"Why fit in when you were born to stand out?"​
-Dr. Seuss

Running is a predictable activity with predictable injuries.If you audited my patients over the last decade, you’d see BSIs in a few specific locations.

A reader reached out to see if I had any thoughts on BSIs of the lesser trochanter, a less common BSI location with very little literature.
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Today, let's use that location as an opportunity to go through how to manage atypical injuries that enter your clinic.

What is the location’s biomechanical role?

The lesser trochanter is a small bump just distal to the medial femoral neck that serves as an attachment site for the iliopsoas. The iliopsoas is your primary hip flexor and a secondary hip external rotator, meaning the lesser trochanter gets tugged in multiple directions. We need to catch these early as they are believed to be precursors to a femoral neck BSI.
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Understanding the location’s anatomy and biomechanics is essential to determine what to avoid in the short term and how to progress throughout a patient’s plan of care. For a lesser trochanter BSI, we need to minimize loads on the hip flexors during the initial stages of recovery. Eventually, we need to load hip flexion during rehab and keep them on flat terrain at an easy pace during their run progression.

Is this really a running injury?

Athletic injuries are assuming to be caused by mechanical loads.
If problems arise somewhere we don’t expect, we may not be dealing with a running problem at all.
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I see this often when runners come in with low back pain, which is rarely driven by running (spinal loads are minimal during running). During an evaluation, we often figure out whether it's a runner's sedentary job, lifting routine, or something else that drives symptoms. BSIs in the sacrum, pelvis, or proximal femur may be driven by an individual's overall health rather than training loads.
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Lesser trochanter BSIs are believed to precede medial femoral neck BSIs, meaning the first step in managing them may be a consult with a primary care doc and dietitian, not getting them on a loading program.
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When the injury location is atypical, health or something outside of running may be the driver.

Treat them like a typical injury

I divide BSI rehab into predictable phases, with specific criteria for moving from one phase to the next. You could argue that all BSIs really need is a period of offloading, a gradual progression of exercise, and a sensible return-to-run program.

So, to a point, managing atypical locations is like managing typical BSIs.

• Refer your patients to a dietitian and get Tier 1 labs.
• Load the bones you want strong.
• Progress heavier weights throughout rehab.
• Perform plyometrics prior to starting a run progression.
• Use a sensible return-to-run program.

But I believe that we should do our best to analyze the specifics of each injury location so that we can tailor our plan of care to the unique demands of the location and the individual.

MY ONLINE BSI COURSE IS ON SALE!

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If you want to sharpen your skills at diagnosing and managing BSIs, my online, CEU-approved bone stress injury course is on sale for $375 (or four payments of $93.75) through the month of November.

To learn more, click HERE.