We've got some time for some questions now. I can see there's a few that have come through in the question box. I have a quick one for Adam to start with. You mentioned shockwave therapy for plantar fasciitis and Achilles tendinopathy. Now, these are two issues that I've dealt with on a personal level in the last 12 months. What kind of timeframe are we looking to restore back to function with shockwave with something like Achilles tendinopathy? Yeah, so our current understanding right now for full tissue remodeling, and this extends also to some of the bone research I've done, is that it appears that tendons and bones have about a six-month full cycle for tissue remodeling. For most of these conditions like Achilles tendinopathy or plantar fasciopathy, if we look at the clinical studies on shockwave, the full effects are oftentimes reported out at three to four months. That does oftentimes correspond with what we'll see for other orthobiologics such as platelet-rich plasma. I'll say anecdotally though, I've seen that when we treat these in the earlier stages, it does appear that we can turn the corner faster. Having participated in this first clinical trial for Achilles tendinopathy, I recognize how hard it is to recruit participants. Most of the studies are really done in chronic cases as part of the inclusion criteria, but in a lot of Division I programs where I've been discussing strategies for implementation, a lot of the feedback I get is it seems like the athletes are turning the corner a lot faster. It may be youth, but it may also be that we're treating the injuries at an earlier stage, which is helping to modify the process. What I tell my patients is that the outcomes with shockwave, and we didn't even get into hamstring tendinopathy where there's one study showing an 80% pre-injury return to sport with shockwave in athlete population. Those studies all show that outcome starting at three months. I will counsel patients that's really the expectation and that with the exercise program and load management, those are really the three tenets for doing shockwave, but they really should be for any procedure. Okay. Thank you. We've got a few questions in the chat box, so I'll open this up to all speakers. You just feel free to answer the ones that you feel most comfortable with. There's a couple of questions here relating to plantar fasciitis and the role of ankle mobility in plantar fasciitis. One particular person has an athlete who is suffering from plantar fasciitis for the last six weeks. They have a stiff high arch and the mobility of the ankle joint is, I'm not sure if this is not great or is great, but is now at a moderate training load. What kind of suggestion would you have for someone with plantar fasciitis to bring that athlete back to full capacity? It's kind of a broad issue without having that athlete in front of you, I understand. Well, I'm happy to start with that. In general, what we're trying to think about is with the foot. You've got 26 bones, 33 joints, six degrees of freedom. Having a hind foot with restriction is certainly something that manual work can be helpful for. When you think about the surgical approach for plantar fasciopathy, oftentimes they're looking to see if someone has a tight heel cord or gastrocnemius contracture, that would be a reason for considering things like a modified strayer technique. When we're really thinking along the lines of what we're trying to do from a non-operative standpoint, we're trying to address those different factors. Ensuring the athlete is doing an exercise progression, getting manual work, trying the taping, really going back to that green, yellow, red zone, a model, temporary orthosis, taping. Then honestly, something like Shockwave would really be something for a high-level athlete that has a fairly low risk, high reward for an intervention. Again, it's really also thinking about when you're introducing that in a training cycle because one of the things that Shockwave also does is it introduces acute inflammation. You're trying to give that athlete the appropriate load management strategies. Okay. Brett, there's a question here around the multiple factors that can contribute to injury other than just load. One of the factors that you had, I think it might have been load was number two and then number three was ache. Is there some practical ways if we're not working with the best of the best athletes who have access to all the technology, all the monitoring, is there some practical ways that we can use those two risk factors to potentially track our athletes better? Yeah. I think there's some interesting tools with wearables and whatnot to help track sleep and other physiologic markers. I think that's going to be part of the equation. That's already built into a lot of these apps that will say your recovery zone or how long you should rest. I don't think any of that has been validated in terms of injury prevention, but it's something that I counsel my patients about after recognizing that that's such an important factor in their recovery or in their injury prevention is that they need to prioritize putting good things in their body and also prioritizing rest. Because if you are working a full-time job and trying to put in 30, 40 miles a week in preparation for a marathon, you might have to be waking up really early to get those in before work. If you are staying up late watching shows or wrapping up email or whatever you're doing, that's probably not a great equation or a setup for a good response to that high training load. You have to think about, like we've talked about, I wish there was on Strava something that you could be like, hey, I slept for nine hours last night. Kudos to you. You want to be acknowledging and appreciating the recovery side of it just as much as the training side. Yeah, that's a really good point, isn't it? Because everyone wants the kudos from the run and the limited edition Strava entry, but that recovery side of it is an important part of maintaining capacity. Maybe that's something Strava can think about building in. Barry, there's something I've seen around bone stress injuries where some recommendations are that you don't start a return to run program until you're pain-free on normal activities for five days. Is that where we're at with best practice now, or can we be a little bit more aggressive with bone stress injuries? Or is the bone just one of the tissues that, unlike other tissues, we can't cheat biological healing time? Where does that sit? That's a good question. I'm not sure I can give you an exact scientific answer or reference, but in general, I think it is safe, especially for the low-risk injuries, for the athletes to go back to at least modified activity, low impact, swimming, biking, start off with the elliptical machine. I really try to wait until the pain is completely gone before returning back to the running. What's really critical is just that stepwise progression, just making sure you're comfortable at one level. Just like with the concussions, you have to be comfortable doing the bike first, then work your way to elliptical. Some places may have the special machines where you can run at 30% of your body weight and then increase it to 50%, the anti-gravity machines. If you have one of those, that's great. But otherwise, I think you just have to just take it step by step, make sure you're comfortable at one level before you bump it up to the next level. There's a question here that's come through around supplementation. The question is, although I recognize the benefits of a healthy, balanced diet, as well as carbohydrate and protein consumption post-session, what specific supplements, for example, collagen, peptides, calcium, would you recommend for female adolescent athletes to take to prevent running injuries? I can't say that there's one supplement that's going to prevent these injuries. I haven't seen any data showing that they can be preventive. The key is really just getting sufficient caloric intake. If you're running 10 miles a day, you need to eat twice as much as you were eating before. A lot of these athletes are not doing that. That's really key. If you're not comfortable, send the athlete to a dietician and they can monitor their caloric intake and make sure they're getting enough calories because that's really the most common. Other than training errors, it's the caloric intake. That is really the key. A lot of these athletes have low calcium or low vitamin D. That may be a way to start to work up. The DEXs aren't always necessary early on unless there's some sort of a high risk or recurrent or some other problem identified. But really, the key is just making sure that they have the caloric intake to match their caloric expenditure. I really agree with Barry. It's so fun to be on a panel with you, Barry. I've been citing your high risk, low risk work my entire career, like bone stress injury. There's really maybe two supplements that I think we struggle to get enough in our diet. One is vitamin D, which erroneously, people just assume that sun exposure is going to be sufficient. There's a number of different factors that are going to affect whether people have that pro-hormone. That plays a huge role in bone metabolism. The other was one of the comments you made earlier, Barry, about iron and our understanding that iron's involved in over 200 enzymatic pathways, including the electron transport chain. Your metabolism and a number of different factors. We've seen low iron status associated with triad risk factors in collegiate athletes. Those are really the two areas where I do think that endurance athletes should consider supplementation. I 100% agree with Barry that almost any of these athletes would benefit from seeing a dietician when they're dealing with a bone stress injury or another injury because there's a lot of unintentional under-fueling and a lot of key micronutrients and even components of the energy availability that we sometimes miss at different stages of the day. Really developing those behaviors early on so that young men and young women look at fuel as a way to recover. Sleep is critical for recovery as opposed to looking for the multi-billion dollar nutraceutical industry to save ourselves and to try to isolate that one thing, that peptide that I was missing from my diet. I was like, for goodness sake, man, eat protein. There's your peptides. Barry, a question here around bone stress injuries. Is blood testing and DEXA scans needed for all? Well, I don't think the DEXA is needed for all. I mean, you could make an argument for any athlete to consider a CBC, an iron panel, checking their vitamin D to start. Again, we talked about the caloric intake is really critical. If they have multiple triad risk factors, you could consider getting a DEXA. I mean, if they have a high risk stress injury, if they have recurrent stress injuries, if they're about to undergo surgery, you could consider getting a DEXA. If they've had significant weight loss, another reason to consider it. So, but not, I wouldn't say that everybody needs a DEXA that has a stress injury, especially, you know, low risk stress injuries. They have a classic history of, you know, they just ninth grader, they just joined the cross-country team, you know, and they're healthy otherwise. You don't have to send all those athletes for a DEXA. Yeah. Yeah, I find anecdotally that you can, the DEXA can be more helpful if you are considering a more extensive battery of blood tests just to document the necessity for that. I do agree with Barry that just the basics of vitamin D, a CBC and a ferritin can be really helpful to kind of pick up on like any of the key micronutrient deficiencies. But yeah, the triad coalition has, you know, the whole concept if you have two of the moderate risk factors or one of the high risk factors, or with some of these bones, there's the whole concept around trabecular rich, cortical rich, which again is maybe an area of controversy. But in general, the femoral neck and the pelvis seem to be associated with a higher rate of having low bone mass. So I oftentimes will look at the, you know, particularly like the female athlete with the sacral bone stress injury. That's almost like a canary in the coal mine where you should at least consider a DEXA in those cases. But to Barry's point, you know, there's oftentimes like, you know, the posterior medial distal tibia or a metatarsal bone injury. Oftentimes it's probably more driven by biomechanics. Adam, shockwave therapy has proven to be a very, very popular from based on the questions that are coming through. How often can you do treatments? I'm sorry, what was the question? What is the frequency of treatments? How often can you do it? Okay, so the general literature is three to four weekly sessions with the full effect scene at three months. I also will use it for bone stress injury where there are, you know, again, lower level of evidence. We have a four center randomized clinical trial that we're about to start to hopefully understand how shockwave may be used for bone stress injury healing. In the management of bone stress injuries, you're actually using high energy focus shockwave every two to three days unless it creates an excessive inflammatory response. And then you're really doing it once a week for three to four sessions. And those were some studies talking already looking at the anterior tibial cortex or Jones injuries where they were using electromagnetic shockwave for three to four weeks and delayed union, non-union and actually seeing radiographic healing and return to support on average three to four months later. To Barry's point though, these high risk injuries particularly when you're working with an athlete population that doesn't wait, there's also the case to be made of considering, you know, surgical pinning in the Jones injury or in the anterior tibial cortex injuries just because of the high risk that it may not heal. And I don't think there's any controversy for the tension sided femoral neck bone stress injury that those really do need to be prophylactically pinned. Right, there's a couple of questions here on pain and load management and maybe I can address this one. The question is, how do we correlate pain and load management? How do we modify training to an objective based treatment since pain is a subjective scale to provide an input to exercise? This is a little bit of a tough one because throughout these three presentations we've been talking about tissue damage and clearly there is a link between pain and tissue damage. When you have tissue damage, then, you know, it'll typically be associated with pain. So the first thing when we have pain is to rule out tissue damage. What we have to realize though is not all pain is driven by tissue damage. You can have pain that's driven by multiple sources. Once we've ruled out tissue damage, we've ruled out a physical component of that pain, then we have to understand that the sensations that that athlete is experiencing are driven by psychosocial. They can't be, if it's not physical then it has to be driven by something else. It has to be driven by psychosocial. Now the trick for us as practitioners then is to spend the time trying to work out what it is that's driving those factors. So if you believe that pain indicates an underlying danger to the athlete or that they're vulnerable, probably what you'll do is you'll back off training with that athlete. But if you back off far enough, you end up with a very deconditioned and a vulnerable athlete. And with no physical capacity, no psychological resilience at all. The other end of the spectrum though is if you believe that pain is a sign of weakness. And we all know the drill sergeant coach who punishes the athlete because they believe they're weak. They train them harder to toughen them up. And what happens then is that pain is exacerbated or that it does actually lead to tissue breakdown. So there's two pathways that you could go down. One where you back off the training, one where you train them harder. The third option though is one where I'd kind of encourage every one of our listeners to think about. And that is that pain can be driven by multiple sources. It doesn't always have to be associated with tissue damage. Now the trick for us as practitioners is working out what is driving those sensations. If we can identify what's driving those sensations, then hopefully we can educate the athlete around managing those sensations a little bit better, managing those triggers. And then as practitioners, what we're trying to do is find the highest load that's tolerable for that particular athlete. And when we can do that, and if we can do that progressively and on a consistent enough basis, then hopefully we're able to restore that athlete back to a capacity that's high enough for them to tolerate their everyday tasks, whatever that tasks are. But there's only really three options. One is you back off your training. One is you push them harder and maybe they break. And then the third is you think that maybe there's a whole heap of possible contributions to that pain experience and trying to work out what's driving those sensations. But I'm happy to open it up to the other presenters as well. Maybe you've got a different view on this as well. Maybe you come at it at more for it. Maybe in your experiences, you deal mostly with the end point of injury and injury is what's driving that pain. I'm not sure. Would you like to start, Adam? Or you want me to go first? Oh, hey, I'm happy to take a stab at this. This is, I agree with Tim. I mean, there's, you know, pain is oftentimes multifactorial and, you know, it depends on the experience of the runner because, you know, runners have to learn that basic tenet of listen to your body. When they learn that they oftentimes will understand how to modify their training loads so that they continue to maintain some level of activity allows for fitness enjoyment and avoids kind of all of the deterioration that the athlete experiences when they're going through a very equivalent of a withdrawal response to exercise. I think of it in a slightly different way though, with a lot of the soft tissue injuries of more of central versus peripheral sources of pain. And really some of the, you know, recent pain science suggesting that we develop more of these centralized pain mechanisms even three months into a soft tissue injury. So again, it really depends on a number of different features, you know, pain that's consistent, builds, you know, those are the types of things that, you know, and really seems to be load dependent. Those are the types of things that oftentimes lead us to be concerned about a more significant injury like a bone stress injury versus a warmup effect, which might lead us to thinking about it as soft tissue. But again, when we see a disproportionate pain response or allodynia or some other features, you do have to start to think about more centralized pain or other pain mechanisms that get in the way. And there is definitely a pain psychology that goes into things, even, you know, runners that have recovered from a bone stress injury and they have radiographic evidence of resolution of bone edema on an MRI or an x-ray that's completely normal. And yet they'll continue to experience something that resembles phantom pain. And that really does require a multidisciplinary team to help the athlete and really to look at both their physical health and their mental wellbeing when you approach how to get that athlete back into the activities they enjoy. Yeah, I would agree with Adam. I think the really critical thing to do is to teach the athlete the concept of knowing your body. And you get the answer to this question all the time in the office. And just from a common sense perspective, I try to teach them, you know, what's normal, what's abnormal. You know, there's normal aches and pains with exercising, running, playing sports, you know, I know things typically go away in 24, 48 hours, but if something becomes more chronic or it's more than usual, the pain is increasing, then, you know, those are warning signs. And I think the really great athletes just know their body so well that they can stay right below that injury threshold, which is really just critical. I'm sure you know that Adam is a high level runner. I mean, you look at people like Michael Jordan, he had a tarsal navicular stress injury his first year of playing, but he had practically no other injuries after that. I'm sure he had aches and pains and things like that, but it's the art of taking care of your body and not, you know, pushing through that abnormal pain, which is really an important lesson to teach the athletes. Yeah, I totally agree, Barry. It's almost as I like to say for athletes, it's the wisdom that injury brings to the athlete. You really become wise when you've learned how to address an injury and hopefully that wisdom allows you not to, you know, exceed the tissue capacity, that envelope of function. Great answers from both of you. Thank you very much. We've got, we're coming up to 90 minutes and I know your time is very valuable and I know the time of our listeners is valuable as well. So we'll finish with one final question and question is for Adam and Barry, what are your thoughts on the effectiveness of insoles and acupuncture? I would answer, you know, soft science. There is no really hard data. I mean, acupuncture can be helpful for pain. Someone's going through a painful phase, you know, reduce the pain while they're healing. I'm not aware of studies that show it's going to, you know, hasten the healing process as far as orthotics go. I think if there's a structural problem with the foot, I think it is reasonable, but I don't think that every athlete needs an orthotic. You know, if they have significant pes planus or plain ovalgus or, you know, that's causing a posterior tibial tendonitis, you know, that's an indication, but I don't think that every athlete needs an orthotic. I think, you know, the shoes these days are very good and a proper shoe is, you know, satisfactory, sufficient for most runners. Yeah, no, I completely agree with Barry. I mean, acupuncture, I mean, let's face it, people will get dry needling, they'll get wet needling in the United States and a lot of Western countries. We're just doing what Eastern medicine's doing with acupuncture. So there's probably some science to it. You know, if you have an athlete that says that works for them and it's not breaking the bank and keeping them away from the basics of load management and doing the appropriate exercises and understanding what the injury is, I don't see huge downside with it, but I agree that the science is probably not as strong as we'd like it to be. Likewise, with the use of foot orthosis, I agree with Barry. I really reserve those for people that have more advanced structural deformities of the foot and ankle. I think oftentimes if we approach it the same way as someone who has back pain, we wouldn't put them in a back brace the rest of their life. We would be thinking about how do we restore good neuromotor control and strength. So, you know, I think you're not wrong sending people to physical therapy and then, you know, considering foot orthosis for more advanced cases or as kind of a bridge therapy to get people to feel better.

shockwave therapy

Achilles tendinopathy

plantar fasciitis

load management

bone stress injuries

multidisciplinary approach