 Hi, I'm Lieutenant Commander Jim Cowan, the physical therapist here at Buds, to talk to you about our most common injury, stress fractures. Historically, our stress fracture rate were some of the highest in the world here, around 15 to 18%. Roughly six guys out of a class of 30 develop some type of stress fracture. With some prevention strategies that we've been putting in place, we find now that our stress fracture rates are about 4 or 5%, which is acceptable, but I think we can still do better. So I hope to put out some information in this segment on probably our most important prevention strategy, which is preventing stress fractures. The most important thing is to make sure that you go to a running store in your local town there and have somebody that knows about footwear fit you for the right kind of running shoes, possibly some orthotics that you need for your boots. It's important to start off with really good footwear for all your training. And we recommend that you change your running shoes every six months or 400 miles. Now if you're running 40 miles a week as we recommend comfortably, that may be a running shoe change every three months. So it's important that you're changing your shoes regularly on a 400 mile schedule, that somebody is looking at your foot, somebody that knows what they're talking about, whether it's a physical therapist or a podiatrist or somebody at a local marathon triathlon store that is very good with shoewear, they're evaluating your foot and putting in the right kind of footwear. Now we run approximately 45 miles a week here and all that running mileage is done in boots and pants. I don't recommend that you do 100% of your training in boots and pants, but you should also be doing some familiarization runs in boots and pants to get used to the added weight and how things are a little different in a boot and a pant. The next most important thing beyond proper footwear is calf flexibility. I tell people here all the time that if you were only to do one stretch for me when you came here to budge to prevent a majority of our injury, it would be just a good calf stretch and you should be doing that two or three times a day. If you're sitting on the table with your foot pointing straight up, you should be able to pull your toes back about 15 to 20 degrees. That's for normal running biomechanics to happen. If you're extremely tight in your calf muscles and you can't pull your feet back, you compensate by your shin bone. That loss of flexibility in your ankle joint because your calf muscles are tight really makes you at a higher risk for stress fracture in the bone because some way or another your body has to get that 15 to 20 degrees. You really want it to happen in the joint like it's supposed to be happening instead of your bone making up for it. It's extremely important that you stretch your calf muscles two or three times a day religiously before you come here. Another thing that we highly recommend and we've mentioned before is proper nutrition before you come here for our stress fracture prevention. The nutritionist that works for Special Warfare recommends 1,000 milligrams of calcium on a daily basis. That's simply three glasses of skim milk a day. If you can't drink milk then chewing a couple of tums tablet is another way that you can supplement with calcium. But you should really be trying to get 1,000 milligrams a day. Now don't go overboard and take 3 or 4,000 milligrams a day because that could lead to kidney stones but we really do recommend at least for bone health 1,000 milligrams on a daily basis of calcium to help your bone stay strong and prevent the stress fractures as well. As always eat a good balanced diet with a lot of different colors on your plate, a lot of different vegetable colors and avoid any kind of illegal supplementation like creatine or protein powders. We mentioned about the importance of calf stretching to prevent stress fractures. You have to have adequate toe up ability to run and if your calf muscles are tight this bone will compensate and break. So what we recommend is that you do at least two or three times a day, two or three repetitions of a minute stretch and it's important and most people tend to know how to stretch your calves but they neglect doing it in both positions. So the first position really is with your knees straight. This gets your true calf muscle that attaches behind your knee and that's a very good way to stretch it. But also you need to bend your knee about 30 degrees and this now gets the muscles that attach below the knee joint, the deepest muscles that affect the ankle range of motion as well. You can see here he has very good calf flexibility and really you should be able to strive for about a 15 to 20 degree toe up position like that. So stretching these calf muscles leg straight and leg bent position is your goal two or three times a day. Okay I want to talk a little bit about the motions that the muscles around your shin bone do and some of the exercises that you can do to help strengthen the bone and keep it from breaking. So the muscles around your leg do four main motions. They point your toes down and that occurs in more of your calf muscles. They roll your ankle in that also involves these backside muscles here. They pull your toes back which involves this front lateral portion here and they pull your ankle to the outside which involves a few small muscles out here. And so stress fractures occur either because you're ramping your mileage too fast but also if the muscles around your bone don't have sufficient endurance and strength it leaves the bone vulnerable to fracture. So one thing that you can work on is trying to work these four motions around your shin bone and keep them just as strong as you can through a couple different ideas that I'll show you right now. So if you can go to a local sports store or if you have access to a physical therapist or any other kind of sports or athletic clinic or even sports store they should be able to give you some exercise band like this. One thing that we have our students do is to use band for the front side of strengthening motion where they can anchor it on and use it to really focus on this anterior lateral compartment right here pulling back and forth for sets here and this is very important and it buds to keep this strong both for the running and for the thinning requirements. We have a lot of students that have a lot of problems with the strength of this front compartment here in the thinning requirements as well as the running protection of their shin bones. So you can use the band to work the front side and you can also use the band to work the lateral part, work in the side as well. Really focus in on this lateral compartment of the ankle and this is also a very important muscle for sand running because it helps with unstable striking on unstable ground and it's also good if you've had a history of ankle sprains to really stabilize the lateral ankle. This is probably one of the most neglected yet important muscles around the ankle joint that we really work hard around here for the sand running. So you can use band to work the front and the lateral compartment. Another exercise if you don't want to use bands to work the front compartment of your legs are heel walking. It's a nice endurance exercise that is so important for that front compartment for the thinning strength as well as the protection of the bone by having a strong anterior group of muscles. It works a lot on endurance. You could do laps around your gym with dumbbells like we're showing here. If you can see that front compartment is really working. It's like I said a really nice endurance and strength combined motion that you can work on. Probably one of the easiest backside calf strengthening drills is just a nice calf raise. Doing it on a slightly elevated platform is a good idea. It really lets you get to the full stretch at the bottom as well as the strength work at the top. So with weighted dumbbells you can do high rep endurance type sets are good. Just nice slow control. This is a good demonstration of that. So we've shown you how to work band for the front and side muscles. We've shown you some ideas with dumbbells on how to work the back compartment here with dumbbell raises as well as heel walking to work a freeway version of that front side of the compartment. So all of these muscle strength exercises for the groups of muscles that surround your shin bone are extremely important to prevent stress fractures. Having strong muscles with a lot of endurance to protect that bone as you slowly ramp up your mileage is your best prevention as well as having a nice flexible calf muscle group. And hopefully that will keep you out of our clinic. So the last exercise we're going to talk about here for stress fracture prevention as well as our knee pain prevention videos is what we call monster walks here. This works a lot of the lateral hip strength that is very much neglected by guys before they come here and it becomes a big problem for them. Having a very strong lateral hip muscle group has been shown to help prevent a lot of running knee pain as well as I feel some of the stress fracture problems that we have here. So once again using some band around your ankles and in this case we're using some nice overhead medicine ball work here to simulate his portion of the log. You can start some lateral hip drills. And it's important while you're doing this to really not let your knees collapse inward. The knees stay open while he's doing this. And then at the end you can actually integrate some squats at the end of the shuffle here. Once again making sure that your knees stay open and that they don't collapse inward. We're really wanting you to make sure that with your run pattern that your knee strike is much better so that when it becomes unstable sand here that your lateral hips are nice and strong. Like I said this is probably the most neglected muscle group that guys fail to work out before they come here to Buds and it really does become a problem for many of them as soon as they get unstable sand running. So make sure that you're incorporating some glute medius lateral hip work. So to wrap up the stress fracture portion I think it's important that you are investing in some good footwear, that somebody evaluates your type of feet and make sure that you're in the right kind of footwear, that you're changing that footwear every six months or four hundred miles, that you're making sure that you have a good diet that includes a thousand milligrams of calcium, that you are stretching your calf muscles for an extremely flexible calf group, that you are running 40 miles a week and that you slowly progress 10% no more per week as you get to that goal and that the muscles around your shin bones are extremely strong with good endurance. So I'm Lieutenant Commander Jim Cowan wrapping up here at Buds and wishing you good health.