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Hi, it is Tom here from Running Physio. Today I'd like to talk to you about bone loading programs. They're a slightly different approach that we can use with patients as a way to try and help improve their bone health and bone density potentially and also introduce them to impact. Potentially they can help with power and plyometrics as well. Now they are a bit different from some of the traditional approaches we would use in strength and conditioning. So today I want to talk to you about the theory behind them, how we might apply them in clinic, what kind of patients are going to benefit, and how we might utilise it to help someone return to their sport.

Now if you'd like to learn more about running injuries, I put a link to a selection of great free injury videos we've got, so do check those out. I got a really nice message this week from a previous colleague Fab who I worked within Brighton, saying that his team have been using the videos and podcasts for their in-service training.

And that's brilliant. That's really what it's there for. Use these videos. If you're short on something to do in your training at work, why not use one of them to help you out with that?

Turner and Robling (2005) running longer doesn't make bones stronger

Okay. So let's talk a little bit about bone loading programs and what they are. We think from the research from papers like Turner and Robling's work back in about 2005 and some more recent work, that bone's response to exercise is perhaps different from what we previously thought.

And what they found in the research is that bone does respond to exercise, particularly exercise with impact in it, but the response that it has becomes saturated quite quickly. So in as little as 40 to 80 loading cycles, and if we continue to load it beyond that, it doesn't lead to more adaptation. So running longer doesn't necessarily make bones stronger. What this means really then is if we want to stimulate the bone to change, we are going to need short periods of impact. Literally, maybe a minute or two, separated by rest, maybe four to eight hours of rest before the bone is ready to be stressed again, to create that adaptation.

So doing great big long runs of two or three hours isn't necessarily going to lead to much more bony adaptation from even a short session of running five to 10 minutes. And that's perhaps part of the reason why our endurance athletes become vulnerable to bone stress injuries because the long distance running doesn't necessarily lead to the gains we would hope for in terms of bone density and bone's ability to tolerate load. If you are a patient listening into this today, before we go into how we apply these, please recognise that this is about being used by clinicians. So if you got a patient with a bone stress injury, please don't go off and create your own bone loading program, based on what we are talking about today, this should be used under the guidance of a clinician.

I do say that cause I know we have some lovely patients that do listening to these. So with this, when is it going to be appropriate? I think it's often appropriate in those patients who are coming back after some form of bone stress injury. Perhaps they've got medial tibial stress syndrome, which we think is overload of the medial tibia, or perhaps they're coming back after a stress fracture and we want to get that bone used to managing impact again, but it does need to be at the appropriate stage of the injury. So we are not going to do this in the acute stage when weightbearing is going to be limited. Where impact isn't well tolerated. And it does need to be at a point where they're non irritable. So usually, we are working with patients that they can walk for at least half an hour, pain free, most day-to-day activity is comfortable and doesn't provoke their symptoms.

They're a good six to eight weeks down the line from a stress fracture, potentially longer if it's a high risk stress fracture. So there are an appropriate stage for us to introduce impact. And they're finding that impact is comfortable. Ideally, really, we want it to be pain-free. Now, these programs, when we use them, are going to be done little and often.

So we might be doing a minute or two of impact twice a day, so perhaps in the morning and then in the early evening. So we've got plenty of time in between for the bone to recover.

So one group of people that don't necessarily respond well to this, particularly if they do too much, is those with tendinopathy, especially Achilles tendinopathy. I've seen some patients with previous Achilles problems go a little bit overboard with their bone loading programs, and that has really irritated the Achilles. So the first point here is to pick your patient. Yes, it's appropriate for those with bone stress injuries if they're non irritable and they're at the right stage of healing, and particularly perhaps if they've struggled with return to sport before and you really want to prepare their body for the impact, the challenges involved in their sport.

If they have tendon pain or a history of Achilles issues, we need to be a little bit more careful. We might go with once a day initially, or go with shorter periods of impact. So let's come back to that theory then. This idea that the bone is going to respond better to short periods of impact separated by rest. We also know that bone tends to respond better to exercise with a higher load magnitude, so more stress on the bone. That bone responds better to varying load. It's almost like bone gets bored if we keep loading it in the same way. It doesn't keep adapting, so we need to vary up and progress it as well.

We also want there to be some speed involved in this because higher loading rate of the bone, again, is more likely to result in adaptation. So what might this look like then if we're applying it in clinic? We might start with some simple low level impact, like jogging on the spot, keeping it pain free, and just doing that for a minute in the morning and a minute in the evening.

And then we might look to see if we can progress it. And we've got multiple different ways that we could progress it. So we could progress it by moving from say, double leg impact to single leg from jumps to hops, for example. We could progress it by adding external load. That would be very appropriate in someone who needs to manage external load.

You think about a military recruit, running with heavy weights on their back, it might be very appropriate to bring in some extra load for their progression. We can progress it by increasing the excursions. So how big are the movements they're making here? So going from a small jump to a very high jump, or a small forward hop to a longer forward hop to progress it in that way as well.

So we've got lots of options with it. And what will guard our progressions is number one, symptoms very important. We want to keep it as pain free as possible. And also the patient's goals. Where are they looking to get to with this? Now, I put together a little video for this to show you some of these exercises.

Now do bear in mind, I've done this in the man cave, which is a little bit small, so I do apologise if the technique isn't spot on. But just to illustrate some of these things in play.

Bone loading progressions

So we've got jogging on the spot here. Good. A good first start. Then we can increase the intensity by lifting those knees a bit higher, so increasing excursion there. Another option is to jog and stop. So we stop and land on one leg, starting to introduce a little bit of single leg impact. Then again, we can increase the intensity by lifting those knees a little bit higher to increase the impact involved. Then we might try and do some jump squats. Very low ceiling in the man cave.

So being cautious here, not to knock myself out before going on to side movement. And this is another option for progression. Add in multi-directional work, stress that bone in multiple different ways. We could also bring in bounding a nice way of developing propulsion and landing control, and then trying go to single leg work, perhaps single leg hops in place initially.

To try and get them used to single leg and then perhaps varying that up by doing some side to side work, some rotation work, some forward and backwards work, whatever's going to be relevant to the patient that we see really. So a few ideas there that you can use, and there's lots of different ways that we can adapt and progress these exercises depending on the individual need, but I would still tend to keep the dosage to this idea of short periods, maybe a minute or two maximum in the morning, and perhaps in the early evening, and try and make sure they stay pain free.

And when we look at bone stress injuries, particularly if you look at things like medial tibial stress, it doesn't seem to respond very well with working into pain. One study instructed runners to continue running with pain up to a four out of 10 with medial tibial stress syndrome, but it took them around a hundred days to build up to about 20 minutes of running, and that's seems to be the case with these bone stress injuries. Working with pain is not helpful. So when we are working on our assessment, we look at what is a comfortable level of impact for them to start with. So it may well be just jogging on the spot and then we progress them on depending on their symptoms.

So we might then, as we said, progress with external load or progress by increasing the speed or the intensity or the direction that we've talked about, but we keep it to short duration so that we are not overstimulating that bone and we keep it as pain-free as possible. Now, hopefully if we follow this approach, we are getting the bone used to multiple different stresses, hopefully from multiple different directions, multiple different tasks, which means then that can really help someone to return to sport that involves impact.

And if we've got someone who perhaps has really struggled with, returned to sport, and we see this in medial tibial stress syndrome, they've come back into their sport, but they've had a big flare of their shin pain, again, we might say let's invest in four to six weeks of using this little and often approach and progressing it through to really get that shin, that tibia used to impact.

And then we can go into a graded return to sport with it ready, with it, feeling like it's good to go. And if we're working with stress fractures, we might, as part of this, set some outcome measures where we want to see the impact being progressed without pain up to hopping repeatedly. One measure we might use is hopping for 30 seconds on each leg without pain prior to return to running in people, particularly with complex bone stress injuries or stress fractures.

Now, let's say you're assessing a patient in clinic. And you are finding that they can't even manage the light impact. They can't really get onto this start of this bone loading program, jogging on the spots immediately painful for them. In that situation, often what we need to do is give it a little bit more time to calm down first, but we might try and bring in other forms of loading again, aiming for pain free to prepare them for that. So it might be that we encourage them to do walking up within the limits of their symptoms, going up and down stairs, maybe bringing in some sidewards walking, some walking lunges, et cetera. Trying to get them to do tiptoe walks, trying to expose them to multiple different movement types without impact.

Prior to getting them to come and introduce the light impact when it's comfortable, you may even get them to do some pool work, perhaps doing some light impact in the pool in the shallow end so that the water is offsetting some of their weight, again, if it's pain free. But the idea there is that we helped him to get used to load bearing in a comfortable way, and then we retest and see, can you start this bone loading program? And as a simple measure to see if someone's ready to start, can they jog on the spot for one minute without pain? Simplest test you can do. I set a timer on my phone and we test them out. If they can do that, and it fits with the stage of the condition and everything else, that is often a time where we would consider it appropriate to bring in a bone loading program.

Analysis of the evidence

Now, a few things to say with this because always I want to be honest with you about these approaches. Is there are very few studies that I'm aware of that have tested bone loading programs in people with pain. So do bear that in mind. This hasn't been studied extensively in people with pain. These approaches have been studied in healthy individuals and in one study they found as little as 30 jumps a week were sufficient to increase bone density. But these studies are largely in adolescent populations that have very responsive bone. They're likely to adapt quite quickly. So we have to recognise the question marks and caveats around this. I'm certainly not saying it's a cure all, but hopefully you can see if we are introducing someone to impact in a manageable way and we are progressing that, that should help even just as a graded return to their activity. And in theory, if it's pain free, if it's short duration, if it's separated by rest and it's progressive, it should help with the bone health and bone density.

Whether loading technique matters

Our final thought with this is do lookout for technique when we're doing this, Now sometimes we'll see people trying to reduce the load on their painful area.

So for example a gentleman in clinic this week when we did the jogging on the spot, he stayed on his toes. He wouldn't bring his heel to the ground because doing so actually caused him some knee pain. So he probably wasn't really ready to bring in impact loading yet. We'll see people sometimes trying to shorten the time that they're in contact with the ground, or perhaps leaning their trunk over towards that side.

These are all strategies to try and reduce the load on the tissue. And if they're doing it because of pain, it may be that they're not ready if they're doing it because perhaps that's their normal movement habit or perhaps because they're not confident in loading that we would want to work with them in the session, give them lots of feedback, use a mirror in front of them to try and get them to actually load in the way that we want to meet their goals because this is a bone loading program. This is not do some jogging on the spot or do some impact and find some way to offload the tissue.

We actually want that load to stimulate things and get changes. So have a lookout for technique. Practice these things with your patients to make sure it's pain free.

Make sure they're happy with it and get them on board. And if they are trying to find ways to offload, see if perhaps it's due to pain or is it just they need some help with their technique.

Summary

Okay, so that's a whistle stop overview of bone loading programs. As a quick summary, then they are going to be appropriate for some patients following bone stress injuries and things like medial tibial stress syndrome.

But it must be at the right stage of the injury. There need to be non irritable and managing some impact, like jogging on a spot for one minute, pain free. Do be cautious in patients with high risk stress fractures, all those with a history of Achilles tendinopathy, because it can stir it up. If you want to apply it, we usually recommend little and often, so maybe as little as a minute or two of impact a couple of times a day in the morning and the evening, and then progress that towards their goal, but keep it pain free and we can progress by adding external load. We can progress by increasing speed. We can progress by changing direction. Potentially we can progress by increasing the excursions, so bigger jumps, bigger hops, et cetera. Lots of different ways that we can progress while keeping it comfortable and pain free. And then once they're at a point where they're managing their single leg impact really comfortably, that may be a good point to start to reintroduce their sport, providing you happy it's at the right stage irritability, et cetera, and gradually get them back into their sport. Often then we back off with these programs and we focus on getting back into sport. Hopefully doing this because there's impact involved, particularly if we progress, the speed can often address power deficits as well.

Okay. Thank you very much for listening into this today. If you've got any questions or comments on this, do let us know. I've put a link to our other videos. We've got videos there on iliotibial band syndrome, tendinopathy, lower back pain, lots for you to choose from. And if you find these videos helpful, do share them, use them in your in service training sessions if you want to with your colleagues.

We really want these to be as helpful as possible for you. Okay. Thanks again for listening. Bye for now.