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Paul Ingraham is a Vancouver science writer and a former Registered Massage Therapist. He left that profession over concerns about pseudoscientific beliefs and practices and went on to create PainScience.com, a website about the science of pain, injury, treatment, and rehab, where he has published hundreds of articles and ten books on these themes, the most successful of which is his guide to the tricky topic of “trigger points.” Today, Paul talks with Brodie about the pros and cons of medical scans. When injured, a diagnosis can help calm down the anxieties and confusion about recovery, but is getting medical scans always the answer? We dive into the protocols and presentations that may indicate getting a scan and the precautions one must consider. Lastly, Paul talks about the myths and misconceptions about bone stress injuries and the general consensus on stress fracture management. Check out Paul's website and books here PainScience.com Follow follow Paul on twitter 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.
Expand your running knowledge, identify running misconceptions and become a faster, healthier, SMARTER runner. Let Brodie Sharpe become your new running guide as he teaches you powerful injury insights from his many years as a physiotherapist while also interviewing the best running gurus in the world. This is ideal for injured runners & runners looking for injury prevention and elevated performance. So, take full advantage by starting at season 1 where Brodie teaches you THE TOP PRINCIPLES TO OVERCOME ANY RUNNING INJURY and let’s begin your run smarter journey.
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On today's episode, when to get medical scans with Paul Ingram. 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 Brodie Sharp. I am a physiotherapist, a 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. I have tried to get Paul Ingram, I think I asked him to come onto the podcast, maybe a year and a half ago. And at the time, like our timelines weren't really matching up and the communication just. Move dawn but luckily Paul reached out to me and a few months ago and said let's give this a go let's give this a shot and we finally organized something and it's been on my mind for a long time now to do an episode about scans to do episodes about like you know. X-rays CT scans ultrasound MRI is like when is it the best time to do that and why what should we consider when getting scans what are the pros what are the cons and. When Paul reached out and said, let's do this. What do you think? I said, can we do an episode about scans? Cause I've asked a lot of other guests and they've kind of shied away from it because it is a bit of a sensitive topic, but he was happy to dive into this topic. And for those who don't know Paul, Paul Ingram is the creator of pain science.com. If you've listened to episodes of podcasts, you know, I am a huge fan of exploring. the complexities of pain, especially chronic pain. Paul is, he creates this really high quality content on the, on the website. He mainly hones in on pain, but also like trigger points and like myofascial release, that sort of stuff, passive treatments, you would call it. But he does into a lot of other things and he is a self-taught health science journalist. And this is what I love. He was a massage therapist by trade, but has since just self-taught, dived into a world of medical research and all the publications, research, systematic reviews, everything that's sort of come out. He's just self-taught himself, which listening to his previous interviews and reading his work, I place him so high up on the ladder of who I trust in regards to advice that is delivered. And. In his website on his articles, it's constantly updating. He's constantly researching, learning something new, and then going back to his website and updating things, which I absolutely love is keeping up to date with current evidence. And I think that kind of suits the narrative of the podcast or suits you listening here because you're one to, well, most of us anyway, don't have health professional degrees, we're just recreational runners, but want to try and inform ourselves as best as possible, find the right information and learn more about the injury, learn more about injury prevention, learn more about increasing running performance safely. And just the journey of being self-taught and surrounding yourself with the right information, the right guidance, I think Paul is a perfect example of that, but just taking it to a world-class level. So today, like I said, we're talking about medical scans. We're going to talk about the pros and cons of when to get a scan, why to get a scan, um, the dangers, possibilities of getting a scan. And I'm definitely going to have Paul back on to talk about the trigger point release, the myofascial release, stretching massage, all that sort of stuff, um, which I'm also excited about. And he agreed to do, which hopefully I'll get him on sooner rather than later. But let's dive into this first interview all about scans. Paul, thanks for joining me on the podcast today. Pleasure. I think we, uh, I've been excited to talk about this topic for a long time and just trying to find the right guest. And, um, I know you said that this isn't entirely within your wheelhouse, but before we get started on today's topic, do you mind giving us a bit of a introduction about like your, your background and particularly like the website and online content that you've been producing for so many years? Yeah. Um, 20 years of, uh, science writing and publishing in this field, musculoskeletal. medicine and pain, injuries and rehab. I started out as a registered massage therapist in British Columbia, Canada, which has a, at the time that I did it, it had pretty rigorous program, three years of training. And we were, you know, the profession was really aiming to upgrade at that time. It's gone backwards a little bit since then, as less training now to become. licensed massage therapist in this area, but back then it was a three-year program. And I did that clinical work for a decade, and while I was doing that I started publishing a website, mostly and originally to write articles to help my clients to provide, you know, continuing education for them outside the clinic. And then it exploded and it found a global audience. And so I've been doing that ever since and it's become my full-time career. That's a painscience.com is the website. And there is no subtopic in this field that doesn't interest me, but imaging is, of all the subtopics, it's not one of my stronger ones. I know a bunch about it, but it's probably not my strongest subtopic. So welcome to the podcast where somebody talks about not his strongest subtopic. Well, it's just because you're, you're strong topics. You're so strong in it might just be that your subtopics are just still elite in nonetheless. Um, if you, if maybe just quickly, do you may maybe want to talk about it is pain science.com, what are the main topics? So I guess the most popular topics that you have on your website. Yeah. Uh, well there, there is, I'm trying to fix this over the years, but you know, for a long time, there was a pretty strong focus on uh, massage therapy, uh, adjacent topics. So lots of muscle stuff, lots of, uh, lots of things result related to soft tissue therapies and manual therapy. Uh, you know, if I were to start from scratch today, I would try to make it a much more general musculoskeletal medicine website. Um, but You know, I spent the first decade writing almost exclusively about things that would interest massage therapy clients and then more and more my massage therapy colleagues. So there's quite a strong emphasis on that. And, you know, an example of that would be, you know, the very tricky topic of trigger points has been a major focus of mine. That's the sore spots that almost everybody gets and nobody actually really understands. And I've done an enormous amount of work on that very specific little thing written, you know, an entire huge book about it and lots and lots of articles. But as I've gone, you know, and particularly in the last few years, five years, I've really tried to widen my scope. And you know, the world of pain is enormous. Everything from, you know, cancer pain to toe-stubbing pain and everything in between. And as I learn and grow and continue to, you know, endlessly study, I've been spreading out more and more into the more medical side of pain. You know, so for example, a decade ago, about chronic widespread pain or fibromyalgia. I was almost entirely focused on sports injuries, running injuries, overuse injuries, and common aches and pains like back pain. But these days I write a lot about fibromyalgia and other weird mystery pain problems and stranger pain problems. It turns out that everything in this field is weird and fascinating, really boring and ordinary at first, like muscle strains, for instance. I have a book about that. It's one of the 10 books that I've written. And you would think that muscle strain is a boring topic, but it's not. Pulling muscles is amazingly weird and complicated. And so I've just continued to spread out into every pain problem I can possibly think of to write about. It's a huge undertaking, like just to cover such a wide scope and just as research comes out and is updated, you're constantly updating, which is, you know, I constantly think about why there's so many misconceptions out there, why it's so hard to find the right information for a lot of running related injuries. And part of that reason is because, you know, someone can write a blog 10 years ago and it just stays there on the internet without being updated or, uh, And when someone searches that topic and comes across that blog, they kind of assume it as, you know, this is what the science shows, but science is forever changing and forever evolving and our understanding is constantly changing and the general consensus is shifting, you know, so much to whenever even I graduated, which is only 10 years ago. And what I like about your website is you're constantly updating if there's something that's required updating or a shift in thinking or some other perspective, then you're, you know, updating it and making comments on it. And when I was looking through your website, that was something that was very, very refreshing. Yeah, and the original blog post from 10 years ago might not have even been good when it was published, but even if it was, it gets stagnant and out of date. It's amazing how often in just one work week, one average work week, you know, I'll find two or three studies that, you know, when I see them, I think, oh, shit, I got to change some stuff. I got to change an article. I got to change three articles. And we're always learning things that... change our understanding of how this stuff works. And you know, the part of the reason that misinformation persists and is so widespread is because we just don't know the answers. And so much of what is, you know, supposedly known is actually just speculation and extrapolation from scraps of inadequate evidence. So, you know, what you read is, you know, was somebody's speculation at the time that it was published and who knows whether or not they've kept up. with an ever updated, I have a really, really smart colleague, one of the smarter people I've ever known, who started a blog and stopped blogging, you know, roughly a decade ago. And at the time, the posts were great, but they did not stay great because the science moved on. So, it doesn't matter how good it was to begin with, if you don't keep updating it, it's probably not going to be useful after a few years. Yeah. Cause people follow credentials. People follow like if someone who had, who is really well respected, writes a blog, you know, that, you know, it'd be gravitated and like their opinions are very, uh, gone, you know, a high sense of value, high worth, but like you say, if it's, if it's left on there and not really updated, then it can be made redundant. You know, in a blink of an eye, like a blink of an eye might be 10 years, but if it's still on there, if it's still on the internet, it can be, you know, quite it's finding mixed messages all the time is quite puzzling. Oh yeah, absolutely. And I find it in my own work. I'm appalled by my own work all the time. A few years will go by and I blink. I'll put a whole bunch of work into something and it'll feel really good and I'll think, ah, this is all really sorted and it's all citing the most recent possible relevant evidence. And I get it all to a nice polished state and I think that's taken care of for a while. And then, you know, the next thing I know, six years have gone by and I'm looking at it. I'm going, Oh God, I really, really need to update that. It's just amazing how fast it happens. Like I said, it's a massive undertaking and great for you to. you know, take on that, that job, that responsibility. I know it's like your primary work and your primary business and you've got books and all that sort of stuff. So, um, that's, that's awesome. It's a logistical nightmare. I could imagine. Absolutely. Um, so I really want to talk about scans and runners running related injuries. Um, people are confused whether to get scans or not, if they should just find like a health professional, if they suggest scans. to get it, but I thought it might be nice to start off with talking about the positives, talking about the negatives, sort of what we both come up with and sort of playing off those before we dive into something a little bit more in detail. Yeah, sure. So if I was just to throw the question to you, what do you think the benefits of getting scans are getting medical scans to diagnose a particular injury? What would they be? Well, the double edged sort of scanning that, you know, one, the great edge is getting awesome diagnostic clues that you can't get any other way or that in practice you're very unlikely to get without the imaging. There are things that are very easy to miss with a physical exam and with history that pop right out on the right imaging. And when all the stars align and you get just the right scan that identifies just the right thing, You can really get a nice strong, you know, myth buster style, well, there's your problem. And sometimes that really obvious finding is correct. That's the thing. And, you know, that's imaging at its best. That's what we always want is the tough problem finally explained by just the right pixels on the screen that show you that's what's actually going on here. And I think probably, you know, the best of the best is that there are so, there are so many injuries that you would think would be obvious and easy to find with history and exam that aren't always. And, you know, good example of this, I was just writing about this today. I think, I think this is a, an old study from the mid 2000s of avulsion. injuries and that's a muscle tied to bone with tendon and when the tendon tears off the bone that is an avulsion and an avulsion seems like you know, that seems like a major injury, especially if it's a big muscle like say hamstrings and You would think that would be kind of hard to miss that you wouldn't need imaging for that but turns out sometimes you do because of Tissue swelling and muscle guarding, perhaps, it's not nearly as easy to identify clinically as you might expect. And yet MRI can reveal it just fine. Most cases are going to be pretty obvious with imaging. And certainly management is going to be different if you know that is an avulsion as opposed to, say, a second degree muscle strain. Uh, so that's, you know, that's when imaging really shines when it helps you identify the stuff that just wasn't probably going to get identified otherwise. And there's lots of interesting examples of that. Hmm. And maybe identifying, yes, the diagnosis, but maybe the, um, condition like the scale of it or the grade of that particular condition if it isn't a evulsion like how much is it uh is it worth conservative management, is it worth like this? And we're going to talk about stress fractures later on, but like the stage of the diagnosis, um, can really tend to manipulate or control the management or the instructions that are given. It might be, you know, you can still run on this or no, you need rest or cross training or offloading or crutches for this amount of period of time. Um, so working out the, the particular grading condition can be important. That can, you know, be pretty, I guess, depending on the injury can be pretty the scans that you'd go with, um, yeah. And can help guide that management. Would you agree? Yeah. I mean, even when you nail the diagnosis, um, you know, uh, what, you know, what kind of problem, uh, just, just grading can be a pretty useful outcome of, uh, of imaging, especially, I think mainly to distinguish, you know, it's when it's when imaging shows you that the injury is more serious than you realize the same kind. Just. worse, right? That's probably when it's most useful for grading. But yeah, of course, it's often helpful to have a better, clearer sense of the severity of the entry. But I think it's most fun when it helps with hard to diagnose problems that just wouldn't have been diagnosed at all. I don't know that I would, you know, if you're reasonably confident about the diagnosis, I don't know how useful imaging is for grading alone. that might constitute or at least risk getting into premature or excessive imaging. Yeah. Well, I guess in saying that with the positives being those diagnostic clues that you're talking about, a lot of people would say, all right, well, let me just get scanned for every injury to make sure that I'm not missing anything or make sure that it's correctly identified straight away. But can you think of any major downfalls or negatives to getting scans or something you might be really cautious about when prescribing or sending someone for scans? Hmm. Let's see. Can I think of a downside? Yeah, yeah, I can think of a few. This double-edged sword, it's, uh, that other edge is, um, is pretty sharp. And the, you know, at its best, imaging is solving hard to diagnose cases. At its worst, it is misidentifying the problem. It is contributing to misdiagnosis. Premature and excessive imaging is a huge problem in the world of musculoskeletal medicine. And the main reason for that is that so many imaging results are not as clinically significant as they look. They seem, you know, that there's that, there's that, well, there's your problem reaction. Well, what if it's not? What if it only looks like the problem? And there's something very captivating about spotting something major on a scan. It's very hard to think past it. When you see, when you've, when you've had, you know, chronic pain for, let's say two years, and you're desperate for answers and that MRI is showing you something that looks like the explanation, but isn't. You don't know that, but it's not. It's not actually the explanation. It is really hard to ignore it. It is really hard not to say, oh, that's got to be it. But here's the weird problem, is that there are so many things that show up on scans that are incidental findings, that aren't actually the problem, that look worse than they are, that do not correlate with the pain, that are not the thing. And yet once you've seen them, and once a clinician has seen those things, man, they just take over. They just, they dominate the discussion. And people in their minds, both the pros and the patients, everybody, once you've seen something, we just, they're just automatically equivalent, right? My problem is that thing that we saw on the scan. They are the same. But the reality, the weird reality, is that pain and tissue state don't correlate neatly. The relationship between tissues and pain is surprisingly janky, and there's a lot of cases of things that look like they should hurt but don't, and vice versa. There's a lot of people out there in pain and there's nothing on the scan that can explain it. So that, you know, that in very broad strokes, but using the widest possible brush, that is the, that is the problem with imaging, is that it shows you things that aren't actually the problem. And everybody gets all fixated on it, like there can, couldn't possibly be any other explanation or any other factors. And, uh, and that leads not just to misdiagnosis, but to really compelling misdiagnosis. It's really hard to see, to get past it, to the right answer. Once the wrong answer has taken over, it's better to not know. It's better to just not know than to think you've got the answer when you actually don't. Like, when you talk about that, it makes me think about my... early physio days when I was working just as a generic physio, um, at a private practice. And so many people have low back pain. It was like 70% of all the people I see low back pain. And we know that the vast majority of back pain is nonspecific. Like there's nothing structurally going on. It's just sore and maybe due to some overload, but structurally there's no change. But then they go and get scans and the scans reveal, you know, moderate osteoarthritis or degeneration or these like disc, um, degeneration and all these sort of findings. What that we try and explain is incidental findings because someone in their forties, someone in their fifties, the, the older they get, the more, um, I think it was potentially like 50 year olds. Like there's about 60% of them have some form of degeneration in their back. That's totally asymptomatic. That's totally like just a normal. incidental finding. And so that can easily be translated to running related. I think it might even be worse than that. I think it's possible that it's signs of degeneration are even more common in even younger people. Hmm. Yeah. And that goes for say osteoarthritic changes in the knee. Um, osteoarthritic changes in the, like the hips and other joints. We know I've talked to Lindsay Plass on the podcast. We've talked about the incidental findings of, um, femoral acetabular impingement and those type of scans of the hips that. can just be asymptomatic in people in about 70% of the population. And if you go and get a scan and you have hip pain and it shows this FAI, you know, like you say, people will straight away link their, their symptoms to that pathology. And so we need to be very careful with how we, you know, navigate this particular predicament because people want answers. They want to know why they have pain and the, like you say, the, the scans themselves can be a little bit inaccurate in terms of the relationship. the pain that someone has and what they have on a scan. And so it needs to be, I guess, the interpretation and the way it's communicated to the person needs to be dealt with very carefully. It requires considerable caution and diplomacy. And the number one thing to do is not to equate the results, the findings, with the pain. Not to say, well, we found the problem and it is a torn meniscus. say you've found a torn meniscus, don't say that it's the problem, because it might not be. And another really important point is that it not only might it not be the problem at all, it could also be only part of the problem. That the problem, the clinical problem, is the tissue lesion plus metabolic or pathological context. And if you get overly fixated on just the finding, right, it's just It's just that torn meniscus. Well, is it really the... Is that really the problem if it would be painless if not for some other biological factor? What's really the problem? Is it that the meniscus is torn or is it the other biological factors? Well, it's both. It's not one or the other. It's the combination. But the finding tends to fixate people on... what can be seen and what can be imaged and leads the mind away from the other things that might be contributing to making that actually a problem. talking about these positives and negatives, it seems like, you know, this could kind of be solved if a runner had the right health professional by their side to send for scans if appropriate. And then they go get the scans and they're not told of their results until that health professional has the results in front of them, looks through it, kind of correlated to their symptoms and their pathology and kind of disuses it as a piece of the puzzle rather than just like a piece of data, not as the definitive conclusion. And then explain to them and communicate to them, you know, what the findings might be rather than the, the runner or the patient themselves reading through and seeing all incidental findings that, you know, contributes to fear and worry and anxiety and that sort of thing. Right. Do you see that often? Do you see that? But like, what's the usual approach for people to go get scans? Because I've seen people I've talked to people who don't even see a health professional. They skip that altogether and go straight to the scans, go straight to the results. And then they're either being explained by a GP who hasn't really known of the nature of the injury or the nature of their pain. They're just like relaying the word for word what's on the scans. Have you seen that particular pattern in terms of when people are getting those results? I think it's exploded in the last couple of years as part of the pandemic with more and more remote healthcare. I think even more people are getting imaging results sent directly to them to then take to healthcare professionals and discuss it with them, but they're reading it first. Uh, and I, you know, I see it all the time in my inbox. People, you know, constantly show, show me their radiology reports. They've got them. They've read them. They, they think or hope that they understand their problem better as a result. And they ask for my take on that, you know, no clinical context at all. Virtually just, you know, I have knee pain and here's my, here's my MRI. And what do you think? And, uh, and so I think, yeah, I think it's. It's really common for people to read their own reports, but it's also really common. So many clinicians aren't savvy about the double-edged sword of imaging, especially GPs, on average, I'm not sure that they're much better at helping patients interpret. and contextualize imaging results than patients are themselves. And I think the educated patient probably has almost as good a chance as the average healthcare provider. You know, a good, you know, a competent clinician is definitely going to be able to perform better in terms of, you know, sensible interpretation and expert interpretation of it and putting it in, you know, good context and helping the patient with it. But they're hard to find and the patient doesn't know. So, you know, I see, I see patients bringing their misconceptions and misinterpretations of their of their imaging reports to me, but just as often I see them bringing a doctor's misinterpretation. It can come from the misconceptions can come from them or from the healthcare provider and it both happen all the time. And like you say, they're heavily rely on those results. And I've seen people not just hand me their results, but like throw it in my face and say these are my scans. Right. Yeah. I think the If you're to the uninitiated or like the untrained or those that don't understand the complexities of pain or their pathology, like it makes sense. Like if someone says, I have knee pain, here are my MRI results. What do you think that makes like total sense? It's like, um, for those who are untrained for the recreational runner, it's like, there's my answer. Just look at my MRI and see what's wrong. But pain's complex and that's. It's why like you've got so much content on your website because pain has so many different topics and the complexities are boundless or endless. And I guess based on your understanding of pain, pain science, why is it so careful to navigate these things? Why is it so, what does it mean for the recovery and the pain experience? If someone does have an incidental finding on their scans, like what does that mean for their recovery? Yeah, the ugly head of Nocebo rearing up like a serpent. So let's talk about that word for a moment, because that's what it's a major piece of this puzzle. Nocebo, the opposite of placebo. Placebo is relief from belief, and Nocebo is the opposite. It's getting worse because of something that you fear. because of something that you believe. And there are very few things that are as good at scaring the crap out of people as scary stuff on imaging reports. Certain kinds of things, particularly. I mean, there's tons of potential for spooking people with radiology, but stuff in the back is particularly common. You know, that it just... Really, the disconnect between like things that as an expert, to the extent that I'm an expert, as a mistake, let me clarify. I try to never ever think of myself or refer to myself as an expert. I am more of a science journalist reporting on what the experts know, but sometimes I screw up and I forget and I think of myself as an expert for a moment before I come back to my senses. When I see imaging results, I may see something that to me, I think is really trivial, and to the patient... It's, am I going to die terrifying? And the gap can be huge, you know, the between what, you know, how clinically important it actually is and how clinically important the patient fears it is. It's, it can be a vast difference, especially in the back. You know, they're basically thinking it's a tumor, it's gonna kill me, I'm gonna be paralyzed, you know, that kind of stuff. And, you know, the reality may be virtually the opposite. Like, not only is that not scary, it's not even the thing that's probably causing your pain, it's probably completely unimportant and trivial. So the gap can be huge and people can get really scared and really fixated. And I think where I see the most disastrous cases, it's not just... it's nocebo. It's not just that it's a source of spooking. It's the obsessive, um, the fascination with this thing that has been found and the way that it eclipses all other possibilities. And that person is now walking around convinced that they've got this thing in them that is ruining their running career. or ruining their job, and it's all because of that thing. And you can almost feel how desperate they are to just cut it out, get it out of there, get that thing out of there, whatever it is, whatever was found. It's the intensity of that fixation on the thing that was imaged can be really impressively strong. And I think that those cases can get pretty tragic, actually. Hmm. And can hinder recovery based on like your mental state as well. Especially if it's barking up the wrong tree, right? I mean, yeah. Yeah. If it's not even the thing that's actually the problem, but even if it is, the obsession can be too intense. Hmm. And. I know we're talking about extreme examples here, but even in the mild cases, it still plays a role in the background because like we say, pain is complex. Pain isn't just tissue damage reflects the level of pain that you feel. It is so much more than that and can be quite, well, not very correlated at all to actual level of damage. It depends on what the brain perceives as a threat, what the brain perceives as danger. can significantly heighten and faster pass like rational threat levels of a particular injury and therefore heightens pain. If the pain's more sensitive, more irritable and heightened because of that threat that's going on, whether that's rational or not, then creates more anxiety and more frustration or more like obsession. Like you're talking about because of the, the level of threat that the brain has perceived and all due to potential And the, the scans never come up with like education or like load management or, um, particular educational parts of the injury that's really good to recovery. It's really reassuring for the recovery. That's never really mentioned in scans. There's just. detailing an image or detailing several images of what they find. Um, and so can play a huge role on recovery stress. If it creates a lot of stress that actually hinders the recovery process. Right, probably. We assume so. It's probably important to acknowledge that we don't really know how much of a role Nocebo and, you know, fear and stress-powered changes in perception actually influence recovery. It probably does, but we don't know how much. We don't know, you know, there could be very severe chronic cases where, you know, perception of pain is not actually playing a significant role at all. And then there's others where it could be playing a huge role. And not only do we not know, you know, in a scientific sense, how much and how, you know, how often does this happen and how badly does it happen, but it's also really, really hard to identify clinically. And incredibly perilous for the clinician to flirt with, you know, you're not actually, you know, telling the patient effectively you're not as bad off as you think is, it's very thin ice. It's a diplomatically really tricky message to get across, even though it might be clinically important because virtually all patients will hear that as, are you saying it's all in my head or mostly in my head? First of all, that's not what it means. The amplification of pain through fear and stress, if it happens, it's not about pain being, quote unquote, all in your head. It's, but you're not, not only is it not that, but it's just incredibly difficult to talk about the role of the mind, any role of the mind in pain without spooking people. So it makes it really hard. Well put. Wish we knew more. If we knew more, it would be easier to have those conversations. So I know we've talked about like kind of aggressive examples or like extreme examples, but for the runner who's listening to this podcast, maybe they're injured, maybe they're considering getting scans. Is there a certain like protocol presentation signs, signals that may indicate you need scans versus you don't need scans? Is there, you know, a certain system to follow? Yeah. I put some thought into this before we, um, talk today. I did some thinking about this question. And. And probably because I don't know that I've got a good answer. Uh, the best, the best stories about, you know, when imaging was most valuable. The expert clinician pulls a bunch of subtle clues out of the ether and realizes that a scan is needed and saves the day by doing a scan when many other clinicians might not have and find something important and everybody applauds and says, well, that's, you know, imaging at its best. And thank goodness that clinician knew to look. But I think usually the, you know, the cues and clues that clinician is picking up on are very subtle. And I don't know that there is anything, you know, I don't know that there are good rules of thumb for this. You know, there's red flags to try to be more definite. For sure you image sooner when there are red flags for scary things, when there are signs of possible scary causes of the pain. But that's pretty rare, especially for running injuries. You know, that's rarely going to be the case. Not unheard of, but you know, it's... when someone comes in with what looks like runner's knee, it probably is. It's probably not something scary. So I think mostly you do imaging, you start to think of imaging when things get more chronic and more desperate. The more severe it is, the more stubborn it is, and the longer it drags on. the more important it becomes to consider imaging. But there's definitely no, I don't think there's any good clinical guidelines for when to image, just not too soon is the main rule to follow. If you wanna take your running wisdom to the next level, then I highly recommend signing up to receive regular Run Smarter emails. Once you sign up, you'll receive my weekly blogs, research paper summaries, and podcast insights. You might be aware that I regularly post information across Facebook and Instagram, but I know not every blog will reach you. There are simply too many posts competing for your eyeballs and I'd rest a lot easier knowing that runners who want this content are receiving it safely into their inbox. Plus, the additional links and resources I include within my emails means you will get the upper hand than reading it on social media. So if this interests you, there will be a sign up link in the show notes. It's kind of like, okay, it's not, it seems like it's up to the clinician. So the, I guess it's the runner's job to find a person that they trust a person that's, um, you know, within their rehab team, that they respect the judgment of, and it's up to the clinician to try and. Determine, okay, first of all, is there any signs of red flags? If so, send off a scan straight away, which would indicate like serious pathology, life-threatening pathologies. Then you have potentially like in my mind, if you think it's something and you treat it like something and it just doesn't respond and there's, there's no response to good management or good treatment and it could potentially be something else. Maybe it's worth getting a scan and seeing if it is that one thing or the other thing. But also certain areas. I know we'll talk about stress fractures a little bit in a second, but say if it's the shin and people think it's just a severe shin splints. when it could potentially be a stress fracture, you'd probably want to send that for scans. Like if you're not responding to shin splints or not responding to, you know, correct load management, it's looking a little bit more like a stress fracture. Would it be worth going and getting scans just to rule in, rule out that particular pathology and then treat the management differently? Yeah, at what point is it acting stubborn enough to justify imaging? Especially when you know that probably the explanation is that, you know, most likely that's a stress fracture and not, for instance, medial tibial stress syndrome. you might have a pretty high clinical suspicion that there's a stress fracture brewing or already happened. But in that situation, I'm not sure it would necessarily justify imaging. You might just say, well, okay, based on how you're responding to rehab, probably a stress fracture, pretty good chance, so let's start treating it like that. Which mostly just amounts to being more patient and cautious. conservative with the progression back to normal activity. I'm not sure at what point you say, let's do some imaging to confirm that it's a stress fracture or to try to confirm because the clinical clues are pretty strong in that case. What would justify the imaging? I think if it's bad enough, If the level of disability is quite high and it's particularly stubborn, then you're not just doing imaging. You don't just choose to do imaging to confirm that it's a stress fracture, but also to rule out other possibilities. That the severity and duration is a red flag, which also deserves checking out. With stress fractures in particular, have you seen, like I've heard, I don't, not sure if I've seen research or not, but I've heard that stress fractures are very often. Misdiagnosed and mismanaged for a very long time before they eventually scan and say, Oh, look, it's a stress fracture, particularly ones that are like around the hip or like the pelvis and like something that's masquerading as something else. And can go several months before, okay, let's just do a scan. Oh, stress fracture and then treat it like a stress fracture. In the research that you've come across, have you seen that particular pattern or that, you know, that missed diagnosis mismanaged for quite a long time? Yeah, I think so. I think that stress fractures just generally aren't on people's minds. They tend to think of them as something that happens to the shins only. And in fact, they're fairly common. And the key to, I think the key to understanding how common they are is to know that, you know, bone is not concrete, it's not dead dumb stuff. It's very metabolically active, biologically fascinating substance that's constantly changing and adapting to stresses. And it doesn't do very well with some stresses. And so bone fatigue, bone stress injuries. stress fractures, right? That's the tip of the iceberg. Long before there's a fracture, you've got bone fatigue and bone stress injuries. And if you appreciate how dynamic bone is, what an interesting and active tissue it is, it's a lot easier to keep it in mind as a diagnostic option that bone could be. could be getting pretty irritated here, along with other tissues, right? All the tissues can get overloaded, including bone. Just remember to include bone. All the tissues can get overloaded, including bone. And I think if more clinicians kept that in mind, there'd be much less of a problem with the, the nine months later, oh, you've got a stress fracture imaging result. Oh, that's what's going on. Imaging is patching up a clinical problem, a diagnostic failure, that shouldn't have happened in the first place in that case. Yeah, well put. And I'm glad that you sort of highlighted that it just needs to be on like, not top of mind, but just in consideration with all the other potential overload, overloaded structures and potentially it might just be sometimes too slow. Like from a runner perspective, if you. used to running five Ks, then you run 10, a 10 K hilly run, and then your Achilles you saw the next day, you know, it's pretty classic overload, but, um, would you is overloaded bone. Is that a little bit slower in response is a little bit hard to directly correlate to a particular, um, overloaded event, or is it more of a chronic overload rather than a particular one event based on your understanding? Yeah, that's a good question, and I'm not sure that I know the answer, but my impression from what I think I know is that, yeah, bone stress injuries are a little harder to diagnose, not just because they're not high in mind, but because the adaptive response curve is a little softer. You get much sharper spikes of symptoms with tendon, for instance. Right? Like you can, you can go out on a run and you can, you can piss off a tendon in one run. No problem. Right. And it's, it's obvious. I went for a run and I irritated my tendons. Um, and I think the same thing can happen with bone stress injury, but it's often, it's more like I went for 10 runs and irritated some bone. Um, it's a little bit, you know, it's dynamic tissue, but it's not, you know, quite as reactive. as tendon and muscle and sometimes ligament, I think. I think that's my answer, but it's a good question. I'd like to actually look into that one more carefully and try to find out how, part of the reason we're talking about this and part of why I was keen on this conversation is because I've been very interested in this question lately of the subclinical stress fracture, the bone stress injury, what it feels like and what happens and how it presents clinically before it's a fracture. And I suspect if I look into it, I'm going to find out that we're just not sure. You know, when, when does that start to hurt? How much does it hurt? Are there a whole bunch of people out there who have almost stress fractures who are in quite a lot of pain or does it really have to actually fracture before people hurt? I suspect it varies a lot. And I suspect we don't know nearly enough. Okay. Heavy. In the research that you've already done, have you established kind of like a bit of more of an understanding of early signs before an actual bone stress, like fracture or bone stress reaction? Any, any subtle signs and symptoms that might indicate you're on that trajectory? Yeah. Well, I think for sure, I have the impression that, you know, there are cases that are symptomatic before there's an actual stress fracture. For instance, before it would show up on an x-ray, right? Because you have to have an actual fracture to show up in an x-ray. Before an x-ray can see anything, you're only going to see something with a bone scan. And that's injecting a radioactive tracer that is attracted to cells, bone cells, that are busily making new bone. So that tends to happen wherever there's injury to the bone. It's basically like detecting, it's the bone scab detector. So you inject this tracer and it's sucked up into the specifically those cells, yay science, that are busy building new bone and so in the bone scan, you know, any area of bone that is under strain will usually light up, as they say. And... So we know that people are symptomatic before they have an actual fracture. But how often and how bad and, you know, are there cases where people have really quite serious symptoms but no fracture? Another clue and a complication is that probably many bone stress injuries are accompanied by stress injuries to soft tissues as well. And the shin is probably the classic example where it's really all of the above. It's the muscle, it's the tendon, it's the connective tissue wrapping of the bone. They're all failing together. They're all going, ah, together. And which one goes first tends to define the injury, right? So if the... the tendon and the wrapping around the bone starts to pull away from the bone first, then we'd call it oh that's a medial tibial stress injury. But if the bone cracks first, then it's a stress fracture. But they tend to all be happening to some degree at once. And tends to be kind of like a sign of fatigue, like running fatigued tends to you know, just not do very well for runners. Like the loads that are accumulated, just a bit displaced a little bit, like a harder foot strike on the ground, maybe like a longer stance time. And there are studies that have been done that show that runners who have a history of stress fractures actually just hit the ground harder. So it could just be that hit the ground harder just puts more strain on bones around the foot and shin and that sort of thing. But like you say, if you're running fatigued, you're also fatiguing the muscles and putting them under unusual strain. The tendons themselves are just, you know, mechanically inefficient when you're running a bit sloppier and a bit like less springy. But then you're also doing like the shock attenuation through the bones is just a lot greater. And whatever fails first at the first point of failure, whatever structure depends, decides to be what you end up with, it seems. Yeah. In the rest of the research you've done around this topic, I'm always curious to ask, have you come across any, I guess, misconceptions, misunderstandings around stress fractures, or maybe what was a consensus around stress fractures 10, 15 years ago, we now have a different understanding of, any revelations or information on that topic? I don't know if I've got anything good on that question, but certainly part of it would be exactly what we've just been talking about. The fact that it's not just the fracture and that they're more common. I think that's the most important one, that they're more common than most healthcare providers. have given them credit for. I think that's probably the big, the biggest change in the field over the last decade is just that it's, it's really something to, to watch out for. Maybe another one, and, and this I, I'm hesitant here because I'm really, I'm like, I'm really still actively looking into this and trying to learn about it. But the, reinforcing the idea that, that bone is tissue and dynamic, to what extent are we more vulnerable due to systemic metabolic and pathological factors? And we know that there are extreme biological and pathological situations which really predispose people to stress fracture. And that's kind of creepy. The question is, how far can we extrapolate from that? You know, is the runner who is simply maybe, and this is a question I'm trying to answer this week, I don't have the answer. Sorry in advance, I don't have the answer. I'm trying to find out, but does the chronically underfed athlete have a higher risk of bone fracture? And that connects with the concept of the female triad. which is an idea that's what, 25 years old now. And there's been a bunch of controversy about that hormonal and metabolic and nutritional changes, particularly in women athletes, leads to much higher risks of bone injury. But there have been experts who have challenged that model and said, it's not exclusively about women, it's not exclusively about diet, it's not exclusively even about being an elite athlete. You don't have to necessarily be... Basically, there are hints that this can basically happen to anyone. That you don't have to be the most extreme example. You don't have to be an elite athlete. You don't have to have an eating disorder. You could just be a tired middle-aged athlete under too much stress who's, you know, chronically exercising while you're not, you know, in a bit of caloric deficit. And metabolically, your body is screaming silently, please stop, and you're getting a stress fracture. And that, if that's a thing. And I really want to be clear, I don't know that it's a thing. I'm wondering if that's a thing, and I've been actively trying to find out lately and doing some relevant reading. It's reasonable speculation at this point only. But if it's a thing, and there are certainly analogies, there are certainly other things like that in the field, then it's really interesting and it's a really good example of how... You know, you can get all obsessed about your running mechanics, and how you're hitting the ground, and how your gait changes when you're fatigued, or, you know, your characteristic gait foibles, and... If the real issue is that you're underfed, and exhausted, and stressed, then the mechanics? Not so important. You'd be fine if you fixed the metabolic situation. It's just a really interesting possibility, and... And, and it, it could be, that could be how it is. I don't know. I'm glad that you're, you're one to, you know, highlight that you don't know. You're, you're trying to work on it, but don't have any conclusions or any like opinions on it. concrete just yet. It goes to show that, you know, you really focus on the research and you really focus on letting that dictate your opinions and the advice that you give out. And I want to thank you for all the valuable information you've had on this podcast so far. Any other final takeaways as we wrap up this episode while we're talking about scans and talking about whether to get scans or not talking about pain, talking about stress fractures, any, any other final takeaways that you'd like a runner to know that we haven't necessarily covered? Um, that's a nice wide open question. What would I like to say to runners? We've talked about so many different things. I really want injured runners to know that initially for a little while, I really strongly believe in resting. in not hitting the rehab exercises too hard too quickly. And you know, everybody's very shy of resting, especially athletes. Very, very worried about it. Very worried about deconditioning. And I want you to know that the only thing worse than getting deconditioned is continuing to overload and never getting better. So there's a tendency and I think it's quite an American tendency. There's a very gung-ho, hit an injury with as much rehab exercise as you possibly can as soon as possible. That'll get you better. And I think it gets overdone. There's definitely... uh, something to be said for, you know, strengthening and building yourself back up as soon as possible. But there's also something to be said for taking it a little easier upfront. When you first notice something's going wrong, uh, think about the, the role of stress in In injury, and I don't mean emotional stress. I mean, I mean everything. I mean the you know, the entire picture of how overloaded your body is. And that is probably the, in most cases, for most runners most of the time, that's the most important thing to address first. Is give it a rest. And as Greg Lehman would say, calm shit down, build shit up. You start with the calming down and I like to emphasize the calming down. You are not going to get really out of shape if you just really take it easy for two or three weeks. It's not going to ruin you as an athlete. But a year of an injury that won't go away, that might ruin you as an athlete. So that's a good one that I like to try to pass on to all the runners I know. We self sabotage ourselves a lot when we get, you know, first signs of an injury where fear of losing fitness, fear of, you know, or just like ignorance, or not wanting to convince yourself that you are injured and you just keep running through it, keep overloading it, keep, you know, doing the wrong things, mismanaging it just keeps getting worse. And I think there's something to be said. Like if you catch it early enough and you find symptoms that are So minute and you, like you say, pay attention to the, maybe you've overloaded it. It just needs to be a minimalist change at that stage. Like the sooner it is, you can just make a slight adjustment in your training and it makes a significant difference, but catching it way too late then it has to be like a significant change, which people don't like and they just ignore it. And then injury gets worse. Yeah, no, I like that. I like that idea. Bravo. It's and I would love to know and we don't we don't have data on it. I'd love to know how clinically significant niggles are. How early can we detect a brewing problem and how much does it matter? And, you know, if every runner immediately took a week off, if they just, you know, pick up on the slightest sign of trouble, what would that do to injury rates? And it's, we don't know. We don't have that data, but I'd love to know. The other side of that, of course, is that every runner constantly has all kinds. If we responded to every niggle by taking a week off, none of us would ever run. Yeah. Like I said, that, um, one of the things I'd love about you is the fact that you, you can say you don't know about a certain topic, but I'm looking more into it. But I also really respect people that are willing to change their opinions based on the, the. different information that comes in. Cause some people can be fixed, rigid, like beliefs on a certain thing. And then as soon as context or information comes in that, you know, might be of a different opinion, they just push it away and just fixate on the stuff that's like that confirmation bias. But whether conflicting information changes your opinion or not, like you considering it, you considering it in the the vast context of what you already understand, which I already, I get that sense from you after talking throughout this podcast. So yeah, your wealth of knowledge and it's... elite in terms of keeping really up to date, being willing to change your opinion based on new information that's coming in and I really respect that. So thanks for coming on and sharing all your wisdom. Thank you, I appreciate that very much. And that concludes another Run Smarter lesson. I hope you'll walk away from this episode feeling empowered and proud to be a Run Smarter scholar because when I think of runners like you who are listening, I think of runners who recognize the power of knowledge, who don't just learn but implement these lessons, who are done with repeating the same injury cycle over and over again, who want to take an educated active role in their rehab, who are looking for evidence-based long-term solutions and will not accept problematic quick fixes, and last but not least, who serve a cause bigger than themselves and pass on the right information to other runners who need it. I look forward to bringing you another episode and helping you on your run smarter path.