Runners DREAD a stress fracture! It is often misdiagnosed or picked up very late. So it is crucial that all runners: Learn why stress fractures occur What the common symptoms are How to effectively manage it How to implement preventative strategies We cover all of this in today's episode! If you would like to support the podcast and participate in future Q&As sign up for $5US per month at https://www.patreon.com/therunsmarterpodcast To learn more about the Run Smarter Online Course, including FREE preview head to https://courses.runsmarter.online/collections To follow the podcast join the facebook group: https://www.facebook.com/groups/833137020455347/?ref=group_header To find Brodie on instagram head to: https://www.instagram.com/brodie.sharpe/ To work with Brodie Sharpe at The Running Breakthrough Clinic visit: https://breakthroughrunning.physio/
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on today's episode, avoiding and managing stress fractures. 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 and smarter runner. My name is Brodie Sharp. I am the guy to reach out to when you finally decided enough is enough with your persistent running injuries. I'm a physiotherapist. the owner of the Breakthrough Running Clinic and your podcast host. I'm excited to bring you today's lesson and to add to your ever-growing running knowledge. Let's work together to overcome your running injuries, getting you to that starting line and finishing strong. So let's take it away. Thanks to everyone who has shown their support for the last episode that I released regarding my journey through six years of managing tendinopathy, pesian, serenis, tendinopathy, and talking through my experiences of how I've overcome it over the last three or four months. Stories seem to resonate with people. And so it seems that it's. helped the running community a lot and yeah, hopefully I can bring more stories like this for the future. So thanks for those who have contacted me and said that that's really helped them and helped their journey. I'll also start with an apologies. I did put on social media that Simon Bartold will be on and if you have any questions, thanks for everyone who submitted their questions. The day of... the recording I just gave Simon a heads up and he accidentally double booked himself and so we have we're discussing when to reschedule him. So all your questions are written down and I have all the interview questions written down and they will be just there when we just when we find a time to get Simon on. So today I still wanted an episode to come out this week and I'm like oh so what should we talk about? And I'm At this stage, I'm building on more modules to go into the online course and just spent the last couple of days working on the latest evidence management prevention of stress fractures. And I hadn't done an episode on stress fractures just yet, so I thought that would be perfect to come on and chat to you guys all about stress fractures. And before we do that, before we go into this content that I have planned, I want to start a bit of a contest to help. promote the podcast and you'll be really excited about this. I came up with this idea and with a little bit of a prize for those who want to participate. So what I ask of you is on social media like on Facebook or Twitter or Instagram, tag me and mention the podcast and it just has to be really brief around your favorite episode or what episode you recommend and why, and on your favorite episode, what you learned, or is there anything that you've changed or anything that's helped you? And tag me in it so that I can keep track of the people who do participate in this contest. It'd be super, super simple. So you can do that right now. You can just pause this podcast and do it, only take a couple of minutes. Make sure you tag me or either screenshot the post and send it to me. And that way I can keep track of everyone that... does participate in this. The winner will get access, unlimited access to this online course and so the value of it is $199 and usually the membership is three months long. You have three month access but for the winner of this contest they'll get access to all of this content and have it for unlimited, well you'll have unlimited access and so a huge value. If you are one. Well, you're obviously one who listens to this podcast and likes the knowledge. If you love this podcast, you'll love this online course. It's got several modules on injury specific stuff, increasing running performance, looking at your running analysis, looking at injury prevention. It's an enormous resource that I've worked really, really hard on. And I've said before, it's like this podcast on steroids, good visual elements. diving into evidence and going through really specifics, but designed for like the jargon that we use is designed for everyday runners. Doesn't go into highly technical physio skills, but if it does touch on some scientific topics, I make sure that I explain it as best I can so that anyone can understand. If you're already a member of the course, you can still participate in this contest. I will give you... You have the choice. I can either give you unlimited access so you don't have to so you'll change from this three month membership to Unlimited or you can gift this course to someone else, which is fantastic in its own right and so please Pause this episode and you can do that now I'll probably do similar contests like this in the future, but the podcast is getting bigger and the listeners, the audience is growing, growing every month. And so this will be your best chance. This is when the listeners are at their lowest, you could probably say. And so this is where you have the best chance and I'll get a list of all the entrants and I'll pretty much just put them all in a list, choose a random number allocator. And then that will be how I'll choose the winner. I know it's like universally known that podcast listeners, the calls to action are very, very low because you just like absorbing information and listening. And you know, usually with big podcasts when they ask for something or they're running these sort of contests and promos, the engagement isn't as much as they'd expect. But I like to think my audience is different. I like to think that based on the feedback that I'm getting that a lot of people are resonating with this podcast has helped them out a lot. So it could help out a lot of runners to hear that this podcast exists. And yeah, it's got a great price to go along with it. So take some time, take two minutes, and it's available for you to do right now. Like you can, obviously listening to this on your phone, you can pop up Instagram, pop up Facebook and do that right now. And the price is unreal. So without further ado, let's move on to stress fractures. And... why do a topic on stress fractures? It's probably a runner's worst nightmare. It is almost like on the, it's almost like the exception to the rule. Like we could have a lot of universal running rules about what to pay attention to, how to interpret certain symptoms, what to do for certain symptoms. But it seems like every time we lay down some principles, you have to say, oh, but. there's an exception to that rule and that would be stress fractures. And so having a topic on its own is very, very important. The more we know about it, the better. Like I think the average diagnosis, like a runner on average would have this for six months before it's accurately diagnosed. And that's because it masquerades as something else and it slowly develops over time. It's very hard to identify in the early stages. and then it's only identified when you're not responding to traditional treatment. It's getting worse and worse. Someone sends you for scans and then we have a stress fracture on our hands. And usually when it's six months down the track and it's pretty irritated, it can be very, very hard to manage as opposed to if it was picked up really early. And so that's why it's best that we know these sort of things. When it's identified, it can become like a... quite hard to manage depending how far down the track it is. And so today we're gonna discuss like the signs, the management and hopefully some preventative tips. So I just went onto Google and looked at like a definition and it said that stress fractures are tiny cracks in the bone. So due to stress, so stress fractures, they're caused by a repetitive force often from overuse, which is repetitively jumping up and down or running long distances. stress fractures can also develop from normal use of bone that's weakened by a condition such as osteoporosis. So it's usually an overload issue. It's an overload to the bone, but the level of load can be exactly the same if there's some sort of osteoporotic or osteopenia conditions where the bones become the bone density becomes a little bit less and it becomes a little bit more brittle you could say. So there's growing consensus that there's an imbalance between load and micro damage formation and removal. So one way I like to think about it is that the bone itself isn't static. It's not just like a static structure. It's actually dynamic. It's a living breathing kind of similar to muscle, similar to tendons. What happens is when you subject the body to load. is that it reacts and it actually starts to stimulate some growth and actually breaks down certain parts of the bone. So we call those osteoclasts and that breakdown is totally necessary. It's totally healthy because when it starts breaking down, what happens is it's getting replaced or the repair, it undergoes a repair phase over time. So it uses osteoblasts and that encourages more bone formation. So exercise and applying stress to the bone is actually really good because that sequence of breaking down, rebuilding and becoming stronger helps the bone, helps the development of the bone, helps it become more rigid and more resilient. And so what we're seeing with this dynamic relationship or this imbalance is that sometimes the breakdown can become greater than the reabsorption or the repair phase. And so as an example, if you have a runner who is doing a lot of exercise and establishing a lot of bone breakdown, but then isn't allowing the body time to recover and say half or less than half of the way during that recovery phase, you subject the body to more running and more loading, then it's going to... going to stress, it's going to go back into that breakdown phase and it's not allowing that optimal recovery phase. So over a long period of time, if that, if the breakdown is greater than the repair, then it starts to become more brittle, it starts to break down, then you start to have these bone stress reactions. This can also be with like acute changes to changes in the bone. So increased mileage would be the most obvious one for runners. a change in surface if you're transitioning to a harder surface. So if you're going from grass to bitumen, road, that kind of thing, and subjecting your body to repetitive loads on that. If there's a change in shoes, if you're heading towards the minimalist side of things with your shoes, that could put more stress on bones around the feet. So any acute changes in that way, mixed with high mileage or a long run, can definitely start to break down these bones past their capacity to adapt. And so the reabsorption phase becomes greater than the remodeling phase, and then you have that breakdown as well. So there's some other examples. If we were to go and look at extreme examples, say for long distance runner, typically someone who is a rear foot striker, so a heel striker, they tend to have higher load rates in bones such as the tibia, fibula and the femur. Whereas someone who might be a sprinter and might be more on the forefoot striking, they are subjecting the body to increased loads around the bones of the feet and so they're more generally speaking at a higher risk of developing things like fifth met or some other if we're applying this principle, it then falls on a spectrum. So you have ideal bone loading, like I was explaining before, you have that breakdown repair and then go repeat that cycle. If the amount of breakdown equals the amount of repair, you have a really nice bone that's growing and growing, getting stronger. You do also down one side of the spectrum have this underloading. So maybe the bone isn't getting stressed enough and just say if someone might be a swimmer or someone might be maybe elderly who don't subject their body to a lot of exercise, their bones become quite brittle because the amount of exercise and the amount of stress that's put through the bone isn't enough to trigger anything and so it becomes more brittle that way. But then on the other side of that spectrum you'll have that overloading and so when you get to that overload you're putting the body at an increased stress of this bone stress injury and these bone stress injuries fall in certain grades between grade one and grade four. And so grade four being the most severe of bone stress reactions and grade one being at those mild forms. If we're talking about maybe risk factors, you have two categories. There's the category that affects the bone, so like the bone structure and then you have the other category that's mechanical load on the bone. And so some examples of that first category, the effect of bone strength would be the density, the bone density, the geometry, so how big the bone is, the take into factors such as your age, your genetics, nutrition is a big one, like vitamins and minerals, vitamin D, calcium, all that kind of stuff, hormonal status, any sort of bone disease and energy availability, which I'll delve in a second. These can all be like hidden dangers and it's one of our universal principles in season one. Things like nutrition, things like stress, it all affects the bone and affects like the structure within the bone. And if the bone is more brittle, you're gonna be more subject to or an increased risk of developing these stress injuries. And the second category is the mechanical load on the bone. So it's those examples I used before with high mileage, change in surface, change in shoes. any other things I can think of like increased frequency, body size, like body composition or that kind of thing. These really, really lean runners can tend to be more prone to risk of bone stress injuries. So there's some risk factors that we need to consider. So sleep, stress, nutrition are also really, really important, which I'll delve to in a second. So they're the risk factors. What about like signs? What are some symptoms? Because like we said, it takes on average six months for someone to accurately diagnose a stress, a bone stress reaction. So are there early signs? In almost all cases, there'll be some sort of history of bone overload or based on the athlete's general health. we can sometimes start to suspect that maybe there's a bone stress reaction. The symptoms can be very gradual, like a very gradual onset, like a sometimes a mild, like diffuse ache during running. So it usually starts off with loading up the bone. And so pain will come on during a run. There won't be like a warmup effect, like a tendon or a muscle might have where once you warmed up, it goes away. It actually starts to increase and increase and increase further into your run. and in the initial stages, it tends to settle down quite quickly. And then as the pain starts to develop or the injury starts to develop, pain would become more severe. It will become more localized to that particular area and it will persist for longer after your run. So longer into your rest period. And then eventually when it gets quite irritated or quite severe, it will stop you from running. too much to bear when you are running and there will be like advanced stages say anti-inflammation responses so it might be red, might be hot, might be inflamed and this usually includes things like night pain as well. So that's sort of how it progresses you could say and some things that you can do to assess as a physio or as a health practitioner, bony tenderness like if you palpate the area. Occasional like observations with like redness, soreness, warmth, like those inflammatory kind of markers Pain with loading tests, like I know a lot of people do hopping tests. So if you can't do say like five to ten hops because of the pain in that area and you just don't have confidence to Weight bear or load through that bone that can be a big sign and you might need to be sent for scans While I'm on that topic if we are looking at scans, I think the first approach is usually to get an X-ray, but an X-ray will only pick up on the grade, like the severe grades. I think if it's a grade 1, grade 2, it usually comes back quite normal. If you get sent for scans and it comes back normal, then you might want to investigate with other means of scanning like a bone scan or an MRI. MRIs gold standard for these sort of things. You'll pick up a grade one, grade two, grade three, or grade four. If it's a severe grade three or grade four, an x-ray will pick up on it. But yeah, it's up to you. It depends on price as well. So usually the most appropriate thing to do is send for an x-ray just to see, and then base your judgment on that. How are we going for time? I kind of want to keep this episode a little bit shorter. Some common areas. So half of bone stress injuries for long distance runners occur in the tibia, so the tibial diaphysis, and can masquerade as kind of shin splints. And there is some evidence to say that, or some beliefs that a shin splint symptoms are actually a really, really mild form of bone stress reaction. So it's worth knowing, but that is a common area. with the majority of other areas being the femur, so your thigh bone, your fibula, which is next to your tibia, the calcaneus being the heel, metatarsals and tarsals, which are bones in the feet. However, there are some really rare cases of bone stress reactions happening in the pelvis or in the lower back, and does happen with runners, so it shouldn't be overlooked. And I should probably mention that the femur, which is your thigh bone, it also happens up at the neck of the femur, so deep in the hip kind of region. And so that can be quite problematic as well. Why we actually need to treat these differently is because, like I said, there's always the exception to the rule and stressed fractures always seem to be that exception to the rule of most managements. why we need to do that is sometimes they can develop into really high risk stress fractures. So if you continue to ignore it and you continue to run, it can start to develop into a complete fracture or it could be really, really problematic with trying to heal and trying to unite. So what we call the two bone parts that come together and start healing, we call that union. So sometimes risk of becoming a complete fracture. And so, usual management injuries for, um, for runners. We have the acronym PEACE AND LOVE, and that's kind of like the new RICE or RISA that people used to rest ice compress elevate. Uh, can't really rattle off all of the PEACE ones, but it's like protect, elevate, compress, like all those sort of acute... inflammatory sort of stuff. But then there's the peace and love and the love acronym is load, optimism, vascularization and exercise. And that's very, very important for any other type of injury, like a tendinopathy, muscle strain. It's really, really important that we load it and we exercise and we keep our motivations quite high during as early as possible. And sometimes that can be through pain, sometimes if it's at those low acceptable levels. For bone stress, that is not the case. For bone stress, especially if it's a high risk, we actually have to backpedal you and take you out of loading for an extended period of time to allow the bone time to unite and heal. And so if we ignore that, it can get very, very complicated and become a very, very serious injury. So depending on the location of the body part, it could be labeled in terms of high risk and low risk. And... Generally speaking, the high risk locations, areas of the body where there's not a lot of blood flow, and so healing times take significantly longer than the ones that are low risk. So high risk would be your femoral neck, so deep in your hip, so it's like the higher part of the femur bone, the anterior part of your tibia, so if you were to feel your shin, the one that's closest to the front of your shin, that can be quite problematic. shin splints are usually on the inside border rather than the outside. The talus and the navicular which are the two bones within the feet, they have really poor blood supply and the fifth met, the foot bone that's like at the base of your fifth toe, so your little toe. So they're high risk, low risk can be things like your shin splint kind of area, so the other side of your tibia. The femoral shaft I think is low risk, the pelvis is low risk and your calcaneus, so like your heel, can be low risk as well. But like we said, the most common area is the inside border of your shin and that's counted as a low risk area. And the timeframes. Depending on the high risk, low risk, for bone stress recovery, like return to sport timelines, they're quite extensive. So if you're looking at a grade one, you're looking at somewhere around 12 weeks, like 11 to 12 weeks before returning to sport. Grade two, it's like 14 weeks. All the way up to grade four, injuries are somewhere like more than 30 weeks before returning to sport. So it can be very, very time consuming. This is why runners dread it so much because they have to rest, they have to unload, and they have to abide by these rules. And it's super, super frustrating to not load. Sometimes on crutches for six to eight weeks is unbearable for some runners. And so how are we managing them? Let me try and summarize this as best I can. So if we have a low risk stress fracture, what do we do? What are the phases? So phase one, activity modification, definitely. we want to try to provide anti-inflammations for some, if some are particularly aggravated or there's some sort of obvious inflammatory component going on. But like the first thing is you need to modify the activities you're doing right now, because what you're doing is not serving that bone, that restructure and formation of new bone. So we need to do that. We need to identify any potential risks. So like we said above with these risk factors, if there's anything to do with your general health, your nutrition. What else did we say for risks? Maybe like low weight, like really, really low weight. Maybe things like spikes, any spikes, maybe change in running shoes, change in terrain, all those sort of things. We need to identify any of those risks and address those. Phase two would be like during your return to running. I should say these activity modifications, they need to be pain-free. So your... walking, your jogging, your cycling, whatever you, whatever modification we have to lead to, there needs to be no symptoms. If there are symptoms that we need to keep pegging you back, maybe doing a walking program. And if that's causing symptoms, maybe we need to spend some considerable time off. But yeah, that's where it's important. Then phase two would be like reintroduction into a running program. So you begin like really, really slow and progressing really, really slowly. with a run program and appropriate loading will be identified as loading that doesn't provoke any symptoms either during or after activity. Once a runner is within this low risk, it becomes pay free during unassisted walking, then they can start trying to do some running and trying to, oh, a walk run kind of program and see how the symptoms respond and there I looked at a study that had a really gradual return to running and it'd be something along the lines of okay you walk for 15 minutes or let's just say walk for 10 minutes and then every 3 minutes you're jogging for 100 meters and do that 3 times and then if there's no symptoms the next day you're jogging for 150, 200 meters something like that. It's just like this really gradual progression into more and more loading. which is definitely necessary for bony stress. So keep that in mind. During phase two, we might often consider like gate retraining. So reducing the ground reaction force and acceleration. So what we're doing is trying to manipulate the magnitude and the rate of loading of that bone. And that could be things like addressing your cadence or addressing how you're contacting the ground, whether it's forefoot, rear foot, the shoes that you're wearing, that kind of stuff. And then from there, we just continue to build up your program. So continue building up your mileage 10% every week. And then, uh, hopefully, uh, symptoms stay at zero to show that you're responding well to those loads. And we just continue onwards and upwards. So that's for like a low risk stress fracture on those high risk side. We have things like, uh, it really, really depends on the location, but it could get as serious as non weight bearing. So you're in a cast and crutches or a boot and crutches, or it might need surgical intervention. So it might actually need to do some plate and screws to actually fixate that, that fracture, but it will depend on the grade. It will depend on the location and yeah, depending how severe it actually is and what the history is like is the runner elite. or novice, how long have symptoms been going on for? Is there any other pathology mixed in with that as well? And so it's hard to really give you solid advice on that. But if you're at that stage, you're probably looking at consulting with a sports physician or someone around that expertise. They can also re-scan throughout your process just to see if the bone is healing. and can make the judgment call if you continue applying the same amount of loads, something like a navicular fracture, they would initially scan it, see how bad it is, six weeks down the track scan it again, see if there's any healing taking place to give you the best management tips. Some exercises, so you want to keep some shock through the body, so this is in the later stages of rehab or even as a preventative. approach, you want to stimulate the bone as much as you can. And there's a lot of research to show that needs to be dynamic. So the exercise, it can't be static, like those isometric hold kind of things, it needs to be dynamic, you need to be moving, because muscle needs to pull on bone in different directions in order to stimulate that bone growth. So you want to put adequate strain of intensity, you want to make sure that the bone actually responds well if it's in intermittent rather than just doing one workout with a lot of loading and then rest. You kind of want to do a little bout of exercise, then rest for a couple of hours, do another bout of exercise, rest for a couple of hours. The bones respond quite well to that. You want to make sure that it's variable. You want to make sure that sometimes it's multi-directional. You want to make sure so it's like side to side hopping. It's not just in one direction the entire time because muscle pulling on bones in different directions helps that. And then you also want to make sure that It includes adequate intake of calcium, vitamins, vitamin D, that kind of thing. Some examples of like shock is, um, what we learned at uni was like doing step ups onto a step, but you're actually slamming your foot down. You're trying, you're wearing shoes and you're trying to be as loud as you can with those step ups. Um, you, you're wanting to slam your foot down on the ground, make a big, loud thud as you step up onto the step and then step back down. repeat that process and that sends shock through the body and that shock actually allows for bone stimulation. I sometimes have this in the clinic with people doing step ups when they're working on their bone density and I tell them I want to hear it as loud as I can. I want to be down the other end of the clinic and still hear you doing these step ups. So that's a good one. There's also suggestions of like off a small step like not jumping but just like falling off a really small step and just landing with straight legs and allowing that shock just to go through the body. Sometimes doing like a double leg calf raise and then just slamming your heels down on the ground and allowing that shock to go up through the body can be really nice to stimulate that bone growth. So there are a couple of ideas. Finishing up, let's let me just give you some tips on reducing the risk of developing this. And so for adolescents, I don't know if a lot of adolescents listen to this podcast, but you really want to do like early screening of things like Red S or like the female athlete triad. So things like optimizing nutrition, encouraging participation in like higher impact activities like multi-directional sports, team sports, all that kind of stuff really helps bone growth. I think 90% of your bone growth is actually when earlier than 20 years old. So in those teen years, that's when a lot of that bone growth takes place. And that's where you build a lot of your base. So make sure you're participating in a lot of sports that give you quite active, often multi-directional kind of sports, that kind of thing. But for adults for preventing these sort of stress reactions from happening, one I'd say training forces, so make sure that we're not doing those real high peaks in training load. allowing our bones time to recover. Two would be muscle forces, keeping really strong. It's believed that the stronger the muscles are around the bone, the more it can attenuate or help the transition of like ground reaction force. And it kind of helps to reduce the loads as it transmits a shock through the kinetic chain. So the stronger the muscles are, the easier it helps the bone apply or like absorb that shock you could say. Number three would be running surface. Be really careful if you're transitioning to harder surfaces and if you do so, make sure you do so gradually and it's quite slower and you're not doing a really hard whack onto the ground. Be careful with that. Shoes, transitioning to minimalist shoes. There's a huge increase in risk in foot stress fractures. If someone's used to having really supportive shoes and then they find out that lighter, flimsier shoes are better for them. And so they transition way too soon. The risk of developing stress fractures in the feet are quite high. The other one, I think we're up to tip like five, energy availability. So if anyone hasn't listened already, go back to episode 35 when we talk about Red S with Isabel Ross. And we pretty much discussed things around energy availability and how, as you exercise, it kind of needs to be a really nice balance between the energy you provide yourself and the energy you expend. So all the running that you do admits energy, you need to replace that energy with food and the correct nutrition. Otherwise there's that imbalance and the body's going to start extracting. It's going to try and get energy from somewhere and so that has to be extracted from things like your bones and other vital organs. So that's when we need to pay attention to things like body mass like bone Densities all that kind of stuff and then the last one for prevention would be calcium vitamin D status So running athletes should ensure that they're getting the right amount of calcium and vitamin D takes the recommended dietary allowance I looked this up was for vitamin D was 1,000 to 1300 milligrams and 600, hang on, I've written this down, let me go through that again. Calcium and vitamin D intakes to meet exceed current recommended daily allowances of. So vitamin D, no calcium is 1000 to 1300 milligrams and vitamin D is 600 units. So make sure that that's up there as well. So that's it, that's all the information I have for today. So we went through like the pathophysiology, making sure that there's the build up and breakdown of the bone cycle. We went through risk factors, like the stuff that's affecting the bone, such as nutrition. And then there's the mechanical things, like changes in surfaces and mileage, all that kind of stuff. The different symptoms, turning into from like a mild, dull ache to something that's really, really severe, like inflammatory night pain, that kind of thing. The... main like kind of response for tests would be like loading, like hopping. You tell someone to hop and they just, they look at you like a deer in the headlights. They just don't want to load that structure. So that's a big red flag. The different locations don't really need to go through that. Make sure that if you are going through a correct management, that you do seek the right advice, but we're looking at gradually building up load. that needs to be pain-free during pain-free after exercise and Yeah, then we've just got our Management or reducing our risk of injury looking at training loads getting really strong muscles Look getting really strong bone. Make sure you're careful with your running surfaces your shoes Making sure you're looking at energy availability as important particularly with younger athletes and then calcium vitamin D status So that's our episode for today make sure if you haven't already gone to social media enter that contest. It's a really good prize and yeah how do I go for time because I kind of wanted to do this around 20 minutes, oh god it's at 40. I can talk about this sort of stuff all day so this is why these things tend to drag on. All right hopefully that's really valuable information, hopefully there's something that you have learnt, hopefully you just didn't know all this stuff and just listened for the Thanks for listening to another episode of the Running Smarter Podcast. I hope you can see the impact this content will have on your future running. If you want to continue expanding your knowledge, please subscribe to the podcast and keep listening. If you want to learn quicker, jump into the Facebook group titled Become a Smarter Runner. If you want tailored education and physio rehab, you can personally work with me at brea Thank you so much once again and remember, knowledge is power.