Wellness Blog
Wellness Resources

Exercise Series: Deadlifts


Deadlifts have long been a staple in strength training. It is a very complex movement that requires movement throughout multiple joints and using multiple muscles. If you’re looking for an exercise that gives you the most bang for your buck to shorten your leg days, look no further. 


Deadlifts can simulate multiple movements and everyday activities like lifting a heavy box from the ground, picking up your kids or grandkids, or even leaning over the sink to do the dishes to a lesser extent. You can see how training with this movement can help to give you functional strength for many things you do in a day. Because the movement is so complex and involves multiple joints, it can help to improve movement control throughout the entire body. Improved motor control will help muscles to turn on and off appropriately during motion or in anticipation for motion. 


We use deadlifts in the clinic for many of our patients due to the high value if the movement. We often use this with our patients who have lower back, hip or knee issues. The muscles that this movement works span across these joints, so strengthening often helps to reduce overloading of painful structures and adds active stability back to the system. Below is an overview of some of the muscles this movements trains, benefits, as well as cues for proper form.


Targeted Muscles

  • Prime movers
    • Glutes: Extends the hip which is important for waking, standing, stairs, and pretty much everything else you do with your legs
    • Hamstrings: Helps to extend the hip and flex the knee. Important in movements like running and walking uphill
    • Erector spinae: helps to extend and support your back when sitting, bending, and maintaining an upright position
  • Secondary muscles
    • Upper traps: Helps to support the shoulder girdle and extend and rotate the neck 
    • Rhomboids: postural muscles to help support your shoulder blades and bring your shoulder back
    • Biceps and brachialis: to a lesser extent. Biceps turns palms up and assist with elbow and shoulder flexion. Brachialis flexes the elbow. 
    • Various forearm muscles: Important for grip

Benefits of the Deadlift

  1. Improve strength of all the muscles listed above
  2. Improve hamstring flexibility and length.
    1. That’s right! Get rid of your static stretching routine for your hamstrings and add these to your workout to stretch out those stubborn hamstrings. 
  3. Improve postural strength which may help to reduce pain with standing and sitting for long periods

Variations and Form for Deadlifting

Standard deadlift

  1. Start with your feet flat and placed hip/shoulder width apart- whatever feels comfortable. 
  2. Squat down to with your hips lower than your shoulders and grasp the bar (you can use either a pronated or double overhand grip, or a mixed grip with one hand supinated and the other hand pronated).
  3. The bar should be about 1 inch in front of your shins. 
  4. The back should be neutral or slightly arched, your shoulder blades down and back, chest up and high, heels on the floor, shoulders slightly in front of the bar and eyes straight ahead. 
  5. To lift the bar extend your hips and knees keeping your torso upright, keep the elbows extended and the shoulders over the bar. Keep the bar as close to your body as possible. Extend until you are standing straight up.
  6. To lower the bar, keep the torso upright and the bar close to your body. Flex your hips and knees to lower the bar to the floor, keeping an upright posture the entire time.

Romanian Deadlift

  1. Start with your feet flat and placed hip/shoulder width apart- whatever feels comfortable. 
  2. Place your hands a shoulder width apart with either a double overhand (pronated) or a mixed grip (one hand pronated, the other supinated).
  3. With you knees slightly bent, hinge forward to grasp the bar. Your torso will be parallel with the floor (or close to it, everyone is different).
  4. To lift the bar extend the hips, raising the torso up, until you are standing erect, keep the bar close to the body the entire time. Safety tip: don’t hyperextend the elbows or the back.
  5. To lower the bar flex the hips and push them backward, hinging at the hips to move the torso forward, keeping the bar in contact with the thighs.
  6. Keep your torso rigid and your spine neutral and keep the shoulders down and back until the barbell is level with your knees.

Single leg RDL

You see this less often with a barbell and much more commonly performed with a kettle bell or a dumbbell. This can be performed conventional style, stiff legged, or Romanian. We will review the conventional style and Romanian style. This can be performed with a kettle bell in one hand, or in each hand. If you perform this with a single kettlebell or dumbbell, then the leg that moves backward should be the SAME side holding the weight.

Sumo deadlift

Exercise Series: Squats

Exercise Series: Squats

The first in our exercise series covers one of the most fundamental lifts: The squat. This is an exercise that simulates and helps to build strength for multiple functional movements like running, jumping, walking, stairs, picking up your children, and even getting on and off the toilet. Staying strong with a squatting movement helps you keep up with life while you’re young and helps you stay independent as you age. 

The squat is a great multi-joint exercise that you can use to increase range of motion and build full body strength. This is why it is a mainstay of almost any strength program. There is a lot of misinformation around the squat and we are here to talk about squatting safely and get more people interested in this exercise. 



We’ve got great news! There is no need to pay super close attention to squat form for most of us. There is no one perfect squat. Form becomes important when we are getting near our max lift as proper form will give you a mechanical advantage and reduce your risk for injury, but outside of that it isn’t very important. 

Everyone has variations in the anatomy of their hips as well as knee and ankle flexibility. These variations can affect form when completing a complex lift like the squat: So how can we say there is only one way to properly perform a squat?

There is little evidence to support that idea that improper form can directly lead to an injury.

  • If you aren’t sure on your form, that’s ok
  • The more you do it, the better you will get
  • If you need to turn your ankles out for comfort or can’t get as low as you’d like, it’s fine
  • The dreaded “buttwink” is when your pelvis tucks under you at the bottom of your squat, which is also totally normal for most people 

Tips and tricks

  • Start with a comfortable weight for YOU, not the person next to you lifting an absurd amount of weight in the gym. We all have our own starting points.
  • We recommend going to at least 90 degrees of knee flexion with your squat if you can comfortably get there with your heels flat on the floor. 
  • If it’s between more weight or more depth, we recommend more depth. Your muscles will only adapt to the ranges you work them in. That means if you squat to 45 degrees of knee flexion with a lot of weight, you will get very strong in this range. Outside of this range though, you will likely be significantly weaker.
    • Once your ideal depth is achieved, you can begin progressing the weight
  • Select the type of squat and depth that will help you reach your goal for training.
    • Box squats may be best to help work on getting in an out of a chair
    • Split squats are beneficial for sports requiring single leg explosive movements like sprinting and ice hockey
  • BREATHING: Breathe in while you are descending in the squat and breathe out when ascending out of the squat
    • You should not hold your breath during the squat unless you are trained in doing this to prevent fainting and extreme increases in internal pressure

Common form issues

  • Knees collapse in when squatting
    • Cause: Poor glute activation
    • Fix 1: by thinking about rotating your feet outward against the ground. Your feet shouldn’t move, but this will help activate the glutes to prevent valgus
    • Fix 2: Put an exercise band around the tops of your knees and actively resist
  • Too much forward trunk lean
    • Cause: Usually due to performing the squats with more weight than your quads can tolerate. The hip hinge will recruit more glutes and hamstrings during the movement
    • Fix: Use less weight and progressively overload to quads tolerance
  • Weight shift to one side
    • Cause: Painful hip or knee; poor ankle flexibility on one side; reduced strength on one side
    • Fix 1: Use mirrors: They’re not for admiring yourself, they’re for assisting with proper form
    • Fix 2: Place a small riser under the foot of the side you are shifting towards
    • Fix 3: Do split squats to increase single leg strength on deficient side.


  1. Squatting is a great way to improve your range of motion over time. You’ll see in our video Bryan is doing a deep squat and loading through his full range of motion. But If you can only manage a half squat to start, that’s ok.
  2. Squats will increase lower body and core strength with a progressive training program
  3. Squatting is a movement pattern that is used in most things we do throughout the day, so these things will likely become easier with increased training. 
  4. They will make you feel great by releasing feel good endorphins, helping you both physically and mentally. 


Squat Variations

There are as many variations of squats as your imagination can come up with. Front squats, back squats, box squats, sumo squats, belt squats, goblet squats, split squats, starter squats… Below are some common variations that we use with our patients and athletes.

Back Squat

  • Grasp the bar with a closed pronated grip
  • Step under the bar with your feet at a comfortable width
  • You can use either the high bar or low bar position
    • The high bar positions the bar above your posterior deltoids and at the base of the neck
    • The low bar positions the bar across the posterior deltoids and in the middle of the trapezius
  • Lift your elbows and hold your chest up and out to create a shelf for the bar using the upper back and shoulder muscles
  • Extend your knees and hips to lift the bar and take one or two steps backward
  • Position your feet roughly shoulder width apart
  • As you squat, keep your back neutral and your chest up. Keep your heels flat on the floor. Maintain this position on your way back up as well. 
  • Slowly lower yourself as low as you can control and then return to the starting position in a slow controlled motion and repeat with the desired amount of reps

Benefits and Uses

  • Is there anything the squat doesn’t do for your body?!?
  • Helps to build whole body strength, especially in the quads, glutes and hamstrings
  • Builds core strength and stability


Box Squat

  • Form for this movement is similar to the regular squat, except you are sitting and then getting back up from a surface (usually a bench)
  • They key to performing this movement is the subtle hip hinge when sitting and standing

Benefits and Uses

  • Simulates getting out of chair, off toilet, or out of a car
  • Will help improve core strength and stability
  • Moves bias more to glutes and hamstrings

Sumo Squat

  • Load the bar on your shoulders as you would with the back squat
  • Place feet roughly shoulder width with toes turned out about 30 degrees
  • Squat as low as you can then return to the starting position

Benefits and Uses

  • A great movement for beginners
  • More comfortable on painful hips that have impingement type symptoms
  • Aids in making the movement more stable for those at risk for falls

Split Squat

  • Grasp the bar in the same position as with the back squat
  • Place one foot flat on a bench, not on live toes
  • Ensure that your front foot is forward enough that your tibia doesn’t move too far forward when dropping into the squat
  • Squat by dropping your back knee straight towards the ground slowly
  • Push up from the down position by extending the knee and hip on the front leg

Benefits and Uses

  • Good for correcting strength discrepancies between sides
  • Useful for sports requiring single leg strength and power (sprinting, long jump, ice hockey)

The Balanced Difference

The Balanced Patient Difference

We often ask ourselves what makes us different from the other clinics in the area and what we can do to help our patients get the most out of their time with our practice. These are the questions that have continued to help us grow both as individuals as well as a clinic. Below are a few of the things that set us apart from some of the other clinics in town. 


  • First and foremost, we believe in treating people, not just conditions or injuries. Care needs to evolve to look at patients as a complex being, not just a sprained ligament or chronic pain patient. Our practice will spend longer with you at your initial evaluation to ensure that we learn as much as possible about you as a person, as well as your condition. Some of the things we may dive into on the first day besides asking about your injury include your diet, sleeping patterns, stressors, and YOUR goals for care.


  • We want to help you reach your goals. Sure, we have objective measures that need to improve like strength, range of motion, and pain to justify a need for care to your insurance company. That being said, these improvements will be targeted on the way to meeting your goals for care. We believe in having patients guide their care within reason. Having our patients set goals allows us to design exercise programs and other treatments around the thing you want to get back to. We put our patients in the driver’s seat of their care.  


  • While we have a research informed bias. Our goal is never to arbitrarily give a patient a series of treatments, we ensure that treatment plans are individualized. Treatment is often based around the best available evidence for treating a condition in a population similar to that of our patients. While we are biased toward evidence, we also take into account our personal experience with working with certain conditions and our patients expectations for treatment and care. 


  • No unnecessary imaging. Choosing Wisely is a campaign to bring healthcare inline with the research. In most cases imaging is unnecessary. The main reasons to perform imaging are to check for red flags (fracture, space occupying lesion) or if a patient hasn’t responded to 6 weeks of chiropractic or physical therapy. We will not order imaging, as it can be costly, expose you to radiation, and is often unnecessary to treat our patients. We believe that unnecessary imaging is irresponsible and causes more harm than good. Going back to bullet point number 1, our patients are people, not pictures. Treatment will not correct an x-ray, it will help to correct the biological processes taking place in your body. 


  • No gimmicks. We provide treatments supported by a sound body of scientific evidence that are widely agreed upon as being effective. You won’t find lasers, magic vitamins, or ultrasound in our office. Lasers sound cool (pew pew), but the evidence is weak, and before we recommend an expensive treatment like that, we want to be sure that it will work for most of our patients. If there was a great body of research supporting lasers, then we’d have two! But until there is, we won’t be recommending any fancy expensive treatments that lighten your wallet.


  • As chiropractors and physical therapists our goals are to help you meet your goals, as quickly and efficiently as possible, and in as pleasant a way as possible. It is also our job to educate! You have questions? Ask away! If you want to know why we are selecting a specific treatment or exercise, just ask and we will be happy to explain. Every patient is treated as an individual, and every individual has their own needs for care.


  • We also offer free consultations and never make you pay for care up front. We don’t think it should cost someone money to know where they should begin with their care: If we think we can help, we will let you know. But if we think that you don’t need treatment, or would be better served by seeing another provider type we will let you know that too. We want patients to see the value in the care at our clinic, and having someone pay upfront is not the way to do this. If a patient feels they are not getting better under our care, they should be free to seek care somewhere else without an added financial burden.


We are always working to improve as a clinic and individuals and we never stray away from these 7 points. We also keep our mission close to heart to serve the greater Charlottesville community by delivering the best in evidence-based care with integrated chiropractic, physical therapy and massage therapy to help each patient reach optimal health and well-being. 

Top 10 Tips for Migraines

Top 10 Tips for Migraines!

  1. Manual Therapy

Spinal manipulation is a useful tool in migraine prophylaxis. One study demonstrated a “significant reduction” of migraine intensity in almost half of those patients receiving spinal manipulation.  Nearly ¼ of migraine patients reported greater than 90% fewer attacks.  (11) Spinal manipulation has demonstrated similar effectiveness but longer-lasting benefit with fewer side effects when compared to a well-known and efficacious medical treatment (amitriptyline).  (11,12,13,14)

A Harvard study found that SMT significantly reduced migraine days as well as pain intensity. (52) And SMT is safe; a study to define adverse events following chiropractic spinal manipulation for migraines found that “adverse events were mild and transient, and severe or serious adverse events were not observed.” (53)

Several recent studies have shown that acupuncture is another viable tool for managing migraines. (49-51,59,60)

  1. Eat Smart & Maintain an Ideal Weight

Dietary fats trigger the synthesis of prostaglandins which are known migraine triggers (19). Low-fat diets have been shown to play a role in migraine prophylaxis. (20,21) Weight loss may decrease the frequency of migraine and other primary headaches (tension, cluster). (16-18)  Patients on a low sodium (DASH) diet report a decrease in headache frequency vs those on a high sodium diet.  (23) One new study showed that “adherence to the Harvard Healthy Eating Plate advice, particularly the reduction in carb, red and processed meat consumption, is useful in migraine management, reducing migraine frequency and disability.” (47)

  1. Drink Water

Increased hydration may produce subjective improvement in headache disability and intensity. (22) A study published earlier this month, showed “The results showed that the severity of migraine disability pain severity headaches frequency and duration of headaches were significantly lower in those who consumed more total water.” (48)

  1. Vitamin D

Vitamin D deficiency is associated with migraine attacks. (54,55) Vitamin D supplementation in a dose of 1000-4000 IU/d has been shown to reduce the frequency of migraine attacks. (55-57)

  1. B Vitamins

Riboflavin (Vit B2) may help prevent migraines. (26, 29-38) Dosage recommendations vary, however, the average dose used in the studies was 400mg/day. Vitamin B6 supplementation (with or without concurrent B9 and B12) has also demonstrated prophylactic benefit. (58)

  1. Feverfew (125mg)

Feverfew may be a useful tool for preventing migraines. (24,25,26) Dosage recommendations vary, however, the average dose used in the studies was 125mg/day.

  1. Ginger

Adding ginger to feverfew may provide relief for acute migraine. (27,28) The proprietary ginger preparation used was (LipiGesicM™ )

  1. Magnesium (400-600mg)

Magnesium may provide migraine prophylaxis. (26, 39-42) An umbrella review found strong evidence that “Magnesium supplementation can reduce the intensity/frequency of migraine.” (61) Dosage recommendations vary, however, the average dose used in the studies is 400-600mg/ day for the prevention of migraine in non-pregnant patients.

  1. Coenzyme Q10 (100mg TID)

Coenzyme Q10 may be effective in migraine prophylaxis. (26, 43-46) Dosage recommendations vary, however, the average dose used in the studies was 100mg TID.

  1. Melatonin (2-3mg)

One systematic review and meta-analysis concluded: “Melatonin may be of potential benefit in the treatmentprevention of migraine in adults.” (62) Study doses varied widely (0.05-50mg), however, the typical dose used in the studies was 2-3mg, taken before bedtime.

Tim Bertelsman, DC

Do you struggle with migraines? Give us a call to see how we can help! 434-293-3800

  1. Lipton RB, Scher AI, Kolodner K, Liberman J, Steiner TJ, Stewart WF. Migraine in the United States: epidemiology and patterns of health care use. Neurology. Mar 26 2002;58(6):885-94.
  2. Burton WN, Landy SH, Downs KE, Runken MC. The impact of migraine and the effect of migraine treatment on workplace productivity in the United States and suggestions for future research. Mayo Clin Proc. May 2009;84(5):436-45.
  3. Wolff, HG. Headache and other head pain. New York: Oxford University Press:  1948.
  4. May A, Goadsby PJ. The trigeminovascular system in humans: pathophysiologic implications for primary headache syndromes of the neural influences on the cerebral circulation. J Cereb Blood Flow Metab. Feb 1999;19(2):115-27.
  5. Dodick DW, Gargus JJ (August 2008). “Why migraines strike”. Sci. Am. 299 (2): 56–63
  6. Waeber C, Moskowitz MA. Therapeutic implications of central and peripheral neurologic mechanisms in migraine. Neurology. Oct 28 2003;61(8 Suppl 4):S9-20.
  7. Moskowitz MA. The visceral organ brain: implications for the pathophysiology of vascular head pain. Neurology. 1991;41(2(Pt 1)):182–186.
  8. Chawla J. Migraine Headache. Medscape. http://emedicine.medscape.com/article/1142556-overview Accessed 2/1/14
  9. Welch KM. Contemporary concepts of migraine pathogenesis. Neurology. Oct 28 2003;61(8 Suppl 4):S2-8.
  10. Kelman L. Women’s issues of migraine in tertiary care. Headache. Jan 2004;44(1):2-7.
  11. Nelson CF, Bronfort G, Evans R, Boline P, Goldsmith C, Anderson AV: The efficacy of spinal manipulation, amitriptyline and the combination of both therapies for the prophylaxis of migraine headaches. J Manipulative Physiol Ther 1998, 21 :511-519
  12. Biondi DM. Physical treatments for headache: a structured review. Headache. 2005;45(6):738–746.
  13. Bronfort G, Assendelft WJ, Evans R, et al. Efficacy of spinal manipulation for chronic headache: a systematic review. J Manipulative Physiol Ther. 2001;24(7):457–466.
  14. Boline P et al. Spinal Manipulation vs. Amitriptyline for the Treatment of Chronic Tension-type Headaches: A Randomized Clinical Trial J Manipulative Physiol Ther 1995 (Mar); 18 (3):   148–154
  15. Orr SL. Diet and nutraceutical interventions for headache management: A review of the evidence. Cephalalgia. 2015 Jun 11.
  16. Hershey AD, Powers SW, Nelson TD, et al. Obesity in the pediatric headache population: A multicenter study. Headache 2009; 49: 170–177.
  17. Di Lorenzo C, Coppola G, Sirianni G, et al. Migraine improvement during short lasting ketogenesis: A proofof-concept study. Eur J Neurol 2015; 22: 170–177.
  18. Verrotti A, Agostinelli S, Dinelli SD, et al. Impact of a weight loss program on migraine in obese adolescents. Eur J Neurol 2013; 20: 394–397.
  19. Antonova M, Wienecke T, Olesen J, et al. Prostaglandins in migraine: Update. Curr Opin Neurol 2013; 26: 269–275.
  20. Bic Z, Blix G, Hopp H, et al. The influence of a low-fat diet on incidence and severity of migraine headaches. J Womens Health Gend Based Med 1999; 8: 623–630. 3
  21. Bunner AE, Agarwal U, Gonzales JF, et al. Nutrition intervention for migraine: A randomized crossover trial. J Headache Pain 2014; 15: 1–9.
  22. Spigt M, Weerkamp N, Troost J, et al. A randomized trial on the effects of regular water intake in patients with recurrent headaches. Fam Pract 2012; 29: 370–375.
  23. Amer M, Woodward M and Appel LJ. Effects of dietary sodium and the DASH diet on the occurrence of headaches: Results from randomised multicentre DASHSodium clinical trial. BMJ Open 2014; 4: 1–7.
  24. Pittler M and Ernst E. Feverfew for preventing migraine. Cochrane Database Syst Rev 2004; CD002286.
  25. Diener HC, Pfaffenrath V, Schnitker J, et al. Efficacy and safety of 6.25 mg t.i.d. feverfew CO2-extract (MIG-99) in migraine prevention—a randomized, double-blind, multicentre, placebo-controlled study. Cephalalgia 2005; 25: 1031–1041.
  26. Holland S, Silberstein SD, Freitag F, et al. Evidencebased guideline update: NSAIDs and other complementary treatments for episodic migraine prevention in adults: Report of the Quality Standards Subcommittee of the American Academy of Neurology and the American Headache Society. Neurology 2012; 78: 1346–1353.
  27. Cady RK, Schreiber CP, Beach ME, et al. Gelstat Migraine (sublingually administered feverfew and ginger compound) for acute treatment of migraine when administered during the mild pain phase. Med Sci Monit 2005; 11: 65–70.
  28. Cady RK, Goldstein J, Nett R, et al. A double-blind placebo-controlled pilot study of sublingual feverfew and ginger (LipiGesicTM M) in the treatment of migraine. Headache 2011; 51: 1078–1086.
  29. Maizels M, Blumenfeld A and Burchette R. A combination of riboflavin, magnesium, and feverfew for migraine prophylaxis: A randomized trial. Headache 2004; 44: 885–890.
  30. Smith C. The role of riboflavin in migraine. Can Med Assoc J 1946; 54: 589–591.
  31. Boehnke C, Reuter U, Flach U, et al. High-dose riboflavin treatment is efficacious in migraine prophylaxis: An open study in a tertiary care centre. Eur J Neurol 2004; 11: 4750477.
  32. Schoenen J, Lenaerts M and Bastings E. High-dose riboflavin as a prophylactic treatment of migraine: Results of an open pilot study. Cephalalgia 1994; 14: 328–329.
  33. Di Lorenzo C, Pierelli F, Coppola G, et al. Mitochondrial DNA haplogroups influence the therapeutic response to riboflavin in migraineurs. Neurology 2009; 72: 158891594.
  34. Sa´ndor PS, Afra J, Ambrosini A, et al. Prophylactic treatment of migraine with beta-blockers and riboflavin: Differential effects on the intensity dependence of auditory evoked cortical potentials. Headache 2000; 40: 30–35.
  35. Schoenen J, Jacquy J and Lenaerts M. Effectiveness of high-dose riboflavin in migraine prophylaxis: A randomized controlled trial. Neurology 1998; 50: 466–470.
  36. Nambiar N, Aiyappa C and Srinivasa R. Oral riboflavin versus oral propranolol in migraine prophylaxis: An open label randomized controlled trial. Neurol Asia 2011; 16: 223–229.
  37. Condo` M, Posar A, Arbizzani A, et al. Riboflavin prophylaxis in pediatric and adolescent migraine. J Headache Pain 2009; 10: 361–365.
  38. Markley HG. Prophylactic treatment of headaches in adolescents with riboflavin. Cephalalgia 2009; 29(Suppl 1): 100.
  39. Facchinetti F, Sances G, Borella P, et al. Magnesium prophylaxis of menstrual migraine: Effects on intracellular magnesium. Headache 1991; 31: 298–301.
  40. Ko¨seoglu E, Talaslioglu A, Go¨nu¨l AS, et al. The effects of magnesium prophylaxis in migraine without aura. Magnes Res 2008; 21: 101–108.
  41. Esfanjani A, Mahdavi R, Ebrahimi Mameghani M, et al. The effects of magnesium, L-carnitine, and concurrent magnesium-L-carnitine supplementation in migraine prophylaxis. Biol Trace Elem Res 2012; 150: 42048.
  42. Peikert A, Wilimzig C and Ko¨hne-Volland R. Prophylaxis of migraine with oral magnesium: Results from a prospective, multi-center, placebo-controlled and double-blind randomized study. Cephalalgia 1996; 16: 257–263.
  43. Rozen TD, Oshinsky ML, Gebeline CA, et al. Open label trial of coenzyme Q10 as a migraine preventive. Cephalalgia 2002; 22: 1370141.
  44. Sa´ndor PS, DiClemente L, Coppola G, et al. Efficacy of coenzyme Q10 in migraine prophylaxis: A randomized controlled trial. Neurology 2005; 64: 713–715.
  45. Hershey AD, Powers SW, Vockell AL, et al. Coenzyme Q10 deficiency and response to supplementation in pediatric and adolescent migraine. Headache 2007; 47: 73–80.
  46. Altamura C, Cecchi G, Bravo M, Brunelli N, Laudisio A, Caprio PD, Botti G, Paolucci M, Khazrai YM, Vernieri F. The Healthy Eating Plate advice for Migraine prevention: an interventional study. Nutrients. 2020 Jun;12(6):1579. Link
  47. Khorsha F, Mirzababaei A, Togha M, Mirzaei K. Association of drinking water and migraine headache severity. Journal of Clinical Neuroscience. 2020 May 20. Link
  48. Chen YY, Li J, Chen M, Yue L, She TW, Zheng H. Acupuncture versus propranolol in migraine prophylaxis: an indirect treatment comparison meta-analysis. Journal of neurology. 2019 Aug 21:1-2. Link
  49. Vázquez-Justes D, Yarzábal-Rodríguez R, Doménech-García V, Herrero P, Bellosta-López P. Analysis of the effectiveness of the dry puncture technique in headaches: systematic review. Neurology. 2020 Jan 13. Link
  50. Xu S, Yu L, Luo X, Wang M, Chen G, Zhang Q, Liu W, Zhou Z, Song J, Jing H, Huang G. Manual acupuncture versus sham acupuncture and usual care for prophylaxis of episodic migraine without aura: multicentre, randomised clinical trial. BMJ. 2020 Mar 25;368. Link
  51. Rist PM, Hernandez A, Bernstein C, Kowalski M, Osypiuk K, Vining R, Long CR, Goertz C, Song R, Wayne PM. The Impact of Spinal Manipulation on Migraine Pain and Disability: A Systematic Review and Meta-Analysis. Headache: The Journal of Head and Face Pain. 2019 Apr;59(4):532-42. Link
  52. Chaibi A, Benth JŠ, Tuchin PJ, Russell MB. Adverse events in a chiropractic spinal manipulative therapy single-blinded, placebo, randomized controlled trial for migraineurs. Musculoskeletal Science and Practice. 2017 Jun 1;29:66-71. Link
  53. Patel U, Kodumuri N, Malik P, Kapoor A, Malhi P, Patel K, Saiyed S, Lavado L, Kapoor V. Hypocalcemia and Vitamin D Deficiency amongst Migraine Patients: A Nationwide Retrospective Study. Medicina. 2019 Aug;55(8):407. Link
  54. Ghorbani Z, Togha M, Rafiee P, Ahmadi ZS, Magham RR, Haghighi S, Jahromi SR, Mahmoudi M. Vitamin D in migraine headache: a comprehensive review on literature. Neurological Sciences. 2019 Aug 3:1-9. Link
  55. Nowaczewska M, Wiciski M, Osi?ski S, Kamierczak H. The Role of Vitamin D in Primary Headache–from Potential Mechanism to Treatment. Nutrients. 2020 Jan;12(1):243.
  56. Ghorbani Z, Togha M, Rafiee P, Ahmadi ZS, Magham RR, Djalali M, Shahemi S, Martami F, Zareei M, Jahromi SR, Ariyanfar S. Vitamin D3 might improve headache characteristics and protect against inflammation in migraine: a randomized clinical trial. Neurological Sciences. 2020 Jan 2:1-0. Link
  57. Liampas I, Siokas V, Aloizou A, Tsouris Z, Metaxia D, Aslanidou P, Brotis A, Dardiotis E. Pyridoxine, folate and cobalamin for migraine: A Systematic Review. Acta Neurologica Scandinavica. 2020 Apr 12. Link
  58. Xu S, Yu L, Luo X, Wang M, Chen G, Zhang Q, Liu W, Zhou Z, Song J, Jing H, Huang G. Manual acupuncture versus sham acupuncture and usual care for prophylaxis of episodic migraine without aura: multicentre, randomised clinical trial. BMJ. 2020 Mar 25;368. Link
  59. Natbony LR, Zhang N. Acupuncture for Migraine: a Review of the Data and Clinical Insights. Current Pain and Headache Reports. 2020 May 29;24(7):32-. Link
  60. Veronese N, Demurtas J, Pesolillo G, Celotto S, Barnini T, Calusi G, Caruso MG, Notarnicola M, Reddavide R, Stubbs B, Solmi M. Magnesium and health outcomes: an umbrella review of systematic reviews and meta-analyses of observational and intervention studies. European journal of nutrition. 2019 Jan 25:1-0. Link 
  61. Liampas I, Siokas V, Brotis A, Vikelis M, Dardiotis E. Endogenous Melatonin Levels and Therapeutic Use of Exogenous Melatonin in Migraine: Systematic Review and Meta-Analysis. Headache: The Journal of Head and Face Pain. 2020 Apr 30. Link

How To Start Running

How to Safely Build your Running Volume and Intensity

While things are slowly opening back up around here after a two-month quarantine, it looks as though gyms and fitness centers will be among the last things to return. And for many of us, it will take a long time before we’re comfortable exercising in an enclosed space with a bunch of heavy-breathing strangers. With that in mind, many of us have taken up running – one of the best full body and cardiovascular workouts out there, and one that can be done literally anywhere and requires nothing but a solid pair of shoes.

Running is incredible. I am of the opinion that human beings WERE indeed “born to run” – we are built for it. It strengthens almost every muscle in the body, it contributes to a robust and durable skeleton, it will quickly develop your cardiovascular fitness; and it’s fun. Joyful. Freeing.  

However, it is also a lot of impact. With each step, running imparts forces up your foot and leg that are FIVE TIMES YOUR BODYWEIGHT. That’s a LOT of force. And for this reason, most individuals need to progress into running slowly in order to avoid injury. All you need is a plan (and some self-honesty), and it IS possible to build your running volume over time without sustaining an injury. 






Step 1: Get Assessed.

 For those of you without pain and without a history of lower-body injury, you can *probably* skip this step, and add some jogging into your routine in a systematic fashion (more on that in a bit). But, if you are coming off an injury and/or having some pain, it’s best to get checked out by a professional. Whether you decide to see a physical therapist, a chiropractor, a PA or a physician is up to you – but make sure they have experience in working with runners. Please note that having some pain doesn’t mean that you can’t start running (especially if your pain is unrelated to, or even relieved by, physical activity) – but it’s safest for you to get a professional opinion first. 

A sports physical therapist will be able to perform a running readiness screen, which includes testing your range of motion, strength, stability, and power output to make sure your muscles, tendons, and bones are up for the task. Additionally, if you’re having pain, we can help determine which tissues might be contributing, and determine whether it’s safe for you to begin running. If it’s not – no worries! We can work with you to get you to the point where it is.

Step 2: Walk 

You have to crawl before you can walk…and you have to walk before you can run. If you already walk regularly, great; it’s likely you can skip this step. If not, I’d recommend starting by walking 30 minutes, 4 days per week.  Gradually add time and days until you can walk 60 minutes without pain and without stopping, on at least two days per week. When you’ve reached this milestone, you can be certain that your body is ready to up the ante a bit

Step 3: Start with intervals 

Where you start when you start running all depends on your fitness level and your experience in the sport. If this is your first time committing to a fitness routine (which, by the way – major props and congratulations!), then running a 5k per day is not a smart way for you to begin (it will likely lead to an overuse injury). If you’re a division I soccer player who’s just graduated and looking for a new way to stay fit, however – you can probably tolerate a three-mile run. 

For those who are new to running, or if you’re coming off an injury, I suggest starting with intervals. These can be as short as 30 seconds of running, or as long as one minute to start with – depending on your fitness and the severity of your injury (for example, if a stress fracture has kept you out of running for 4+ months – start small. If you pulled a muscle and were out for 4 weeks, you can start with a little more). Give yourself a minute to rest in between sets, and repeat 8-10 times. That’s your run for the day.

I recommend repeating each “level” of progression three times before increasing the time spent running and decreasing your rest intervals. Almost every major sports medicine center has a “return to running” progression; Feel free to search the googles, but i feel strongly that progressions should be highly individualized based on the nature and severity of the injury and the athlete’s fitness levels. 

Follow the 10% rule. When increasing your mileage, don’t add more than 10% of your total volume from week to week. For example, if you ran a total of 10 miles this week, then next week, you can add one mile to your weekly total.

Step 4:  Add Volume before you add Speed. Never add both at the same time

Speaks for itself. Build yourself a comfortable base – I’d say of at least 15-20 miles per week – before you start increasing the intensity of your runs. This allows both your cardiovascular and your musculoskeletal system to adapt to running. Both volume and intensity contribute to the overall load of running; so adding both at once will likely just overload your system and create injury. CONSISTENCY is key; don’t be afraid to build slowly, because that is your ticket to a lifelong relationship with running. 

Step 5: Don’t Ignore Pain

If you should feel pain while progressing your running, a good first step is to simply take 1-2 days of complete rest, and then resume your running intervals at the level below where you were when you felt the pain. This is going to look different on every program, but for example: if you were running for two minutes, walking one minute and felt pain, then you would, after rest, initiate running at run 1: walk 1, a level below.  If you’re still having pain after a few days of rest and dropping it down a level, now’s the time to call your PT or physician. 

Remember that any time you push your body’s limits, it’s going to respond by pushing back a little. Some aches and pains here and there are a normal part of life for a runner. I don’t want you to think that every little niggle requires medical attention. However, pain that is persistent and prevents you from finishing your runs or forces you to change your gait, definitely warrants a workup. 

If you have questions, or want a personalized plan for building your running volume after an injury or time off (or for the first time!), don’t hesitate to reach out to [email protected]

Training, Fueling, Fitness, and Body Image During COVID19

This started as a blog on “how to keep training during quarantine”. Which is an important topic, especially because it seems as though this is how life is going to be for the time being. But as I was writing, this is what came out instead.  There are questions I need to answer, thought patterns I need to shed light on, and reassurance that needs to be given….so here it is.

“Training looks different for me now and I’m scared I’m going to gain the “COVID-19 Pounds that everyone keeps joking about”

I have several responses to that.  For one, it goes without saying that if the worst thing that happens to you during this pandemic is that you pack on a few extra pounds, consider yourself very lucky. I would much rather gain weight than get sick and die, or see my loved ones get sick and die.  I don’t think there’s anyone who doesn’t truly feel that way deep down. In the grand scheme of things, this is an incredibly scary and unprecedented time, and if you need an extra snack or two to cope with it? There’s nothing wrong with that. No one is judging.

That being said, being worried about your weight and fitness when your entire routine has been upended by the universe does not make you a bad person. If you are a female of any age, any background, any shape, size, activity level – you’ve had diet culture forced down your throat since the day you were born. You’ve most likely been made to feel, your whole life, that your body is inadequate and that it must be small to be “worthy”. We all have. I don’t know a single woman who’s somehow escaped that message. Men too, for that matter. If you find yourself freaking out a little extra about your weight, it doesn’t make you selfish and uncaring about the rest of the world – you literally can’t help it because this is what you’ve been taught by society to value. Regardless of whether you got that message from a magazine, a movie, your mom, or your coach – it’s ingrained.

For individuals with eating disorder history, this is also an especially difficult time because many eating disorders are a form of control.  There’s a LOT of things we don’t have control over right now, and it is terrifying. When the rest of your life is scary, uncomfortable, and inconsistent, focusing in on your body and food intake is a way to cope and feel like you have control over SOMETHING.  Is it a healthy coping mechanism? NO, of course not – but it is effective. If you’ve fallen into this kind of pattern when stressed over midterms, deciding on a university to attend, going through a divorce or a death or a marriage…then a global pandemic is most certainly going to trigger you too, and that’s not your fault.

If this is you, I suggest forgiving yourself, showing yourself some extra love, and meeting virtually with a therapist who can help you get through this time.

On the opposite side of the coin:

It is also totally okay to continue caring about your health and fitness during this pandemic! And in that regard, I am pleased to report that the laws of physics remain the same regardless of whether you are still at work or you’re on house arrest.  Physics doesn’t care about Corona. The calories in/calories out rule still applies for weight loss or weight maintenance! So, all the “covid-19 pounds” memes are truly kinda dumb. Staying at home doesn’t cause weight gain – eating more calories than you burn does (regardless of your location).

 If your activity level has changed drastically and you don’t want to gain weight, eat less calories. If your activity level has increased, then rest assured that extra coronasnack isn’t doing you any harm.

Some general rules of thumb that still very much apply in this pandemic:

-Eat only when you are hungry, most of the time. Stop when you are satisfied, not stuffed

-Choose mostly whole, unprocessed foods (bonus: they’re better for your immune system than pop tarts!)

And it’s highly unlikely that your weight or fitness will be impacted by staying at home. If you are still concerned and want something more specific, I highly recommend connecting with a sports dietician – most of them do remote consults and they can put you on a plan that will take a lot of the stress out of eating. Who needs one more thing to stress about right now anyway?

As for your activity level?  Keep in mind that we are all, collectively, under a great deal of psychological stress right now. Your body does not know the difference between physical stress and psychological stress so…it all adds up in the same way.  Think of your stress capacity like a bucket.  Both physical and psychological stress fill up the bucket, so the more emotional stress you have – like living through a global pandemic– the less room in the bucket there is for adding physical stress (workouts) – before the bucket spills over (aka you get injured or get sick).

That being said, most of us actually need to slow down with our training, rather than ramping it up. Have you noticed your legs feel heavy? Or that you wake up stiff as a board? Or that you’re sleeping way more than usual, or having more trouble sleeping than usual?  That’s the stress – and those are the same symptoms as overtraining syndrome.  Slow down, and your body will thank you.

If you are struggling with this quarantine in any way – with body image, with food intake, with exercise, with training for a sport, with an injury – please reach out to me: [email protected]  Let’s talk, I’m happy to help you with all of the above.


COVID-19 Update:

In order to keep our patients safe who still wish to be seen in the clinic, we have established new guidelines and requests for patient care. :
1. If you have traveled outside of the country, please do not request or attend an appointment until you have surpassed the minimum 14 days of quarantine. The same applies if you have traveled to a domestic ‘hot zone’ NY, CA, LA, etc.

2. If you are feeling unwell (whether you think its allergies or not), please reschedule your appointment. No cancellation fees will apply during this precautionary timeframe.

3. If you are over 60 years of age or have any underlying health conditions, please reconsider attending your appointments at this time. You have an increased health risk associated with this virus and we would like to minimize that risk, if at all possible.

4. Upon entry and exiting our clinic, please sanitize your hands with the sanitizer located near the check-in kiosk.

5. Please be cognizant of our social distancing measures. Our waiting room allows 6ft of distancing as does our treatment area. Our providers will adhere to maintaining 6ft of distance whenever possible during your treatment.

6. We will be keeping windows and doors propped open as weather permits to allow constant air flow and to prevent our patients from repetitively touching door handles etc. Please dress appropriately as the clinic may be cooler than usual.

7. Our providers may wear masks and will be wearing gloves when performing any manual therapy on our patients.

As we remain open, the safety of our patients and staff is our number one priority. We have made changes to cleaning of the clinic space and equipment as well as to our scheduling policies during this time. Thank you for your patience and understanding during this trying time.

Sport Specialization: How Soon is Too Soon?

Abby Wambach. Golden Tate. Morgan Brian. Colin Kaepernick. Sue Bird. RGIII. Mia Hamm. Allen Iverson. Tom Brady .

What do these individuals have in common, aside from being highly accomplished professional athletes? 

They were multi sport athletes all the way through high school. That means they played one sport in the fall; another one in the spring; some of them a third, still different, in the winter; and likely took summer as an off-season where they remained physically active – playing kickball with friends, jumping in the lake, riding bikes around the neighborhood – but weren’t formally training for a sport. 

As a sports specialist physical therapist, parents are constantly asking me when, and whether, their child should specialize in a certain sport. I understand -when you notice that your child is good  – even exceptional! – at something, you want to help them develop that as best you can, as soon as you can. You also generally have the ability to do so, with school teams, travel teams, and local leagues in abundance. 

So when SHOULD a young athlete specialize in one sport?  As late as possible. Here’s why. 

Risk: Overuse Injury 

Repetitive stress is one of the primary causes of sports-related injury. Despite how we usually consider children to be “spry” and “resilient”, they are actually much more susceptible to certain kinds of overuse injury than adults because 1) their skeletons are not fully developed and 2) they are not able to build muscle strength and hypertrophy the way adults are. When a young athlete participates in the same sport year-round, they are only developing one set of skills, one set of movement patterns; this can lead to increased risk of injury outside their sport too.  Additionally, repetitive movements like pitching a baseball, bringing the shoulder through a swim stroke, or striking a soccer ball actually involve higher forces going through the body than you might think. This puts extra stress on the athlete’s still-developing muscles, tendons, bones, and especially growth plates. 

It needs to be said too that the number one risk factor for sustaining a sports injury is….having had a previous sports injury! Overuse injuries, while they’re rarely a career-ender (but can be!), are in many ways setting the young athlete up for a tough ride in their sport. 

Risk: Burnout 

The developing brain of a young athlete is not meant to focus on a singular task day after day, year after year. Quite the opposite – children and adolescents need variety in order to thrive and grow, both mentally and physically.  The more specialized a young athlete becomes, the more likely they are to become frustrated and, well….burned out. Did you think burnout was just for medical students or adults working desk jobs they hate? Think again. When kids do too much of one thing, and experience too much pressure from coaches and parents, they will fold, and it is harder for them to recover than it is for adults with fully developed brains.

Burnout is a huge problem that has dire health consequences for young athletes. Involvement in sport has endless benefits, from learning how to work as part of a team to keeping a person’s heart and lungs healthy to controlling their weight. If an athlete becomes burned out by their sport at a young age, they are much less likely to ever participate in sport; and are even less likely to continue with physical activity. This puts them at risk down the road for obesity and cardiovascular health issues. You can see how this is not just a problem at the individual level, but at the societal level as well. The key to keeping young people involved in sport all through life is VARIETY. 

Reward of Waiting: Athletic Prowess 

You read the names I listed above. There are countless more.  The more variety a child has in their athletic activity, the more comprehensive their athletic development. Athleticism is not the same thing as having skill at a particular sport. Athleticism refers to strength, power output, speed, agility, reaction time, and endurance. Sport-specific skill refers to things like refining your pitching biomechanics, honing the accuracy of your shot on goal, working on your running form, gaining confidence with tackles. Sport-specific skill, of course, is important for performing well and reaching the highest levels of a particular sport BUT, this should be built on a foundation of athleticism.  Skill work is the steering wheel, athleticism is the engine. Build the engine first; and the best way to do that is variety. Running cross-country in the fall is a great way to build endurance so that you can play the full 60 minutes of your lacrosse game in the spring without needing a sub. Playing soccer in the fall helps build that sprint-endurance capacity you need for your finishing kick in the 800m spring outdoor track season. Riding bikes through the neighborhood with your buddies all summer allows you to rest and recover from a tough spring season while still keeping you active. Sport variety, with natural periods of exertion and rest, help your athlete grow from a curious child into a strong, athletic adult.

Reward of Waiting: Growing a high-functioning, well-adjusted adult. 

Above EVERYTHING else, sports should be fun. This obviously goes for adults as well as kids, but it needs to be said that your child is not a small adult – they do not have the mental capacity to go to work at the same job day in and day out the way we do as adults. Think of their sport like a job; it is not hard to see how playing soccer 365 days a year can eventually come to feel like a job. Kids are meant to spend most of their time playing, exploring and having fun, and movement is one of the best ways to do that. There is no reason for any child under the age of 18 to be experiencing burnout or injury; let’s not take their childhood from them too early. I promise, it will have no detrimental effects on their ability to be a high-performing adult. Quite the opposite in fact. 

If you are curious about how to optimize your child’s athletic development, reach out to our sports specialist Dr. Wason. She can answer any questions you may have, provide athletic development training sessions for healthy athletes ages 10-18, and physical therapy services for young athletes with overuse injuries. [email protected]

So you tore your ACL…now what?

Anterior Cruciate Ligament (ACL) ruptures are one of the most common injuries in sport. Most occur without contact, and occur far more often in female athletes than in males. There are many ways to injure the ACL; maybe you’re a soccer midfielder who got into a 3-way tackle at practice. Maybe you’re a goalie who went to clear the ball and felt your plant leg crumble underneath you. Or maybe, if you’re really unlucky, you stepped in a pothole walking home from a game. Regardless of the scenario, when an ACL ruptures you will feel a pop, likely feel your knee “go inward”, and experience immediate swelling.

While there are several clinical tests that a physical therapist can use to determine the status of your ACL, the gold standard for diagnosis is MRI. Once an ACL tear is confirmed on imaging, the gold standard of treatment is still surgical reconstruction.  Research is coming out now suggesting that some individuals can “cope” with intensive rehab, but what we see in the literature is that this only occurs for about 25% of patients who sustain an ACL rupture. If you are going to return to a high-level contact sport – and especially if you’re female and under 30 – your best bet for returning to optimal performance is a reconstructive surgery. 

While it’s a common injury in sport, it’s also an emotionally difficult one; it’s likely your season will be over. Athletes will usually feel grief grief over suddenly not being able to do the thing you love,  anger at watching your teammates continue to thrive and perform in your sport, and fear that you’ll never be the same again.  

 These are all normal feelings to have, but in excess, they’re actually going to prevent you from making a solid comeback. So, here are some steps to take to get your head back in the game, and some information for you so that you know exactly what to expect after you’re wheeled out of the operating room. 

First: Know that it’s going to be okay. 

While an ACL rupture is likely a season-ender, it doesn’t have to be a career-ender if you find the right orthopedic surgeon and a physical therapist who specializes in sports. How many of you watched Megan Rapinoe this year in the world cup? Did you know she tore her ACL – for the THIRD time – in 2015, and was back on the field for the Rio Olympics? . Yes it takes a long time and a lot of hard work, but know this: you WILL play again. 

 Second: Learn about what’s going to happen in the Operating Room.

Surgeries are scary,  but the good news is that sports medicine surgeons perform this operation all the time. Choosing your surgeon is important – you want someone who is board-certified in sports medicine and who does this operation regularly. It is more than okay to ask your surgeon how many ACLs they have reconstructed! Choose your surgeon well – make sure they have LOTS of experience with this operation and make sure that they share your goal of getting back with your team – and you will be just fine. In the operating room, the surgeon will make a small incision and will first debride, or clean up, the inside of your knee. She will likely remove the torn portions of your old ACL.  Then, she will take a portion of one of your tendons – either your patellar tendon (front of your knee), hamstring tendon (back of your knee) or quad tendon (just above your kneecap) and creates a “graft” by re-inserting the tendon into the joint, such that it will act like a new ACL. 

 Third: Get your dang knee straight!

 After you wake up from surgery and make it home from the hospital, you’ll likely be sore, but it’s important to get that knee moving. Check with your surgeon about specific precautions and limitations, but in most cases physical therapy should begin 1-5 days after your surgery. The most important thing in the early phases of rehab is to regain full range of motion, especially extension. Without full range of motion, strength gains will be hard to come by. The earlier you start working on this, the less painful and difficult it will be over time! 

Fourth: Train Hard. 

Find yourself  a physical therapist who specializes in sports rehabilitation. Your physical therapy sessions should feel progressively harder and harder, and your PT should be stressing your cardiovascular systems in addition to getting you strong. If you’re not sweating during your sessions and have mild DOMS afterward – and if you’re not eventually doing things that look and feel like your sport – find a new PT.

Lastly: Be Patient. Play the Long Game. 

 You’re six months out from surgery, running intervals, doing box jumps, and feeling GOOD. So…why can’t you play? The sports medicine and rehab research overwhelmingly and unequivocally shows that for every month you wait to return to play after that 6 month mark, you decrease your risk of reinjury by 50% . That’s huge. Even if your ligament has healed and you’re passing your return to sport tests, the extra three months to get fitter and stronger matter so much to keeping you in the game.   You can reduce your risk of re-injury by waiting until you are stronger and fitter than you were even before your injury. Your physical therapist should be guiding you there and encouraging you every step of the way.

If you have questions about how to prevent ACL ruptures, or whether we’d be a good fit for your pre- and post-operative rehab following this injury, reach out to our sports specialist Dr. Wason: [email protected]

What You Need to Know about Stress Fractures

A more accurate term for a stress fracture is “bone stress injury” (BSI).  This is because bony stress injuries occur along a continuum based on how much loading the bone is being asked to sustain.  When caught early, that dull ache at the front of your shin, for example, might just be what we call a stress reaction: there is edema (fluid) in the bone marrow, but no visible fracture line.  If a stress reaction isn’t caught in time and/or the athlete continues to run through the pain, the bone can be stressed to the point of a partial fracture, what we call a “stress fracture”. Usually, pain with a stress fracture is significant enough that the athlete cannot continue to run through it. However, in cases where the bone continues to be loaded beyond what it is capable of tolerating, a stress fracture can widen and deepen and eventually progress to a complete break in the bone. Again, this is rare because most athletes will voluntarily stop their training due to intolerable pain with a stress fracture. 

Who gets stress fractures?  Bones respond to impact. Moderate amounts of impact activity, such as walking, running, and jumping – when progressed appropriately – are actually GOOD for your bones. Bones actually cannot get strong and dense (aka, strong enough to resist fractures and stress fractures and reducing the likelihood of osteoporosis in your later years) without some impact loading.  The best way to go about this – if you’re not already a runner or involved in a running/jumping based sport like basketball or soccer – is to schedule a visit with a sports physical therapist who can help create a program for you to safely and effectively load your bones. 


However, when it comes to loading your bones, it’s very easy to have too much of a good thing.  HIgh volumes of load, or increasing your load very suddenly, will “stress” the bone and eventually cause it to crack. Generally, stress fractures occur in athletes who run – cross country, track, marathoners, as well as running-based sports like soccer and lacrosse – and in athletes who jump.  They also occur commonly when an athlete is transitioning from a nonweightbearing sport like cycling or swimming into more running. A stress fracture is typically preceeded by a significant increase in impact activity beyond what the athlete is used to. 


Stress fractures can also occur in the absence of an increase in training load. However, the reason is always due to an increase in stress on the body.  This can be physical stress in the form of training load, but can also be emotional/psychological stress (for example, making the transition from high school to college), or metabolic stress from not eating enough. Bones, just like muscles, need fuel to build themselves up and keep from breaking down. For more information on the relationship between energy balance and bone health, see our last post on relative energy deficiency in sport! 


A clinician will usually be able to determine whether or not they suspect a stress fracture based on the patient’s history and on several clinical tests. However, imaging is necessary to rule these in or out. Despite being a bony injury, most stress fractures will NOT show up on X-Ray; MRI is the gold standard for diagnosis. 


Following diagnosis, a stress fracture will usually require a period of unloading depending on severity. Stress fractures in the foot and ankle will usually require a walking boot; stress fractures higher in the leg will require crutches. THe length of time on crutches is entirely dependent on the severity of the fracture.  During this time, most athletes will be allowed to cross-train in the pool (swimming or deep-water running) or on a stationary bike – again, depending on the severity of the injury. 

Most stress fractures take 6-8 weeks to heal. A common misconception, however, is that once the bone is healed the athlete is clear to resume running.  While it’s true that after the bone has healed, the athlete can resume LOADING the bone, this does not mean they are ready to run. With every step you run, your leg has to absorb forces that are FIVE TIMES GREATER THAN YOUR BODY WEIGHT. Starting at this amount of load will likely just lead to a second fracture.


This is where physical therapy comes in! A sports specialist will be able to design a gradual loading program for you, involving progressing walking speed and distance, improving global lower body and core strength, and eventually, progressing plyometric activity in order to guide you safely back into running. This way, you can return to your sport stronger than you left it, and with full confidence that you will not experience an injury like this again anytime soon.  Additionally, a female athlete specialist (like Dr. Wason!) can help coordinate the resolution of any risk factors you may have, such as your training volume, your fuel intake,body image issues, and your menstrual cycle status (for more on how your menstrual cycle affects your bone health, see our previous post on RED-S). 


If you are a runner or running athlete and you: 

-have been diagnosed by a physician with a stress fracture

-have had a bone stress injury in the past and are struggling to return to training

-are having pain with training and suspect you might have a stress fracture

-just want to avoid a bone stress injury


Send an email to Dr. Kate with any questions or concerns or to set up an appointment!

[email protected]