this vulnerable part of the bone stress injury. They’re able to weight bear, they’re able to do more. What strategies do you use to get these women on to strength, training, flexibility programs?
Speaker 2 (23:49):
Honestly I show them, I think that’s like a big component of how I work with the people that come to see me is showing them what they need to be doing. And first of all, that it’s fun and that it can be fun that it’s not intimidating and that we can keep it really simple and easy. And it doesn’t have to be a huge long laundry list of exercises to keep them healthy. And FEMA women especially are so subject to carrying, you know, a list of 20 to 30 exercises that they’re doing to, you know, through the guise of staying, I’m going to use air quotes, healthy and keeping tissues healthy, and it’s just way more than it’s necessary. So I think part of why women, like working with me is I have been able to really speak their language, pare things down significantly. So that it’s simple. It’s, you know, 25 to 30 minutes, one, one to three times a week is really all runners need to, to keep that bar trending in the positive direction.
Speaker 1 (24:56):
Yeah. And I think that’s an important distinction to make because oftentimes we think we have to work out five days a week and it has to be this like really complicated. I have to do a chest day. I have to do a leg day. I have to do a hamstring day. I have to do a quad day. I have to. And with all of that said, you’re like, Oh, screw it. This is too complicated. I’m just going to run. Yeah, no,
Speaker 2 (25:20):
I do not blame them whatsoever for giving up on programs in part, because they’re just so complicated. And for runners, we just need to keep it simple, keep it clean, keep it short and sweet and to the point and get on, get on our way.
Speaker 1 (25:37):
Yeah. Excellent. Excellent advice. Now, is there anything that we missed as far as that treatment aspect with these women with bone stress injuries, and obviously we’re not going into like individual programming for an individual person because it’s so varied. I’m sure. But I guess, are there X speaking of exercises, are there exercises that you do like to include with most of your runners?
Speaker 2 (26:06):
Yes. So they’re getting lower extremity strengthening exercises. So, you know, a squat and a deadlift of some sort, all of my runners will give that we’re also going to be incorporating and especially for bone stress, injury, plyometric, explosive exercise. So, you know, squat jumps, counter movement jumps, broad jumps, Pogo jumps. We don’t have to do those in like a hit style. If that makes sense. We don’t need to be like every minute on the minute you’re doing this many jumps or whatever for runners, what we need to be doing is doing it to load the bones for one and two, doing it to create and foster tendon stiffness. And so I think there’s a little bit of a misnomer amongst women athletes, especially that in doing plyometrics, they have to be really, really intense. And I’m of the opinion that we want your running to be really, really intense. We don’t also need your strength training and your physical therapy to be to the nth degree, intense just needs to be targeted.
Speaker 1 (27:21):
Yeah. That makes a lot of sense. So you don’t need to like kill yourself on your workout day and then go out and run the next day with like jelly legs. Right.
Speaker 2 (27:30):
Speaker 1 (27:32):
Yeah. It doesn’t make sense. It doesn’t make sense from a running standpoint. It may make sense in, in another population. Yes. But you have to be specific with your population. And this is where the skill of a good physical therapist comes in to be able to tailor that program, to that specific runner and what their needs are, especially coming off of a bone stress injury. Right. Exactly. And is there a fear in the runner after a bone stress injury, and you say to them, let’s start doing some jump squats. Like what lady are you kidding me? Yeah.
Speaker 2 (28:08):
Yeah. I think people are pretty forward with some of their concerns and their worries. And depending on the capacity that you’re seeing them, you see it in their body language. Right. But that’s why physical therapy is so advantageous because that’s where we Excel is helping people understand why something is valuable and then why it’s safe. So I think it’s about addressing those fears, head on getting at the heart of what they’re concerned about and meeting them exactly where they’re at. You know, maybe if they’re not ready for that, we just try something else. In the meantime, until they’re building up confidence, there’s not a single person that I’ve worked with who has had a bone stress injury that doesn’t have some of those fears pop up. It is a very real piece of a return to sport on any level. So,
Speaker 1 (28:59):
Yeah. Agreed. Excellent. Now, is there, is there anything that we missed, anything that we glossed over that you feel like you want to explain to the listeners a little bit more, or do you think we’ve covered, you know, sort of the high level basics on how you would look at one of these patients with a bone stress injury?
Speaker 2 (29:20):
Yeah, I think we covered most of it. You know, I think in, you know, reflecting back, it’s really just understanding that we don’t want to make assumptions about somebody’s circumstance. You don’t want to assume that somebody with bone stress injury has an eating disorder. I’ve worked with a number of people who have bone stress injuries, who do not have what I would consider disordered eating to the level that it’s clinical. They just didn’t understand how much fueling might be required for their activity. So I think in your subjective and in your relationship building with these people, it’s important to keep that in mind that we don’t need to medicalize everyone that walks in our door with a bone stress injury, but certainly we want to prepare them better for the future. I should also add that history of bone stress injury having had one in the past is the number one risk factor for a new bone stress injury. So in your history, in your subjective exam, that’s another great question to ask. Have you ever had a bone stress injury before? If the answer is yes, you’re already starting to postulate that that could be a possibility.
Speaker 1 (30:33):
Got it. Excellent. Excellent. Well, this was great, Ellie. I think that you gave the listeners a really, really robust understanding of looking at bone stress injuries from the point of view of a physical therapist. So thank you very much. This was great. Thank you. Yeah, I appreciate being here. Of course. And then where can people find you?
Speaker 2 (30:57):
Yes. So you can find me on my website, www.cc wolf.com. It’s brand new. I’m just going to say brand new France shine. You can also find me on Instagram handle firstname.lastname@example.org. And if you want to reach out to me personally, I love getting emails from folks it’s Ellie, E L L I E at [inaudible] dot com.
Speaker 1 (31:23):
Awesome. Well, thank you so much. I have one final question for you and it’s one that I ask everyone. And that’s knowing where you are now in your career and your life. What advice would you give to your younger self? Let’s say right out of PT school.
Speaker 2 (31:39):
There’s no rush. There’s no rush. I think, you know, as a young PT, it was like, I want to be the best now. And you have your entire life ahead of you to work and refine and you know, as long as you’re working on something, you’re working towards it. So there’s no
Speaker 1 (31:58):
Excellent advice. I love that. So everyone, no rush, no rush to all those student physical therapists out there. Well, Ellie, thank you so much. This was great. I really appreciate your time. Thanks Karen and everyone. Thanks so much for listening. Have a great week and stay healthy, wealthy and smart.