Belinda Beck is a Professor in the school of allied health services at Griffith University. She has been involved in bone health research for 20 years and published over 100 research papers. Today, we discuss stress fractures and bone health. We start with the adolescent population and why diet, bone loading & peak bone mass is so important in this population. Secondly, Belinda dives into symptoms, risks, causes and treatment of stress fractures. Lastly, we talk about the masters runner and aging populations. What is the best approach for the treatment and management of bone conditions such as osteoporosis? Click here to head to the bone clinic website You can also find the bone clinic on facebook Also follow Belinda Beck on Twitter (Apple users: Click 'Episode Website' for links to..) Become a patron! Receive Run Smarter Emails Book a FREE Injury chat with Brodie Run Smarter App IOS or Android Podcast Facebook group Run Smarter Course with code 'PODCAST' for 3-day free trial.
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On today's episode, stress fractures and bone health with Belinda Beck. Welcome to the Run Smarter podcast. The podcast helping you overcome your current and future running injuries by educating and transforming you into a healthier, stronger, smarter runner. If you're like me, running is life. But more often than not, injuries disrupt this lifestyle. And once you are injured, you're looking for answers and met with bad advice and conflicting messages circulating the running community. The world shouldn't be like this. You deserve to run injury free and have access to the right information. That's why I've made it my mission to bring clarity and control to every runner. My name is Brody Sharp. I am a physiotherapist of former chronic injury sufferer and your podcast host. I am excited that you have found this podcast and by default become the Run Smarter Scholar. So let's work together to overcome your injury, restore your confidence and start spreading the right information back into your running community. So let's begin today's lesson. Alright time to get an expert to talk about stress fractures and bone health rather than my solo episode on stress fractures which was back in episode 56. I will include that in the show notes if you haven't listened to that already because it ties in really well with this interview, Blenderbeck. And also our episode 35 talking about Red S. It all ties in really well. So if you haven't listened to those already, I'll include those in the show notes and then we'll delve into our chat with Belinda, who is a professor in the School of Applied Health Sciences. She has been in bone research for the past 20 years and she'll delve into a little bit of that in a second. Her primary work is around mechanical load on the bone. She's published over 100 papers on this particular topic and... She has transitioned a little bit more into osteoporosis, but yes, she's a wealth of knowledge when it comes to stress fractures and just general bone health. So I picked her brain and you did as well. You submitted your questions. So thank you to Jill, Christine, Anna, John, Virginia. Thanks for submitting your questions. I apologize Rachel because you did submit your question after I finished the interview, unfortunately. However, looking back on your question, around dietary factors, overuse and prior history. I think we ended up answering your question anyway. So, but thank you for submitting and yeah, so we delve into the adolescent population, what we need to consider when it comes to bone health, bone growth, bone density, peak bone mass. And then we just talk about stress fractures, what bone pain is. what we should do for management. And in our later years, if we don't have osteoporosis or if we don't have a stress fracture, what we need to be wary of. So it covers a whole bunch of things, preventative stuff, treatment, risk factors. And it was a really fun conversation. And I think Belinda Beck just loves talking about bones and. she finds it super interesting. You can tell when she answers the question. She just loves this topic and that's why it made it such a great interview. And so without further ado, let's bring her on. Belinda, welcome to the Run Smarter podcast. How are you today? Very well. Thank you. That's very good. Did you have a yawn as we just got started? Just trying to clear my throat. Okay. That's all right. I wanted to get started with you just And for those who might not be familiar with you and how you got involved in the topic that is all things around bone health. Well, so I'm a professor at the, at Griffith University on the Gold Coast and the director of the Bone Clinic, which is a translational research facility in Brisbane, primarily focused on osteoporosis. So, How did I get into this field? As most things that you're most interested in things that affect yourself. And I was a runner and a hockey player and I had dreadful painful shins my whole running career. And I just couldn't understand how nobody could fix me. And it seemed like such a simple problem. So I started my master's research, just looking at muscles attaching in the area. where the pain was and then it moved on to a PhD project, looking at the signals that occur when you're loading bone electrical signals. And then I moved on into clinical trials and into the area of osteoporosis. So I've moved away a little bit from stress fractures, but they are my first love, my first research love. Good to know, because we'll be talking about stress fractures and some to do with osteoporosis and bone health anyway. So it seems like you're the one to ask all these questions too. I wanted to have a, not necessarily a theme, but start with the youth and adolescent population and kind of as we keep asking questions, start heading more towards the advanced masters runner and the older population. And so if I, I guess the first question around the adolescent runner I have written down here is what message do you wish that athletes they don't necessarily need to be runners, but athletes have in relation to bone health. If you were to educate a whole bunch of adolescent people around things bone health, what are some key messages that you wanted them to receive? Well, I think I would break that into two things really. The first bone health and the other bone stress injury. So for bone health, adolescence is just an incredibly vital time for skeletal growth. So you wanna provide the best possible stimulus for growth and then also the best building blocks to allow that growth to happen. So that means food is your friend. This is not the time to be going on massive diets if you're upping your training load. And also it's not the time, many girls in particular, but also some boys remove dairy from their diet under the mistaken belief that it increases their fat intake. And that's certainly not the case. And actually what we know that if you drink skim milk, it actually has more calcium in it. And it's the calcium that is key, but also the protein and many micronutrients in dairy. So dairy is your friend and don't under eat because that will set you up for insufficient nutrients of all kinds to build your skeleton, but particularly calcium. And also... The other thing is loading. So while you're growing, you want to load that skeleton as much as you possibly can and not just in one way. Don't keep to one particular sport. Variety of loading is really crucial, especially weight-bearing loading. So that's bone health in general. Load yourself up and give yourself the building blocks. Maximize your, what we call peak bone mass, which you gain by about the time you're 20. But in terms of bone stress injury messaging, you've just always got to be really mindful that what causes these is a change in loading. And normally that's an increase, but not always, it can be a change in type. So if you are changing loading, you have to do it gradually, and you have to rest to allow your bones to recover. Menstrual dysfunction is a flag, if that occurs. That's a flag that estrogen levels are fluctuating, and estrogen is really incredibly important for bones, very protective. pain is a flag. Don't ignore pain. If you've got pain in the bone, then something's going wrong because bones don't typically hurt. You have to recognize the difference between bone pain and other pain, but one of the clues is night pain. Because normally if you've got aching muscles, when you lie down, they don't tend to hurt unless you're moving. But your bone, if that has a bone stress injury, that will actually throb and be quite painful at night. last a particular period of the night? Would it, if it's, if you're noticing like a throbbing for say five minutes, is that any different to throbbing for a couple of hours? Oh, it's a, it does depend how severe it is, but normally it's a low grade pain that if you thought about it, you would probably be able to detect it most of the time. So, but also, you know, bone pain is very specific to bone. And, if you've got a muscle tear or something, moving that muscle or stretching it will cause that to be worse. That won't cause bone pain to be worse. It doesn't move and you can normally touch exactly where it's hurting on the bone. So your bone pain is different from soft tissue pain. Yeah, and I guess depending on the location of the pain, you'd notice that there would be pain, like depending on the location of the bone that's affected, you'd... notice a sparking pain with certain loading activities, like if you were to load that bone, would you notice pain? Yeah, that's right, exactly. So whatever caused the injury in the first place is gonna make it hurt. Okay, and you mentioned the loading stuff and making sure there's a wide variety of loading that someone's going through, particularly in this adolescent phase. From my understanding, it seems that... bone growth happens through, I guess, ground reaction force kind of stimulates a little bit of bone growth, but also it seems that the muscles and the tendons pulling on the bone actually helps stimulate a bit of growth as well. Is that, am I on the mark there? Uh, you are, but I think it's even more simple than that. Bone responds to strain and strain is actually a measure of deformation. So if you're bending the bone, doesn't matter what's causing it, but if you're bending it, that's the stimulus. So it could be ground reaction forces. It could be muscle forces. It could be both. Um, but that is what it's the actual bending of the bone during loading. That is the stimulus. Okay. And even for short bones of the feet, same, same thing applies. Yeah, that's right. Okay. Yeah. And that would make a total sense why you want variety. If you say, if you're a runner who's very, it's very one directional, you're applying stress to the bone, but it's the same stress every time. However, if you're doing say a team sport, playing soccer or playing basketball and you're changing direction constantly, then you're applying. You're pulling on the bone in different directions. And so the stimulus might be more preferable. Yeah. I think we'll say. My recommendation was for bone health in general to improve that variety of loading. That's really to maximize the growth because if you do get stimulus from different directions, the bone is likely to modify to all those different loads, not just one. So, it's a sort of a more holistic, just trying to get a big bone that is happy playing tennis, it's also happy running and it's also happy cycling and it's also happy playing basketball. So it's just, you know, getting used to all those different strains. That's nice to hear because it's the same principle that I teach when it comes to injuries, you want like, you want to adapt to a whole bunch of different things. If you want to become resilient and you want to successfully attempt a whole bunch of things without breaking down the same way that the body will adapt to bone strength or tendon loading, it can for the bone health as well. It's very good to know. Um, how, like back to the diet. questions and the diet topic, you mentioned, okay, dairy and calcium are very important in these early phases. Are there any other messages, any other intake that we wanna see or any misconceptions that you often hear when it comes to diet in this particular phase of bone growth? Uh, not really misconceptions. I think most people know that, um, uh, disordered eating doesn't go well with any kind of performance or, um, and it does lead, it is more associated with injury rate of injury. And so you can be talking about absolute calories and you can be talking about quality of those calories. So proteins important during growth. Um, of course. But then those other micronutrients. Now I'm not a nutritionist, so I don't sort of speak to those very much, but I tend to focus on calcium because bones comprise 99% of the calcium we have in our body. And it is a calcium reservoir. We use calcium in different places. So you wanna be eating enough so that in those other places in your body, if they need it and you haven't eaten enough, it's not constantly, you're not constantly making withdrawals from the bone bank. Um, so get enough daily so that you can be using what, what you're eating rather than diminishing your skeleton. Okay. And that peak bone mass gets a certain time, like you said, around about your twenties, where your growth and your, you will achieve this peak bone mass. And we want to make sure that throughout this phase of our life, we're trying to restore and build up and get these bones as big as we can, essentially. because once you've reached that peak bone mass time of your life, after that, it's just trying to preserve as much as you can. Is that pretty much as it is? Well, this is where I go out on a limb a little bit, because there's not a huge amount of evidence to support what I'm going to say, because nobody does whole of life research. Nobody measures... a group of people from birth until death, because it's just not feasible to do research like that. So we don't know whether the loss of bone across life that happens after peak bone mass, and that peak bone mass is anywhere between 20 and 30, we don't know whether that is something inherently related to aging or whether it's because from those young adult years we become less active. And it's my belief. that the latter is the case. And there's plenty of evidence to show that people who remain as active as they were in their youth, maintain their bone throughout their life. And that makes perfect sense to me. The human bone and muscle remain very responsive throughout life. You won't necessarily make as much bone and muscle when you're 90 as you would have when you were 20, but you still will make a fair amount. all the bone and muscle that you need. Um, so yeah, I believe that, um, attrition or the loss across life, which has always been called age related loss. I think it's sedentary related loss. That's my belief. Yeah, that's very good. And it might be reassuring to, as a lot of people hear that, because by the way I described, it's kind of like you almost reached this point where you're kind of. If you haven't looked after yourself in those adolescent years, if you haven't known much about bone health, or maybe you are under eating and you haven't taken full advantage of that, um, real crucial period, then, you know, there's not a lot of hope for you. But what you're explaining is there's actually might be reassuring to know that the bone can be very responsive in later years to building up some sort of bone density or, um, at least adapting to a lot of different loads and a lot of different, as long as you're feeding the right nutrition and you're doing all the right things. Well, you have to target bone very specifically with the right kind of exercise. And that's exactly what we do at the Bone Clinic. And so we show it every day with women at the average age of people who come to the Bone Clinic are about 65. Many of them have never done exercise before. So this is very new to them. and they grow tons of bone, lots of muscle, get very strong and all of a sudden they're feeling better than they did when they were 30, when they never used to do any exercise. So the body is incredibly responsive. And actually one of the coolest things is the people who have the least bone respond the most. Ah, that is cool. And the least muscle, you know, it's this principle of initial values. If you start in a position of greatest weakness you have the most to gain. And there's an element of diminishing returns. The stronger you are, the less benefit you're going to get from additional loading. And that's, you did mention common misconceptions and with teenagers and adolescents, and it's not just teenagers, but if you're thinking about the kinds of misconceptions with bone stress injuries, The biggest is that you can apply things like stretching, massage, taping, hot, cold, orthotics, and it will do anything that is utterly ridiculous. That will do nothing for a stress fracture. There is nothing that you can apply externally like that, that will help your bone to heal. You have to eat the right food so that you've got the building blocks and you have to rest it. but adding all of those techniques, and there's some other things we can talk about later with some actual stimulation, but adding those kinds of very fundamental physical techniques, all they do is they make the therapist feel better because they're doing something, and they make the patient feel better because they feel like they're getting treatment, but it is not doing anything for a stress fracture. Okay, well, let's dive into stress fractures. And I do in... I've done an episode on stress fractures and I've also done an episode on red S and I wanted to just kind of skim over like the, the overall theme of those episodes and just get your opinion on whether we're on the right track. Because a lot of people think that bone doesn't really have this, it's not really living tissue like muscles and tendons and that kind of thing. So. in the stress fracture episode that we talked about, we mentioned the balance between the breakdown of bone during exercise and then the rebuilding phase of bone after exercise. And there's kind of like this balance between the two. And if there's ever an imbalance, maybe you're overloading with, and it's breaking down too much or you're almost under recovering and under loading. Oh no, like. you're not getting that rebuild phase, it's becoming too inadequate with things like redness or some dietary issues or maybe something that's stress related that might be relating to something under recovering. The bone starts to break down more than build up and if that tips a scale, then you start to get these bone stress reactions. Am I on the right track there at the moment? Kind of. I think I'd probably be a little more specific. And I mean, bone is an incredibly clever tissue. It just, it has this incredible ability to adapt and remodel to changes in patterns of loading so that the next time you put those loads on, it's stronger and able to manage them without fracturing. And this happens through, as you say, a normal process of remodeling and that these are cellular processes. So this is pretty effective for most people under normal circumstances where there's a gradual change in load. It's really effective. It's why most of us don't fracture throughout life. But so if we have this fabulous system, why in athletics or the military do people begin to fracture? It's because that remodeling cycle that bone undergoes as it's changing and adapting takes a long period of time. Four months is the absolute minimum for a full remodeling cycle. And so if you think about the nature of a training routine, a lot can happen in four months, right? So aerobically and muscle strengthening, you can ramp up quite a lot in four months and be a very different person. in terms of your strength and aerobic capacity at the end of four months. But that is too fast to be ramping up very much for bone. You can ramp up a bit because as your muscles get stronger, they actually help to protect the bone a little bit. So that's good. But the problem is, there's actually two main ways that bone will fracture. Either imagine... If you've been on the couch for 10 years and then you decided you wanted to do the Kokoda trail, so you grab a 20 kilo pack and put it on your back and away you go. And that is just like getting a piece of wire and bending it backwards and forwards to eventually it breaks because each time you bend it, you'll form a little crack. The load that you're putting on it is too great and so you have this acute actual fracture of the tissue. Now that's when you just overload. And that's your classic military training. That's why there's so many in the basic army recruits, they fracture. But there's this other process. It's a positive feedback cycle where somebody begins to train. It's not as dramatic as that massive overload of a pack and a great big hike. It's much more gradual than that. But as they start to overload, the first thing that happens in that remodeling cycle is resorption. It's the first stage of remodeling is the rem- resorbing cells chew up little packets of bone. And then the second phase is the building cells come along and replace that and they replace it in ways that the bone is stronger. And the problem is if the loading continues during the resorbing phase, when the bone is actually weaker, is this little window where the bone is weaker, even though you've been loading it, it weakens before it gets stronger. And if you keep loading it or heaven forbid you increase the loading during that time, then you're actually at greater risk of fracture. Now that's, that's how most stress fractures occur in someone who's, who starts a training program. But what about athletes who are very well trained and they perhaps change something subtly. either they up their intensity just a little bit, or they change the surface they're running on, they get a new pair of shoes, or they start doing heels instead of flats, something changes. And what that causes is some remodeling to start, but also remember that, especially elite athletes, they train pretty close to this dangerous zone of injury versus performance, and it might tip them over into injury. Now, the other cool thing about bone is that if there is a little microcrack, those resorbing cells are drawn to that area and they resolve the crack. So now you've got resorbing cells that are resorbing trying to remodel. You've got resorbing cells that are resorbing microcracks. And so you've got this much weakened tissue, high loading, more cracks. And that's what we call the positive feedback cycle. Really it's a recipe for disaster. something's got to give and it's going to be the bone. And that's normally when someone who's training at a really high level, just something gives and they start that positive feedback. And I can imagine if it is that very gradual process that from what the runner might experience, it might be a very gradual onset of symptoms. It might not necessarily be an injury. Um, you wake up one morning, I feel sore. It might be a couple of weeks of feeling like, Oh, it feels a little bit tight in that area, or it's just like, if you're starting to notice a particular area and then all of a sudden you've had it for three months and then it becomes worse and worse and obvious, I guess a bit more obvious as time goes on, is that what you might see clinically or what a runner might experience? Um, if they're having that, they're not really taking advantage of that reabsorption phase. Possibly. It, it, um, The resorption itself isn't painful. It's the cracking and the inflammation that happens along with that cracking. That's what causes the pain because the periosteum around bone is highly innervated. And so you stretch that at all and it's painful. And also the pain, there are nerves inside the bone. So any kind of swelling in bone, it's gonna be painful. You know, I mentioned before, pain is a flag. The minute you have bone pain, there's an injury. And if you don't stop, it's just gonna get worse. There are very few people who can run through a bone stress injury. You have to rest. That's your big signal that the osteoblast needs some time to catch up to fix the damage that's done. And if you don't do it now, you're gonna be off for longer later. So even a little bit of rest at the first signs of pain and definitely. If you can put your finger on a spot, a single spot on a bone, that's a big signal that there's probably a stress fracture in the making there. A lot of times people call it stress chin splints, it's actually medial tibial stress syndrome. Along the border of your tibia, the whole area feels painful and that's a little bit of a precursor. Everything's fired up and there's a lot of remodeling going on there, but with a stress fracture you can feel a very distinct spot. And, uh, that's, that's definitely, if you can ever feel that you get, got to get off your feet or it's just going to get worse. And you, there's no avoiding it. You can't, once you're there, you've just got to, uh, admit defeat, get off your feet for a while. That's why all runners just read the stress fracture. It's like the one injury that they never want to hear up because in some cases, like if it's a tendon issue, then they can just find what level they can tolerate. And then just. back off their mileage considerably and then work their way back up. Whereas with bone stress, you need to take it very seriously and it's time off and it's no running and it's the last thing a runner wants to hear. Well, having said that though, you know, bone is so it's got such a great blood supply and it's very good at fixing itself. So if you, you don't need to take, I mean, a lot of people would say for a full blown tibial stress fracture, you're eight weeks off, but if you probably If you have four weeks off and then you start some light in saddle cycling, and you can certainly be doing pool running and that sort of thing, you can do some stuff. You just got to try not to overload that particular bone. And the same principle applies for swimmers and tennis players who are loading other bones. It's the same concept. Over bending of that bone, just got to rest the bone. Yeah, I want to get into some listener questions. The first one being from Jill, she asks as a mature female, 54 years old, who's keen running, who's been running for around about 15 years, should I be concerned with bone health and any tips to keep the bones healthy? And I'm happy if you retouch anything that I've already discussed to answer the question, but what would you say for Jill? Well, the easy answer is everybody. should be concerned with bone health, not just Jill, and not just runners. But how much you're concerned actually depends largely on your parents because bone health is very, very much genetically determined. So your risk of osteoporosis is pretty much determined by your genes, about 70 to 80%. So the primary tips for keeping bone healthy at any stage of life is the same, be as active as you can with as much variety in your exercise routine, including impact and muscle strengthening and eat a balanced diet, making sure you're getting plenty of calcium. And again, for a lot of people who say to me, I hate milk, what else can I eat? And there's plenty of calcium in green leafy vegetables, but unfortunately we don't absorb them very well. So... If you can tolerate some form of dairy like yogurt and cheese, then you definitely need to try and get some dairy in. There's actually a little bit more to unpack in this question because of Jill's age. At 54, she's gonna be perimenopausal, and that means that all her circulating estrogen has suddenly vanished. And the minute that goes, you take the lid off those resorbing cells, the osteoclasts, the ones that do the resorbing. So her bone mass will be dropping just by virtue of going through menopause. So there's no need to panic. You just needs to continue to be active and eat well, but probably round about menopause when there's a bit of bone loss happening, be it particularly vigilant about any pain, bone pain. Okay. I might skip ahead a couple of questions because you did mention around calcium. Virginia asks, is there much relationship between calcium absorption and vitamin K? And I don't know a lot about this. I'm looking forward to your answer. Well there's actually no relationship between calcium absorption and vitamin K. She may be getting confused with vitamin D because we're relying on vitamin D for absorption of calcium from the gut. So it means you could be eating heaps and heaps of calcium, but if you're not getting enough vitamin D or if... if your vitamin D is low, then you're not getting that calcium into your system. But there has actually been some increasing interest in vitamin K in recent years. And, you know, some people are claiming that vitamin K supplementation is important. Of course, the companies selling those supplements are very quick to jump on that bandwagon. And when that happens, good marketing often takes the place of good science. So, The rationale is that people who don't get enough calcium in their diet tend to take calcium supplements and those supplements tend to transiently elevate calcium in your blood. And what happens with that is it may increase the risk of heart disease because of the deposits inside your arteries or in the vessel walls. And there's an idea that vitamin K might inhibit that deposition. But we haven't seen any decent trials actually showing that, that it does prevent vessel decalcification or calcification. And there's definitely no strong data that supplemental vitamin K reduces bone loss. So we've got a long way to go. And I suspect this is a classic storm in a teacup over the latest trendy nutrient, which vitamin K is very trendy at the moment. It was vitamin D a couple of years ago, now it's K. I think what people need to remember with nutrients and nutrition is that food is the best source of nutrients and food is not the sum of nutrients. There's much more to food. It's a matrix of substances, many of which we probably don't even know because they're not measured. And so there's many things in food that are beneficial for us, including the interaction between things in food. So focusing on one nutrient is a really bad way to manage your nutrition. Even if a multivitamin, try and get your nutrition from food. That's how we evolved. It's absolutely the best way to do it. This answer might be, it depends, but if you are talking about the benefits of dairy calcium, vitamin D. Um, do you have recommended daily intakes if someone wants to, if the bones want to stay healthy? Yeah, well, rather than me list off what they are, I can probably say the easiest thing would be to Google it. But as a general rule, because it does depend on the person's age, but as a general rule for adults, you could roughly say a thousand milligrams a day is what we should all be eating. Now, what does that mean? What's a thousand milligrams of calcium? A glass, like a measuring cup sort of glass of milk is about 300 milligrams. of calcium. So you'd need three of those or a very large milkshake would be your whole probably your whole daily requirement of calcium but not too many people would do that every day because it's horribly fattening. But you know some milk on your cereal, some cheese especially things like halloumi and parmesan very high in calcium and then read labels look at look in your onion cereal. When you're making soup, put milk in, low fat milk so that you get the most calcium. Look for foods where calcium is supplemented in it. Try and stay away from calcium supplements for exactly the reason I was telling you before. It's not good to have big sudden boluses of calcium floating around your blood. Definitely better to get it in your food. Okay. I'm getting hungry now. Um, we'll, we'll move on to, uh, Christine who asks, is running enough to maintain bone health in midlife? I'm, I'm curious to hear your answer. Cause, um, I think I might have a small take on it, but what would you say? So starting running in midlife is not an effective way to increase your bone mass, because the loads aren't high enough. It seems like when you're running and you feel really tired and you're thumping along there, it seems like you're putting enough load on, but actually running loads are not that high. But I'm gonna interpret the question to mean, will continuing to run throughout life be enough? in which case the answer for some people will be yes and some people will be no. If you have been running all your life and you've never had, you've got good genes and you've maintained your diet and you've stayed active and you've probably not lost very much bone throughout your life, then running might be enough. But you have to remember that you only bones that are loaded. So unless you're running on your hands every now and again, you're not growing any bones, bone mass in your forearms. And that's one of the most common places to have an osteoporotic fracture. So you need to do some other things to load your upper extremities so that you also are growing bone there. The other thing is oftentimes if people have been long time runners, particularly when they were young and women, have gone through phases of either disordered eating or reds, you know, not enough energy and their bones will have suffered. So their bone bank may not be as healthy as it could be. So if you're starting with a less than optimal peak bone mass just running throughout the rest of your life is probably not going to be enough to protect you from osteoporosis in later life because you haven't got enough in store. In fact, your risk of osteoporosis can be can occur quite early if you've been a memory for years, tiny little frame, you probably, you can have osteoporosis as young as age 30. Okay, wow. And when we, I guess we'll dive into specific exercises to help, like if someone does have osteoporosis and it might answer the why running isn't enough load. for the bone itself because Anna asks, what are some specific exercises recommended for a runner who does have osteoporosis? So what would you say for Anna? Well, it's the same for anyone with osteoporosis. So you want to do exercises that load the whole skeleton and you need to increase the intensity of loading and add some heavy resistance training. You're probably getting enough impact from the running. but it's the resistance training, the muscle building that you need. The thing is, if you already have osteoporosis, you need to do this under supervision. It's to tell somebody with osteoporosis to just go ahead, lift heavy is a recipe for disaster. You're risking fracturing. It's the whole reason the bone clinic exists because you need people who are trained in lifting techniques to teach you the safe technique and to give you the... gradual progression, so where to start and give you gradual progression so that you don't actually cause the fractures you're trying to prevent. So it's a little bit fraud. And for years, we thought that people with osteoporosis shouldn't even do this kind of lifting. It's the reason we did the lift more trials to test it. And we tested it in women with osteoporosis and men. And we showed that it was safe, but you must be supervised. Okay. And even if someone is osteoporotic, just say, lower limb or lower back or something, you'd still recommend upper body work for them? Absolutely. Yeah. It's just, you never know how, what's gonna come along. The neighbor's dog could come flying out of the yard as you're running past, run into your legs and knock you over and you land on an outstretched arm and straight away you've broken your right hand and you can't write, you can't stir the, cooking, I mean, you're out of action for four to six weeks. So absolutely. You want your whole body to be strong. So absolutely. It's a whole body, um, exercise routine. I know some listeners like specifics when we're talking about resistance training. Are we talking about squats, lunges, deadlifts, anything generic, um, just anything and everything that's heavy and they can tolerate Well, we have a very specific exercise routine at the bone clinic. And to be honest, I don't tend to disclose that when I'm talking under these scenarios, just because I have a duty of care to protect people from themselves. I could tell them what we do, but that will send people off into the gym doing these massive heavy weights and they're going to hurt themselves. So I prefer not to say what we do, because the only way it's safe for us to do what we do is under supervision. with people who are well-trained. Okay. But you know, it's, I know that's, that seems like it's ducking the question, but there are ways that you can go to the gym, find yourself an EP and get them to, to supervise you. And there's also licenses for the Oniro program where people are able to coach you. And I really recommend you do get a coach if you have osteoporosis. Okay. So that's heavy resistance training. I have also seen some like ground reaction training where people do a calf raise and then they quickly slam their heels down onto the ground. I don't think it's for osteoporosis like if someone's advanced in that sort of condition but for someone to trigger or stimulate some bone density or bone growth in there you see them either like jumping off a step that's a couple of inches like two or three inches and landing with straight legs and kind of sending a shock through their body. Is that those who want to stimulate some bone density or have we moved away from that? No, it is, impact is still really important. And for people who are not doing any impact in their lives, yes, and it's one of the things that we do at the clinic. It's part of our program and there is an impact activity. But again, for people with osteoporosis, it's a little bit fraught because this is probably the thing that I would be least likely to encourage people to do by themselves because Sudden jolts, particularly for the spine, can cause fractures. So fast rates of loading can be, they make me nervous. And that's how many people do get their first vertebral fracture. They've misstepped, they haven't watched where they're going, they've stepped off the curve and come down really hard on one foot, big jolt to the spine and all of a sudden there's a sharp pain in the middle of their back and they've had a compression fracture in the spine. So there's a way to do it with very gradual increments to increase intensity. Yes, it is good, but just be really careful. You also have to remember that in this demographic that we're working with, these are older people, there are very few people that get to the age of say 60 without having arthritis somewhere or some degree of arthritis. And knee and hip are the two most common places. So if you tell someone with really bad... knee arthritis to start jumping like crazy, they're going to look at you like crazy. So there are ways and means to introduce it in those demographics. And I shouldn't, I should say that it's not bad to do impact exercises when you do have osteoarthritis, you just have to do it in the right way and very, very gradually listen to your body. If it causes any inflammation or an increase in pain, then you just step right back. and go much more gradually, but it can be done. I think the more I learn about this area, the more I realize that we are way, way too conservative with our therapies for older people. You know, they're not snowflakes. They can absolutely do a lot more than we take them for. Yeah, we see them as fragile and wanting to take things super conservative and when in fact we should be challenging them and finding their adaptation zone, but then challenge them to continue to push themselves in a safe manner, you could say, but we shouldn't be putting a ceiling on them. How often do you hear someone say, I'm downsizing my house to get rid of stairs because I'm too old? That is the worst thing they can possibly do. Keep those stairs in your house and walk up those stairs every day, up and down, a couple of times. Yeah. It's really good for you. You can easily see like someone who is quite frail and cannot really tolerate a lot, but exactly what you're saying, they're almost justifying, almost having these expectations like I should be pulling back, I should be pulling back. And then year over year, decade after decade, they've just deconditioned themselves to a frail state when in fact they should be doing the opposite. They should be doing the absolute opposite. If they want to be that frail person, then start behaving like one. Go and sit down all day, and then you'll never get out of your chair again. Yeah. And then they might say, they might go to, um, a house that does have stairs and they're sore or they're unable to do it. And, um, they might be going up and down stairs that day. And then I feel really sore afterwards, almost like justification for themselves. Like, I know I shouldn't be doing this because I'm so old and frail, but the fact that you've avoided it for so long means you're just so deconditioned and, um, in their, in their eyes, it's almost confirmation that, yeah, that's why I don't have a house with stairs. But in fact, it's, you know, proving the point that if you decondition yourself enough, then it's gonna be sore and it's gonna be tough to do. And when push comes to shove, we can't see our bones. And if we never fractured, we wouldn't really care about them too much as long as they keep us upright. It's actually all about quality of life. We want to stay as able to do as much as we possibly can to enjoy life. for as long as we possibly can. So removing things that we like to do from our life because we think we can't do them is just that is the beginning of the downward spiral. I think sometimes people interpret a little bit of DOMS, the delayed onset muscle soreness as injury. And so we do need to educate people that, yes, doing a different exercise, it is gonna make you a little bit sore and people who haven't. had doms in their life might think, oh my God, I'm dying. I need to go and lie down. It will go away. It shows that you've used your muscles and it's really good. So just toughen up, work through it and you'll be really glad you did. I hope the listeners of this podcast are well on top of that. I think they're well familiar with the difference between the two. But I talk about this constant pattern of retreating to safety that people have, like they'll... They'll train for a marathon. They'll get injured and they say, I'm just not a marathon runner. And then they'll try and do 10 Ks and they'll get injured. And it's like, Oh, 10 Ks must be too much for me. And then all of a sudden they keep backing off, backing off, backing off constantly, constantly until they're not doing anything. And as soon as they try and reintroduce one thing, then their injury or something flares up. They're like, I knew I shouldn't do that. It's too much for me. And then they just continue backing off, backing off, retreating to safety, and then they just become way too. way too weak, way too fragile, way too vulnerable. Yeah, when in actual fact, it's the way they're doing it that is the problem. You know, for example, if somebody can't even run a kilometer anymore, then they're not doing it right. If they've been running marathons previously, they haven't fully recovered from their injury or they haven't... you know, not wearing decent footwear or they're, you know, just doing too much too soon. It's your classic situation. Too much too soon is exactly how stress fractures happen. Yeah. One more question from John. He's had 12 months, 12 months ago, he had a stress fracture of his sacrum and he is back to pain-free back to doing all the things he loves doing, but is it because he's had that stress fracture in the past, is there anything he should really be mindful of moving forward? And we can kind of apply this to all stress fractures, I guess you could say. Yeah, that's true. It's hard to speak to a specific injury without knowing the history or the person, but basically if you've done it once and you haven't changed what you're doing before you injured the first time, there is actually a likelihood you'll do it again, and not just to your sacrum, but... So you want to avoid doing what you did before in the lead up to your sacral stress fracture. And after injury, always start back at a much less intense level than before your injury and increase your training more gradually than you did when you got injured. So, but as you say, that's the same advice for any stress fracture. Look to the history of what you were doing. And That's probably one thing that I would say with age, recovery tends to be a little slower. So some people who used to be runners when they were in their twenties, start running again when they're in their fifties and they don't realize how they need a little bit extra time to recover. And so don't expect you to be 20, you're not. But you will get back to, I'm certain you can get back to what you were like when you were 20, it just might take you a little bit longer. And if I... I'm happy that you say that because, uh, a lot of people have the mentality of back in my twenties, I used to do this, but you're not 20 now. You have to accept the fact that sometimes the body takes a little bit longer to recover. You might not be able to do back to back days like you did in your 20s. You might need to take some extra time for the body just to, just to like handle the load, just to recover, rejuvenate does take a little bit more time. And if someone does have a. Like you said, if someone does have a stress fracture, make sure you identify those training errors moving forward. So we're learning along the way with our training habits, but should we be cautious of like diet? Should we have, should we take more calcium? Like if someone's had a history of stress fractures, or do we just need to identify if that was a factor prior? And then if it was, that's when we should start implementing something different. Yeah, I think it's a matter of looking at the, the whole, you know, everything that you're doing. And the two main things of course, are your pattern of loading and your diet, your building blocks. We always come back to those two things, but by far, the most important thing is the pattern of loading. So it's, you know, that it is all about prevention. Once you've got the stress fracture, as I said, it's you really just waiting for those cells to do what they do best and they will fix you. Um, but if you prevent, it before it happens, then that is by far the most effective way to, um, to stay injury free. I mean, I know that sounds like self-evident, but, um, a lot of people only discover that after the fact. So you just, um, you know, take it. It's far better to take your training program slowly and avoid the injury than to be a little bit of a cowboy and have the first injury. Because we all know that recovering from that injury is very fraught as you go up and down with your pain and re-injury and you try something else so that you keep fit while you're recovering from that and you've managed to mess something else up on the, screwed up your knee when you, when you were doing that pool running with that stupid board, you've got a hole between your knees. And, uh, so yeah, it's just prevention. Avoid, avoid, stay away from overload, uh, rapid overload. with bone and it will be your friend. You've just got to treat it kindly. Yeah. I guess the preventative tips that you would have for someone who has had a stress fracture in the past would be the same for anyone who hasn't had a stress fracture in the past. It's making sure you do have the right dietary requirements, making sure you don't have any errors in training, like that spikes in bone load and you're keeping a nice variety of load. throughout the week and you're doing, you're not just running, you're mixing things up and challenging the bone and getting that bent in the bone in different variety of ways. Would there be anything else to add? The only thing, and this is extremely rare, but occasionally you'll come across somebody who does have low levels of circulating estrogen or testosterone, even when they're very young and that may make them more susceptible. So if, um, You know, you've had seven stress fractures in the last 12 months and you've been taking things as, as carefully as you, as you think you can, then maybe it's time to go and have a blood test and see what your hormones are doing just to check everything out. But in the main, it's just about, yep. You're gradual loading and feeding yourself healthy bone friendly food. Yep. And as we wrap up, are there any other tips that we might not have covered today that you want listeners to take across? I suppose the only other thing that we haven't really touched on is the therapeutic devices, the stimulation electrical stimulation and ultrasound. I did a randomized control trial with electrical stimulation and look the jury is still out on these measures. There's some evidence, a small amount of evidence that sort of stimulation may increase the rate of healing But I think for your average person who's gonna take eight weeks to heal, it may just speed you up a week, potentially. But, and then again, it may not speed you up at all. So for the expense and the bother, I don't know that you should be putting a lot of hope into those strategies. Certainly the evidence is not that convincing. However, if you're an Olympic athlete and you're a month away from the Olympics, I would be throwing anything at it. And I definitely would be trying, you know, electric stimulation and, or ultrasound to try and hurry those cells along a little bit, but the stakes are much higher in those situations. Otherwise just give yourself the time of day. Okay. Um, and what about say in severe cases, are they still putting casts on people? Are they still like just non-white bearing? I really hope not. Um, because the minute you put a cast on somebody, you're unloading all the other tissue around the bone as well. So it's not just the bone that's gonna suffer, but the muscle will atrophy and all that's doing is reducing the ability of the muscle to protect the bone when you take the cast off. So no, look, weight bearing recovery is the way to go, except in those very early days when any weight bearing activity is painful. If something's painful, you should not be loading it. You should be on crutches. Yeah, actually completely unloading it, but that should only be for about a week. After about a week, you can probably get back to, uh, weight bearing. And, uh, the, the rule of thumb is you shouldn't be back to full training until you can hop on that injured limb for 30 seconds. So, um, you know, if you've got pain while you're hopping, you're not ready to go back to running. Yep. Nice little tip at the end. Um, Before, I guess the social media or links I should include in the show notes, I did find the bone clinic.com.au. Um, I did find the bone clinic on Facebook as well, which I'll include in the show notes. Um, is there any other links or any other social media things that you want me to add in there? No, I think that's, that's basically it. Um, yeah, I'm on Twitter, but I don't think that really matters too much. Are you active on Twitter? Do you do like showing stuff on Twitter? Yeah, I do. Um, I definitely too. A lot of it is academic stuff. And you know, most of the researchy stuff. So, um, do a lot of backwards and forwards with that. Um, I noticed somebody just, um, is that the, is that the at one? Yeah, I'll just check. Cause somebody just put my handle in a tweet just before, which reminded me I needed to respond to them. Um, I should know this. It's at Belinda Arbeck. Okay, cool. I'll definitely add that in. All right. That was great. I think we've covered so much. We've covered like throughout the lifespan things we need to consider. And it was all around like symptoms when people do have a stress like bone sort of pain. I think that's really, really important. One of the key takeaways. And I think we've shed a lot of insight around treatment and prevention and it's been great. So thanks, Belinda, for coming on and sharing your knowledge. You're very welcome. Thanks once again for listening. To take full advantage of the knowledge you are building, you need to download the Run Smarter app. This contains all of my free access podcast episodes, written blogs and eBooks, along with my paid video courses, all neatly housed into categories for you to easily navigate through and find content you're interested in. Also be sure to check out the show notes for links to the podcast Facebook group and links to learn more about becoming a podcast patron who contribute $5 Aussie per month to get inner circle VIP access including an invitation into the exclusive Patreon Facebook group and a complete back catalogue. Patreon only podcast episodes, which you can access within the app. Also on the app you can even find a link that takes you to my online physio clinic where I assess and treat runners from all over the world, so I can be on standby if you ever need one-on-one physiotherapy assistance. Once again thank you for listening and becoming a Run Smarter Scholar and remember, knowledge is power.